Review
Non-invasive ventilation in the treatment of sleep-related breathing disorders: A review and update
Ventilação não invasiva no tratamento de distúrbios respiratórios do sono: análise e actualização
A. Nicolinia,
, P. Banfib, B. Grecchic, A. Laxb, S. Walterspacherd, C. Barlascinie, D. Robertf
Corresponding author
a Respiratory Diseases Unit, Hospital of Sestri Levante, Italy
b Neuromuscular Diseases Unit, Don Gnocchi Foundation, Milan, Italy
c Rehabilitation Department ASL 4 Chiavarese, Italy
d Department of Pulmonology, University Hospital, Freiburg, Germany
e Forensic Medicine Unit, ASL 4 Chiavarese, Italy
f Emeritus Professor of Medicine, Claude Bernard University Lyon, France
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"apellidos" => "Lax" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "S." "apellidos" => "Walterspacher" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "C." "apellidos" => "Barlascini" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 6 => array:3 [ "nombre" => "D." "apellidos" => "Robert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Respiratory Diseases Unit, Hospital of Sestri Levante, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Neuromuscular Diseases Unit, Don Gnocchi Foundation, Milan, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Rehabilitation Department ASL 4 Chiavarese, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Pulmonology, University Hospital, Freiburg, Germany" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Forensic Medicine Unit, ASL 4 Chiavarese, Italy" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Emeritus Professor of Medicine, Claude Bernard University Lyon, France" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ventilação não invasiva no tratamento de distúrbios respiratórios do sono: análise e actualização" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Noninvasive mechanical ventilation (NIV) is any form of ventilatory support without an endotracheal tube. NIV was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases, as an alternative to the endotracheal tube. Over the last thirty years NIV has been also used during the night in patients with stable chronic lung disease such as obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), the overlap syndrome (COPD and obstructive sleep apnea), neuromuscular disorders, obesity-hypoventilation syndrome (OHS), and sleep disorders associated with congestive heart failure (Cheyne-Stokes respiration).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In this review we discuss the different types of NIV, the specific conditions in which they can be used as well as the indications, recommendations and evidence supporting the efficacy of NIV.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical conditions for NIV</span><p id="par0010" class="elsevierStylePara elsevierViewall">Alveolar hypoventilation is a result of an imbalance between the capability of respiratory muscles to maintain ventilation and gas exchange and is characterized by hypercapnia assessed by blood gas analysis. If pathologies related to either peripheral and/or central nervous system dysfunction are excluded, the other conditions associated with developing alveolar hypoventilation are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Of note, alveolar hypoventilation primarily develops during sleep<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>; moreover, in all these entities daytime breathing abnormalities must be considered. These respiratory “daylight” deteriorations (particularly in patients with neuromuscular disorders) require an appreciation of the diagnosis, the progression of the disease, and the particular circumstances of the patient.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Obstructive sleep apnea–hypoapnea syndrome (OSA)</span><p id="par0015" class="elsevierStylePara elsevierViewall">OSA has an incidence of 2% in women and 4% in men.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> It is characterized by recurrent episodes of partial (hypoapnea) or complete (apnea), obstruction of the upper airway during sleep, and is associated with episodes of arousal and/or oxyhemoglobin desaturation.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> Symptoms of the syndrome include excessive daytime sleepiness, choking episodes during sleep, frequent awakenings, unrefreshing and unstructured sleep, daytime fatigue, difficulty concentrating and short-term memory loss<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The pathophysiology of OSA remains controversial. Obesity, the classic hallmark in OSA, is associated with obstruction of the upper airways.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Possible hypotheses include adipose tissue infarction of the tongue and/or the dilator muscles of the pharynx.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The upper airway becomes less efficient, reducing oropharyngeal space especially at the end of exhalation. As a result, at the beginning of the next inspiration the dilator muscles of the pharynx must produce a greater contraction to overcome the tendency of the pharyngeal wall to collapse (due to the negative pressure inside the cavity and pharynx).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The supine position is potentially dangerous in some circumstances<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> because the tongue tends to occlude the rear wall of the oropharynx which can increase the oropharynx occlusion.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> This syndrome has been associated with the development of hypertension,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> coronary artery disease, bleeding disorders, stroke and increased risk of sudden death during sleep.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–14</span></a> It is also associated with a higher rate and greater severity of traffic accidents, increased use of health care facilities and reduced capacity for work.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,14,15</span></a> Strong evidence exists that non-invasive ventilation, usually continuous airway positive pressure (CPAP), has significant advantages in this type of disease, improving sleep quality, daytime wakefulness, and cognitive function<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and so the quality of life improves. These improvements are wide-ranging: reduction of traffic accidents, lower arterial blood pressure and reduction in the morbidity and mortality rates of myocardial infarction and stroke demonstrate the wide spectrum of CPAP's benefits.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,12,15,16</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Complex sleep apnea</span><p id="par0020" class="elsevierStylePara elsevierViewall">We use the term “Complex Sleep Apnea” (CompSAS) to indicate a condition initially diagnosed as OSA. This syndrome is characterized (while CPAP is being used) by the frequent occurrence of central apneoa after elimination of obstructive events.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> CompSAS is diagnosed based on minimal apnea–hypoapnea index (AHI) of five events per hour of sleep with a majority of obstructive events. If during titration there is a reduction in the number of obstructive events to <5 events per hour of sleep, while the central apnea index (CAI) is >5 events per hour sleep, the diagnosis is established.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> Rather than starting further treatments it is useful to consider whether CPAP pressure is too high and is provoking CompSAS (pressure toxicity).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Patients with CompSAS most often respond to positive airway pressure, but the obstruction cannot be eliminated without producing central apnea. A possible preventive measure is the so-called permissive flow-limitation: the pressure is set at a level that permits a mild degree of airway obstruction, without disturbing ventilator control mechanisms.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Also oxygen administration may lead to a decrease in the hypoxic ventilatory response.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,21,22</span></a> Also BiPAP in the spontaneous-timed (ST) mode<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,23</span></a> or adaptive servo-ventilation (ASV) can be useful in the treatment of CompSAS.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18,24</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Sleep-disturbances associated with cardiac dysfunction</span><p id="par0025" class="elsevierStylePara elsevierViewall">The prevalence of obstructive sleep apnea in patients with impaired left ventricular ejection fraction is estimated to be about 11–53%.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> It is also known that the sleep obstructive apnea–hypoapnea syndrome can worsen a state of congestive heart failure, by causing a periodic increase in negative intrathoracic pressure, by raising arterial blood pressure, and causing tachycardia from sympathetic nervous system stimulation from hypoxia, hypercapnia and arousals.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">CPAP treatment produces a reduction in blood pressure and improves left ventricular systolic function in patients with chronic heart failure and obstructive sleep apnea.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,25</span></a> Recent studies in patients with chronic heart failure associated with obstructive sleep apnea have shown a further improvement in cardiac function in patients treated with bilevel positive airway pressure ventilation (BIPAP).<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> This may be due to the lower respiratory muscle work due to BIPAP. Moreover, reduced work of breathing, a lower positive intrathoracic pressure gives a greater ejection fraction.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Central sleep apnea (CSA) is associated with periodic breathing. Periodic breathing, Cheyne-Stokes respiration, is a particular variety of central sleep apnea which is frequently associated with congestive heart failure.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> CSA with its characteristic desaturation (apnea-related) and sympathetic hyperactivity tends to worsen the prognosis of heart failure. CSA is characterized by cessation of respiratory drive during sleep, which causes impaired gas exchange.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Unlike the OSA in which there is a respiratory effort to overcome the resistance of the upper airway, CSA is characterized by the absence of respiratory movement due to the cessation of ventilation. In the heart failure patients, the onset of apnea occurs through a redistribution of blood volume from the lower limbs to pulmonary circulation that is primarily triggered by the supine position.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,29</span></a> Stimulation of pulmonary vagal receptors causes hyperventilation which results in hypocapnia. When the value decreases below the hypocapnic apnoeic threshold, stimulation of the bulbar center ceases, inspiratory drive stops, and apnea occurs. In patients with chronic heart failure, the prolonged circulation time due to the reduction in cardiac output leads to a delay of feedback between chemoreceptors and bulbar centers resulting in hyperventilation and respiratory instability.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The main risk factors for CSA are male sex, hypocapnia, atrial fibrillation and advanced age. CPAP and BIPAP are often unable to correct this category of apneas; therefore, a servo-assisted mode (ASV or adaptive servo ventilation) is recommended.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,31</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The ASV device determinate automatically the extent of ventilatory support based on a continuous analysis of the breathing pattern and in more advanced machines also the expiratory pressure adjustment.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,24</span></a> Some studies have shown it to be most effective in controlling this type of apnea;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> it remains unclear whether ASV increases survival in these patients.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33,34</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Obesity-hypoventilation syndrome</span><p id="par0040" class="elsevierStylePara elsevierViewall">Obesity hypoventilation refers to a syndrome including daytime hypercapnia (PCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mmHg) in obese people in which no other cause of hypoventilation is present.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Its prevalence among patients with obstructive sleep apnea is 20–30% and is greater in extremely obese patients (BMI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>40).<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36,37</span></a> Approximately 10% of patients with obesity-hypoventilation syndrome do not have obstructive sleep apnea syndrome. Additionally, nocturnal hypoxemia and diurnal hypercapnia persist in about 40% of these patients after the treatment when CPAP eliminated apnea.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a> Other factors contribute to the development of obesity-hypoventilation syndrome associated with the persistence of daytime hypercapnia: these include body mass index and apnea–hypoapnea index, mean overnight oxygen saturation, and the severity of restrictive ventilatory syndrome.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> CPAP treatment is most effective when there are certain predictive values: better spirometry results, and a higher apnea–hypoapnea index. BIPAP therapy may be useful in those patients for whom CPAP has failed or given unsatisfactory results. Titration of non-invasive ventilation pressure should follow the recommendations of pressure titration in obstructive sleep apnea with the goal of eliminating (hypo)apneas, snoring, respiratory effort-related arousals and lowering pCO<span class="elsevierStyleInf">2</span> levels to at least daytime values.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> No recommendations exist regarding the ventilation mode to favor in OHS.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Trials exist providing evidence that a high backup respiratory rate leads to superior night-time control of respiratory events.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,41</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The average volume-assured pressure support ventilation seems to be able to lower pCO<span class="elsevierStyleInf">2</span>, but data regarding effect on oxygenation and long-term outcome are conflicting.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42–45</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Neuromuscular and chest wall disorders</span><p id="par0050" class="elsevierStylePara elsevierViewall">NIV has been used in patients with progressive neuromuscular disease or serious abnormalities of the thoracic cage, with recognized benefits, which include an improved survival rate and an improved quality of life. The benefits of NIV in this type of patient includes improvements of daytime levels of blood gas (including hypercapnia), a reduction in the oxygen cost of breathing, an increase in the ventilatory response to increased carbon dioxide, and improved lung compliance.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Chronic obstructive pulmonary disease and sleep apnea (overlap syndrome)</span><p id="par0055" class="elsevierStylePara elsevierViewall">COPD is a challenging and ever increasing chronic pulmonary disease, affecting health care systems worldwide. It is projected to be fourth leading cause of mortality by 2030. COPD severely impacts quality of life.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> In severe COPD acute exacerbations often lead to acute hypoxemic and/or hypercapnic respiratory failure, resulting in further disease progression and possible chronic respiratory failure.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">NIV is considered first-line treatment in acute exacerbations of COPD requiring ventilatory support,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> but recommendations regarding establishment of domiciliary long-term non-invasive ventilation in chronic hypercapnic failure due to COPD are conflicting.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Sleep-disordered breathing (mainly obstructive sleep apnea) and chronic obstructive pulmonary disease (COPD) are the most common lung diseases: a large number of patients have both disorders, hence the term “overlap syndrome.”<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51,52</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The COPD overlap syndrome was first described by Flenley in 1985 as a combination of COPD and obstructive apnea–hypoapnea syndrome.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Epidemiological studies have not shown a consistently higher incidence of sleep apnea–hypoapnea syndrome in patients with COPD compared to common OSA.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Nevertheless, the coexistence of these conditions can lead to severe episodes of desaturation during sleep (particularly during rapid eye moviment – REM-sleep),<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> thus increasing the risk of hypoxemia, daytime hypercapnia and pulmonary hypertension.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> This results in a substantially greater morbidity and mortality, compared to those with COPD or OSA alone as well as more hospitalizations and higher mortality. Many questions remain about the definition of the disease, the prognosis and the optimal treatment which currently consists of CPAP and oxygen. Non-invasive ventilation may be useful in patients with overlap syndrome, but there are no controlled studies.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56,57</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical criteria for starting non-invasive ventilation</span><p id="par0070" class="elsevierStylePara elsevierViewall">The presence of symptoms and physiological markers of hypoventilation are useful in identifying the clinical severity; moreover, these factors relate to therapeutic decision-making, especially initiating nocturnal non-invasive ventilation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In a typical “progressive disease” two consecutive steps occur:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(1)</span><p id="par0075" class="elsevierStylePara elsevierViewall">Initial phase of nocturnal hypoventilation reversible during waking hours, associated with few or no clinical symptoms.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(2)</span><p id="par0080" class="elsevierStylePara elsevierViewall">Nocturnal and daylight hypoventilation associated with clinical symptoms (see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) which shows a reduced respiratory reserve.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Continuous sleep monitoring of pCO<span class="elsevierStyleInf">2</span> and O<span class="elsevierStyleInf">2</span> saturation values is necessary to document the presence of nocturnal hypoventilation which may be present in all the stages of sleep (in some cases only during REM sleep). Daytime hypoventilation is defined by reduced values of arterial oxygen tension (PaO<span class="elsevierStyleInf">2</span> <55<span class="elsevierStyleHsp" style=""></span>mmHg), high levels of arterial carbon dioxide tension (PaCO<span class="elsevierStyleInf">2</span> 46–50<span class="elsevierStyleHsp" style=""></span>mmHg) and/or high serum bicarbonate levels with a relatively normal pH. Chronic daytime hypoventilation is an important indicator always associated with nocturnal hypoventilation (PaCO<span class="elsevierStyleInf">2</span> ≥55<span class="elsevierStyleHsp" style=""></span>mmHg or a rise in PtcCO<span class="elsevierStyleInf">2</span> to ≥10<span class="elsevierStyleHsp" style=""></span>mmHg).<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> In the presence of daytime hypoventilation, polysomnography is recommended to exclude sleep apnea.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Clinical symptoms, although modest, should be evaluated carefully, because they are very important determining disease severity and prognosis as well defining the need for NIV. Pulmonary function tests may be helpful in defining the reduction of lung function, but they have a low predictive value for patients with sleep-related hypoventilation.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,52</span></a> However, in patients with neuromuscular disease, there is a good correlation between lung function and nocturnal hypoventilation: it has been shown that hypoventilation during REM only or during all sleep stages or in the daytime, appears respectively with supine inspiratory vital capacities of less than 40%, 25% or 12% of predicted values.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,58</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Types of NIV and their use</span><p id="par0090" class="elsevierStylePara elsevierViewall">We now consider the main types of ventilation used to treat sleep-disordered breathing and respiratory conditions associated with hypoventilation and hypercapnia.</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">CPAP (continuous positive airway pressure)</span><p id="par0095" class="elsevierStylePara elsevierViewall">CPAP is currently the most widely used mode of NIV in the treatment of obstructive sleep-disordered breathing<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> and acute hypoxemic failure associated with chronic heart failure.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59,60</span></a> It consists in the application of a constant level of positive pressure during spontaneous breathing. However, it has to be noted that CPAP should be only applied in sufficiently spontaneous breathing patients. It is not considered as a mode of mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> The mechanism of action of CPAP includes a series of actions on pathophysiological mechanisms:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(a)</span><p id="par0100" class="elsevierStylePara elsevierViewall">It prevents intermittent narrowing and collapse of the airways in patients with obstructive sleep apnea–hypoapnea syndrome (by acting a virtual splint during sleep).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(b)</span><p id="par0105" class="elsevierStylePara elsevierViewall">It counteracts auto-positive end-expiratory pressure, which reduces respiratory muscles load, the work of breathing and daytime PaCO<span class="elsevierStyleInf">2</span> in patients with overlap syndrome.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">(c)</span><p id="par0110" class="elsevierStylePara elsevierViewall">It improves lung function, particularly the functional residual capacity, daytime gas exchange in patients with obstructive sleep apnea–hypoapnea syndrome.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">(d)</span><p id="par0115" class="elsevierStylePara elsevierViewall">It improves systolic function of the left ventricle in patients with heart failure coexisting with obstructive sleep apnea–hypoapnea syndrome.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Auto-CPAP (automatic adjustment of continuous positive airway pressure)</span><p id="par0120" class="elsevierStylePara elsevierViewall">Auto-CPAP (APAP) is delivered via a self-titrating CPAP device, which uses algorithms to detect variations in the degree of obstruction and adjusts the pressure level to restore normal breathing. Auto-CPAP compensates for factors that modify the upper airway collapsibility, such as body position during sleep, stage of sleep, use of alcohol, and drugs that affect upper airway muscle tone.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The auto-CPAP can be used during polysomnography or cardiorespiratory monitoring to titrate a single pressure value to be used later with fixed CPAP for treatment of OSA in patients without comorbid conditions (chronic heart failure, COPD, central apnea syndrome or hypoventilation). The use of auto-CPAP is reserved only for those patients with sleep apnea syndrome only present during REM or respiratory events related to position, in whom constraining positional maneuvers are poorly tolerated.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Adaptive servo-ventilation (ASV)</span><p id="par0125" class="elsevierStylePara elsevierViewall">The adaptive servo-ventilation (ASV) has been developed for the treatment of Cheyne-Stokes respiration-central apnea syndrome in patients with chronic heart failure who have a breathing pattern characterized by periods of crescendo–decrescendo change in tidal volume. This more complex device can use patient expiratory positive airway pressure (EPAP) level sufficient to control the obstructive apnea. The device then automatically adjusts the inspiratory pressure support for each inspiration within a pre-specified range, to maintain a moving-target ventilation set at 90% of the patient's recent average ventilation. The aim is the stabilization of breathing patterns and to reduce the respiratory alkalosis which can trigger apnea re-entry cycles.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,30,63,64</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">BIPAP (bilevel positive airway pressure)</span><p id="par0130" class="elsevierStylePara elsevierViewall">Bilevel positive airway pressure (BIPAP) is also used for sleep-related disorders, but its main indication is in pathological conditions associated with hypoventilation. The BIPAP devices deliver a higher pressure during inspiration (IPAP – inspiratory positive airway pressure) and a lower pressure during expiration (EPAP – expiratory positive airway pressure). The gradient between IPAP and EPAP (pressure support ventilation) is crucial in maintaining adequate alveolar ventilation and reducing paCO<span class="elsevierStyleInf">2</span>.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The IPAP acts also in reducing the work of breathing and fatigue, reducing the workload of respiratory muscles; EPAP has the function of maintaining the patency of the upper airway, to control obstructive apnea and to improve the functional residual capacity.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,65</span></a> BIPAP is now proposed for the type of patients who require high expiratory pressures to control obstructive sleep apnea–hypoapnea, but who cannot tolerate exhaling against a high-fixed CPAP pressure.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Other indications of BIPAP are the treatment of coexisting central apnea or hypoventilation, the obesity-hypoventilation syndrome, the overlap syndrome and neuromuscular disorders. Although the patient should be able to maintain spontaneous breathing, it is used to set a back-up rate option for those patients whose ventilation during sleep may be particularly impaired (neuromuscular disorders, complex sleep apnea, central apnea in chronic heart failure, obesity-hypoventilation syndrome).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,65</span></a> Recently a new device has been introduced: an auto-adjusting bi-level positive airway pressure (auto-BIPAP) to provide greater flexibility in pressure changes for bi-level therapy. This treatment results in AHI (apnea–hypoapnea index) reduction equivalent to that provided by a conventional BIPAP.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Average volume-assured pressure support ventilation (AVAPS)</span><p id="par0135" class="elsevierStylePara elsevierViewall">Average volume-assured pressure support ventilation (AVAPS) is used in patients with chronic hypoventilation and in particular with obesity hypoventilation syndrome,<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> neuromuscular diseases, and sometimes, in chronic obstructive pulmonary disease. In this mode a target tidal volume is set; the device adjusts the pressure support which to reach the selected tidal volume. It guarantees a delivered tidal volume adjusted despite variability in the patient effort, airway resistance, and lung or chest wall compliance. A particular benefit of this mode is that it may be modified as the disease progresses (as it occurs in neuromuscular disorders such as amyotrophic lateral sclerosis).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Yet, this system remains controversial. It is not known if and to what extent hybrid ventilation modes (i.e. pressure-targeted ventilation with assured volume support) are beneficial in the management of chronic hypercapnic failure. Further large-scaled studies are needed.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The various types of non-invasive positive pressure ventilation and their indications for the non-invasive ventilation for the various disorders are shown in <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Application and management of NIV</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Nocturnal CPAP titration</span><p id="par0145" class="elsevierStylePara elsevierViewall">The titration of the therapeutic value of CPAP (value of positive pressure necessary to eliminate the sleep apnea) can be made with one of the following methods:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">(1)</span><p id="par0150" class="elsevierStylePara elsevierViewall">Sleep study with complete laboratory staff dedicated to monitoring and manual CPAP titration performed during polysomnography (the pressure is gradually increased to normalize the breathing pattern during sleep).<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">(2)</span><p id="par0155" class="elsevierStylePara elsevierViewall">Complete polysomnographic study (with or without the continued presence of dedicated staff) with titration performed with auto-CPAP (usually the value of the 90th percentile).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">(3)</span><p id="par0160" class="elsevierStylePara elsevierViewall">Polysomnographic full study or complete cardiorespiratory monitoring performed during nocturnal CPAP therapy whose value has been obtained on the basis of data extracted from the device auto-CPAP in the previous nocturnal recording (usually the value of the 90th percentile).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">(4)</span><p id="par0165" class="elsevierStylePara elsevierViewall">Sleep study with complete laboratory staff dedicated to monitoring and titration of CPAP polysomnography performed in the course of using the split-night in which the patient is evaluated for 50% of the night in spontaneously breathing and the other 50% in incremental CPAP.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,69,70</span></a></p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">Titration of PAP obtained by auto-CPAP therapy should be derived from visual analysis of a large recording period free of artifacts. The optimum pressure value of CPAP is the value which eliminates (in the course of a complete polysomnographic investigation) each apnea, hypoapnea, arterial desaturation, snoring, respiratory effort-related arousal (RERA) in each stage of sleep and body position. The same applies in the course of a complete cardiorespiratory monitoring.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> An acceptable level of CPAP leads to a low number of events residues during the titration procedures. The final value of pressure (PAP) is always a compromise between the function of patient adherence, the absolute value of PAP reached, and the clinical benefits derived.</p><p id="par0175" class="elsevierStylePara elsevierViewall">It is also recommended that the procedures for titration of CPAP in points 2, 3 and 4 are made exclusively in patients with OSA in the absence of comorbidities such as COPD, chronic heart failure, and neuromuscular disorders.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,69–71</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Management of non-invasive ventilation</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Initiation and settings in case of nocturnal ventilation</span><p id="par0180" class="elsevierStylePara elsevierViewall">The main objective of NIV use is the correction of blood gas values to near “normal” with the least possible discomfort or sleep disturbance. It is good practice to proceed in three successive steps.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The first step is to choose and adjust the ventilator settings while the patient is awake, assuring physiological adequacy and patient comfort for at least 1 or 2<span class="elsevierStyleHsp" style=""></span>h. In the second step the clinician should evaluate the adequacy of the settings when sleeping during a nap and a night's sleep. Different options, according to the resources available in each center, are used. A full polysomnography recording oxygen saturation (SpO<span class="elsevierStyleInf">2</span>) and trans-cutaneous pCO<span class="elsevierStyleInf">2</span> (PtcCO<span class="elsevierStyleInf">2</span>) or end-tidal (PetCO<span class="elsevierStyleInf">2</span>), flow, tidal volume, airway pressure, rib cage and abdomen excursion and sleep-staging allows a complete assessment.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,52</span></a> When the resources are not available fewer parameters may be used. The minimum required is recording SpO<span class="elsevierStyleInf">2</span> on room air, assessing that the normalization of SpO<span class="elsevierStyleInf">2</span> accompanies the normalization, or at least the improvement in PaCO<span class="elsevierStyleInf">2.</span></p><p id="par0185" class="elsevierStylePara elsevierViewall">The second step relates to patient tolerance, comfort, changes in sleep quality and well-being; these data should be obtained. The third step consists of looking for reduction in PaCO<span class="elsevierStyleInf">2</span> and augmentation of PaO<span class="elsevierStyleInf">2</span> without dyspnea during the day in free ventilation after several nights of NIV. This is done to confirm that the settings are adequate for the patient's needs.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,71</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The main purpose for the application of NIV is the correction of hypercapnia to physiological levels.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Lately, a technique called “high-intensity NIV” has emerged, applying inspiratory pressure levels up to 28<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and high back-up respiratory rates in order to achieve pCO<span class="elsevierStyleInf">2</span> control in stable hypercapnic COPD patients.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> This approach has been physiologically proven to reduce inspiratory effort, when compared to conventional ventilation strategies.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> Furthermore, high-intensity NIV does not negatively influence sleep quality,<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> and improves blood gases, lung function, hematocrit, and decrease COPD exacerbations rates.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> However, it remains controversial what impact the setting of the breathing frequency has on ventilation quality in COPD.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">If the results are not satisfactory, changes must be made to the settings. One may also change the type of mask and ventilator. At the beginning a starting level of pressure support of 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O is recommended. Continuing the adaptation, the pressure level can progressively be increased to achieve evidence of improvement. Pressure support higher than 20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O is rarely necessary.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A back-up frequency set close to the spontaneous frequency of the patient during sleep is a reasonable step.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> When employing a volume-preset ventilator, the initial suggested setting may be established by adjusting the frequency of ventilator-delivered breaths so that it approximates the patient's spontaneous breathing frequency during sleep, an inspiratory time/total breathing time between 0.33 and 0.5 and a relatively high tidal volume of around 10–15<span class="elsevierStyleHsp" style=""></span>ml/kg to insure sufficient tidal volume in case of leaks.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,71</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Supplemental oxygen (O<span class="elsevierStyleInf">2</span>) will be added to the ventilator circuit, especially in those patients who require oxygen during the daytime (COPD, cystic fibrosis, bronchiectasis). However, oxygen delivery varies greatly with the tubing system used (active valve port, leak port circuit). Furthermore, optimal mask fitting must be titrated in a clinical setting.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> In the absence of obstructive pulmonary disease, the addition of O<span class="elsevierStyleInf">2</span> to the ventilation circuit may be justified only to maintain an acceptable level of PaO<span class="elsevierStyleInf">2</span> during sleep and only after all the parameters have been optimized.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">The choice of the mask</span><p id="par0205" class="elsevierStylePara elsevierViewall">The interface is of paramount importance for adherence to NIV therapy. The choice of this device should be done with special care to meet patient's needs. Considering the type of treatment planned and favoring masks which deliver positive pressure through both the nose and the mouth (if the patient is a mouth breather) is of great importance.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> Every effort should be made to minimize air leaks, maximize patient comfort and optimize patient–ventilator interaction.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> Technological issue to consider when choosing the NIV interface include the site and type of exhalation port, and how the ventilator algorithm functions with different masks. Heating and humidification may be needed to prevent adverse effects from cool dry gas.<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80,81</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Continuous NIV</span><p id="par0210" class="elsevierStylePara elsevierViewall">In patients with neuromuscular disorders (to a lesser degree in end-stage stage lung disease), ventilatory dependency can be total at the starting of non-invasive ventilation or may gradually increase following the progressive worsening of the disease. In case of continuous need for assisted ventilation, non-invasive ventilation may be started and maintained with modifications of the mode of ventilation (e.g. changing ventilation mode between day and night and/or alternating various interface types: nasal, oral, oronasal, mouth-piece) and associated, where possible, with assisted coughing.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,82</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Follow-up</span><p id="par0215" class="elsevierStylePara elsevierViewall">Clinical follow-up and daytime arterial blood gases should be performed at least twice a year.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The recordings during sleep (possibly identical to those performed for the adaptation to non-invasive ventilation), are useful. At any time, when there are indications of unsatisfactory results such as the recurrence of clinical symptoms and/or signs of hypoventilation on arterial blood gases, inadequate non-invasive ventilation should be suspected, and a complete objective assessment of ventilation during sleep with polysomnography must be undertaken.</p><p id="par0220" class="elsevierStylePara elsevierViewall">When the NIV is not proven to be optimal, a change of ventilation modality and/or parameters of the ventilator and/or a revision of the interface may be indicated. In case of disease progression one should be considered increasing the duration of ventilation during the day. The interfaces need to be regularly checked and modified or adapted to changing needs of the patient.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,69,71</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Management of complications</span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Air leaks during ventilation</span><p id="par0225" class="elsevierStylePara elsevierViewall">The major potential adverse effect is the loss of effectiveness of the ventilation and therefore the potential fragmentation of sleep. A variety of more or less effective measures have been suggested to tackle the problem of leaks during NIV. These include the prevention of neck flexion, the semi-recumbent positioning of the patient, the use of a chin rest or a cervical collar to prevent opening of the mouth, switching to controlled pressure mode, decreasing the peak inspiratory pressure and increasing the delivered volume, optimizing the interface (using full face masks if possible). The effectiveness of each of these measures must be confirmed during sleep recording.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Nasal dryness, congestion</span><p id="par0230" class="elsevierStylePara elsevierViewall">As shown in the CPAP literature, the side effects of nasal dryness, congestion, and rhinitis are related to a defect of humidification. For the patients with nasal and mouth dryness, a cold pass over or a heated humidifier can be used.<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84,85</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Aerophagia</span><p id="par0235" class="elsevierStylePara elsevierViewall">Aerophagia (swallowing air) is frequently reported but is rarely intolerable. Minor clinical signs are eructation, flatulence and abdominal discomfort. Aerophagia usually depends on the level of inspiratory pressure and is more common when using a volume-controlled ventilation, especially with mouthpiece, in patients with neuromuscular disorders. The incidence decreases if the peak inspiratory pressure is maintained below 25<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O pressure.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,85</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The management of the most important complications and side effects is reported in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0245" class="elsevierStylePara elsevierViewall">Optimizing patient acceptance and adherence to non-invasive ventilation treatment is challenging and can be influenced by several factors (i.e. age, outcome expectations, leakages, and measured efficacy).<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">86,87</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Sleep-related disorders are life-threatening conditions. The optimal level of treatment should be determined in a sleep laboratory. Side effects directly affecting the patient's adherence to treatment are known. The most common are discomfort wearing the mask and leakages followed by nasopharyngeal symptoms including increased congestion and rhinorrea; these effects are related to reduced humidity of inspired gas.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Humidification of delivered gas may improve these symptoms. Sleep specialists should review the results of objective testing with the patient. Education of the patient is mandatory.</p><p id="par0260" class="elsevierStylePara elsevierViewall">The choice of ventilator, its setting, the choice of interface between patient and ventilator are crucial for the success of NIV. A variety of masks are now available and manufacturers continue to improve mask design. Oronasal mask should be considered if the patient is mouth breather to avoid leaks through open mouth. In the past there were ventilators which had only pressure or volume controlled modes. Today most ventilators can work in either mode and the choice of the equipment should be considered by the patient's point of view. The patient's point of view is clinically relevant because better patient well-being is related to a better treatment adherence. This is a critical issue especially in patients chronically treated with non-invasive ventilation.</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Ethical disclosures</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Protection of human and animal subjects</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Confidentiality of data</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Right to privacy and informed consent</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflicts of interest</span><p id="par0280" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres390753" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec368881" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres390752" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec368882" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Clinical conditions for NIV" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Obstructive sleep apnea–hypoapnea syndrome (OSA)" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Complex sleep apnea" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Sleep-disturbances associated with cardiac dysfunction" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Obesity-hypoventilation syndrome" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Neuromuscular and chest wall disorders" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Chronic obstructive pulmonary disease and sleep apnea (overlap syndrome)" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Clinical criteria for starting non-invasive ventilation" ] 7 => array:3 [ "identificador" => "sec0050" "titulo" => "Types of NIV and their use" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "CPAP (continuous positive airway pressure)" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Auto-CPAP (automatic adjustment of continuous positive airway pressure)" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Adaptive servo-ventilation (ASV)" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "BIPAP (bilevel positive airway pressure)" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "Average volume-assured pressure support ventilation (AVAPS)" ] ] ] 8 => array:3 [ "identificador" => "sec0080" "titulo" => "Application and management of NIV" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Nocturnal CPAP titration" ] ] ] 9 => array:3 [ "identificador" => "sec0090" "titulo" => "Management of non-invasive ventilation" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Initiation and settings in case of nocturnal ventilation" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "The choice of the mask" ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "Continuous NIV" ] 3 => array:2 [ "identificador" => "sec0110" "titulo" => "Follow-up" ] 4 => array:3 [ "identificador" => "sec0115" "titulo" => "Management of complications" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0120" "titulo" => "Air leaks during ventilation" ] 1 => array:2 [ "identificador" => "sec0125" "titulo" => "Nasal dryness, congestion" ] 2 => array:2 [ "identificador" => "sec0130" "titulo" => "Aerophagia" ] ] ] ] ] 10 => array:2 [ "identificador" => "sec0135" "titulo" => "Conclusions" ] 11 => array:3 [ "identificador" => "sec0140" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0145" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0150" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0155" "titulo" => "Right to privacy and informed consent" ] ] ] 12 => array:2 [ "identificador" => "sec0160" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-16" "fechaAceptado" => "2014-03-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec368881" "palabras" => array:4 [ 0 => "Sleep-related respiratory disorders" 1 => "Non-invasive ventilation" 2 => "Continuous positive airway pressure" 3 => "Bi-level positive airway pressure" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec368882" "palabras" => array:4 [ 0 => "Distúrbios respiratórios do sono" 1 => "Ventilação não invasiva" 2 => "Pressão positiva contínua das vias aéreas" 3 => "Pressão positiva em dois níveis nas vias aéreas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Non-invasive mechanical ventilation (NIV) was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases as an alternative to intubation. Over the last thirty years NIV has been used during the night in patients with stable chronic lung diseases such as obstructive sleep apnea, the overlap syndrome (COPD and obstructive sleep apnea), neuromuscular disorders, obesity-hypoventilation syndrome and in other conditions such as sleep disorders associated with congestive heart failure.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this review we discuss the different types of NIV, the specific conditions in which they can be used as well as the indications, recommendations, and evidence supporting the efficacy of NIV.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A ventilação mecânica não invasiva (VNI) foi originalmente usada em doentes com insuficiência respiratória aguda ou em exacerbações de doença respiratória crónica, como uma alternativa à intubação. Nos últimos trinta anos, a VNI tem sido usada durante a noite, em doentes com doenças pulmonares crónicas estáveis, como a apneia obstrutiva do sono, a síndrome de sobreposição (DPOC - doença pulmonar obstrutiva crónica - e apneia obstrutiva do sono), disfunções neuromusculares, síndrome de hipoventilação e obesidade, e em outras doenças como os distúrbios do sono associados a insuficiência cardíaca congestiva.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nesta análise discutimos os diferentes tipos de VNI, as condições específicas em que cada um deles pode ser usado, assim como as indicações, recomendações e a evidência que comprova a eficácia da VNI.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Parietal disorders</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chest wall</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Kyphoscoliosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sequelae of tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Slow worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Obesity hypoventilation syndrome (OHS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Depends on obesity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neuromuscular</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Spinal muscular atrophy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Acid maltase deficit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Slow worsening (>15<span class="elsevierStyleHsp" style=""></span>y) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Duchene dystrophy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermediate worsening (5–15<span class="elsevierStyleHsp" style=""></span>y) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Myotonic myopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermediate worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Amyotrophic lateral sclerosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rapid worsening (0–3<span class="elsevierStyleHsp" style=""></span>y) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Lung diseases</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chronic obstructive pulmonary disease</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Bronchiectasis and Cystic fibrosis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Predominant ventilatory control abnormalities</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ondine's curse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cheyne-Stokes breathing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Depends on heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Upper airway abnormalities</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pierre Robin syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Obstructive sleep apnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No worsening \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab602599.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Main diseases which can benefit from NIV classified according the cause and progressiveness of the respiratory impairment.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Snoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nocturia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unrefreshing sleep \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Choking \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Daytime sleepiness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decreased libido \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morning headache \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enuresis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab602597.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Typical symptoms of OSA.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p>" ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shortness of breath during activities of daily in the absence of paralysis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orthopnea in patients with disordered diaphragmatic dysfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Poor sleep quality: insomnia, nightmares and frequent arousals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nocturnal or early morning headaches \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Daytime fatigue, drowsiness, loss of energy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decrease in intellectual performance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Appearance of recurrent complications: respiratory infections \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical signs of cor pulmonale \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab602595.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical features frequently associated with alveolar hypoventilation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p>" ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Continuous positive airway pressure (CPAP)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Applications: obstructive sleep apnea; congestive heart failure with coexisting obstructive sleep apnea; Obesity-hypoventilation syndrome with coexisting obstructive sleep apnea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Setup requirements: CPAP level \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Advantages: simple to use; relatively inexpensive \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disadvantages: minimal or no ventilation support; preset pressures may not address variability in obstructive sleep apnea or severity with sleep stages and positional stages \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">AUTO-CPAP</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Applications: obstructive sleep apnea; congestive heart failure with coexisting obstructive sleep apnea; Obesity-hypoventilation syndrome with coexisting obstructive sleep apnea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Setup requirements range of allowable CPAP levels \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Advantages: reduces number of titration studies; self-adjusting to adapt to variability in obstructive sleep apnea with sleep stages and positional changes; maybe useful for patients with ongoing weight loss such as after bariatric surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disadvantages: more expensive than fixed CPAP; may not be effective for patients with cardiopulmonary disorders or other conditions in which desaturation may be unrelated to obstructive events \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Adaptive servo-ventilation (ASV)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Applications: congestive heart failure; central sleep apnea; complex sleep apnea syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Setup requirements: maximum and minimum inspiratory pressures; end-expiratory pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Advantages: adapts pressure to maintain more consistency of respiration over time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disadvantages: more expensive than other modes; may worsen ventilation in disease with chronic ventilator insufficiency such as COPD or restrictive thoracic disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Bilevel positive airway pressure (BIPAP)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Without backup rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Applications: obstructive sleep apnea with CPAP intolerance; obstructive sleep apnea with central sleep apnea; restrictive thoracic disorders; severe chronic obstructive pulmonary disease; obesity hypoventilation syndrome with coexisting obstructive sleep apnea and residual hypoventilation despite CPAP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Setup requirements: inspiratory and expiratory positive airway pressures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advantages: promotes alveolar ventilation; unloads respiratory muscles; decreases the work of breathing; controls obstructive hypopnea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disadvantages: more expensive than CPAP; may generate central apnea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>With backup rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Applications: central sleep apnea; complex sleep apnea syndrome; worsening restrictive disorder \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Setup requirements: inspiratory and expiratory positive airway pressure; backup rate; ratio of inspiratory time to expiratory time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Advantages: provides mandatory respiratory support during central or pseudo-central apneas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disadvantages: more expensive than conventional BIPAP; may generate central apnea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Average volume-assured pressure support (AVAPS)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Applications: obesity-hypoventilation syndrome; neuromuscular disease; chronic obstructive pulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Setup requirements: target tidal volume (8<span class="elsevierStyleHsp" style=""></span>ml/kg of ideal weight); inspiratory positive airway pressure limits; respiratory rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Advantages: ensures a delivered tidal volume; compensates for diseases progression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disadvantages: more expensive than other modes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab602596.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Types of non invasive positive pressure ventilation.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,49,50,59</span></a></p>" ] ] 4 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Chronic obstructive pulmonary disease (COPD)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> ≥50<span class="elsevierStyleHsp" style=""></span>mmHg when the patient is awake and O<span class="elsevierStyleInf">2</span> saturation ≤88% (≥2<span class="elsevierStyleHsp" style=""></span>h of recording on nocturnal oximetry) while on the higher of 2<span class="elsevierStyleHsp" style=""></span>L per minute of O<span class="elsevierStyleInf">2</span> and obstructive sleep apnea and CPAP treatment have been considered and ruled out by facility-based nocturnal polysomnography. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with backup rate, anytime after use without backup rate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> ≥7<span class="elsevierStyleHsp" style=""></span>mmHg greater than the original qualifying result and O<span class="elsevierStyleInf">2</span> saturation ≤88% for ≥5<span class="elsevierStyleHsp" style=""></span>min (2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography) while on NIV without backup rate and apnea–hypopnea index <5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Restrictive thoracic disorders: progressive neuromuscular disease or thoracic cage abnormalities</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with or without backup rate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> ≥45<span class="elsevierStyleHsp" style=""></span>mmHg or O<span class="elsevierStyleInf">2</span> saturation ≤88% for %minutes (≥2<span class="elsevierStyleHsp" style=""></span>h of recording on nocturnal oximetry) or (for neuromuscular diseases only) maximal inspiratory pressure (MIP) ≤60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O or FVC ≤50% of predicted \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Central sleep apnea or complex sleep apnea syndrome</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with or without backup rate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>All the following on facility-based on nocturnal polysomnography: apnea–hypopnea index >5, central events >50% of total, central events ≥5 per hour, excessive daytime sleepiness or disrupted sleep and significant improvement on NIV and FiO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Obstructive sleep apnea</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Continuous positive airway pressure (CPAP)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Apnea–hypopnea syndrome index/respiratory disturbance index ≥15 (minimum 30 events) or apnea–hypopnea index/inspiratory disturbance index 5–14 with symptoms or cardiovascular risks (excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, history of stroke) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Above criteria and CPAP ineffective on polysomnography or at home cardio-respiratory monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Hypoventilation syndrome</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Awake PaCO<span class="elsevierStyleInf">2</span> ≥45<span class="elsevierStyleHsp" style=""></span>mmHg and PaCO<span class="elsevierStyleInf">2</span> ≥7<span class="elsevierStyleHsp" style=""></span>mmHg greater during sleep or upon awakening or O<span class="elsevierStyleInf">2</span> saturation ≤88% for ≥5<span class="elsevierStyleHsp" style=""></span>min (≥2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography) with an apnea–hypopnea index <5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with backup rate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Awake PaCO<span class="elsevierStyleInf">2</span> up ≥7<span class="elsevierStyleHsp" style=""></span>mmHg from initial qualifying PaCO<span class="elsevierStyleInf">2</span> despite using NIV without backup rate or O<span class="elsevierStyleInf">2</span> saturation ≤88% for ≥5<span class="elsevierStyleHsp" style=""></span>min (≥2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography) while on NIV without backup and apnea–hypopnea index <5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab602594.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Non-invasive ventilation indication.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,49,50,59</span></a></p>" ] ] 5 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Complication and/or side effect \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Action \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Air leaks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prevention of neck flexion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Semi-recumbent positioning \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of chin rest \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of cervical collar \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Switch to controlled pressure mode \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decrease peak inspiratory pressure and increase volume \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optimize the interfaces (using oro-nasal mask) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nasal dryness, congestion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cold pass over \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heated humidifier \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aerofagia, eructation, flatulence, abdominal discomfort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decrease peak inspiratory pressure below 25<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => 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