Noninvasive Mechanical Ventilation for Post Acute Care

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Noninvasive mechanical ventilation refers to the delivery of mechanical ventilatory assistance without the need for an invasive airway. Numerous forms of noninvasive ventilation have been used over the past century, including negative-pressure ventilators, rocking beds, and pneumobelts. For reasons of enhanced convenience and effectiveness, however, noninvasive positive-pressure ventilation (NPPV) has become the predominant form of noninvasive ventilation worldwide. Both in the chronic setting to treat chronic respiratory failure caused by restrictive thoracic diseases and, more recently, in the acute setting to treat conditions such as chronic obstructive pulmonary disease (COPD) exacerbations and acute cardiogenic pulmonary edema, NPPV has gained wide acceptance. Less attention has been paid to applications in the post acute setting, but noninvasive ventilation clearly has a role to play in this setting. The following article discusses the rationale for use of noninvasive ventilation, briefly reviews applications in the acute and chronic settings, discusses appropriate applications in the post acute setting, and describes techniques of application.

Section snippets

RATIONALE FOR THE USE OF NONINVASIVE VENTILATION

Noninvasive ventilation has gained acceptance because it offers the potential of avoiding the complications of airway invasion.70, 82 These include trauma to the upper airway, hemorrhage, and esophageal or tracheal perforation that occurs during airway insertion. Subsequent complications include subcutaneous emphysema, pneumothoraces, and peritracheal abscesses. The invasive airway bypasses the normal airway defense system, promoting chronic aspiration and entry of irritants and infectious

Acute Care Setting

To anticipate which patients will use NPPV in the post acute setting, it is necessary to understand the appropriate indications for NPPV in the acute and long-term settings. Many applications of NPPV in the acute care setting have been described over the past decade.

APPLICATIONS OF NONINVASIVE POSITIVE-PRESSURE VENTILATION IN THE ACUTE SETTING

  1. Obstructive diseases

    • Chronic obstructive pulmonary disease

    • Asthma

    • Cystic fibrosis

    • Upper airway obstruction

    • Obstructive sleep apnea or obesity hypoventilation

  2. Hypoxemic respiratory failure

    • Acute respiratory

MONITORING AND ADAPTATION OF NONINVASIVE POSITIVE-PRESSURE VENTILATION IN THE POST ACUTE SETTING

Monitoring of NPPV is determined by the goals established by the clinician (Table 1). Improvements in symptoms and gas exchange are major goals of NPPV. Subjective indicators of improvement, including alleviation of respiratory distress, daytime hypersomnolence, and morning headaches, therefore should be sought. Vital signs, subjective comfort, and measures of gas exchange are other key variables to monitor. As an objective correlate of respiratory distress, respiratory rate almost invariably

ADVERSE EFFECTS AND COMPLICATIONS OF NONINVASIVE VENTILATION

In properly selected patients, adverse effects and complications of noninvasive ventilation are generally not life threatening and can be ameliorated by appropriate measures (Table 2). Most are mask-related, result from excessive air pressure or flow, or derive from problems with patient–ventilator interaction or airway secretion management.

SUMMARY

The increasing use of NPPV in both acute and chronic settings has added to ventilator options in the post acute setting. Some patients start NPPV during their acute presentation and continue use during their post acute stay. Others are difficult to wean from invasive mechanical ventilation, and, if selected carefully, can be extubated and weaned using NPPV. Still others may initiate NPPV in the post acute setting with the anticipation of long-term use. In any care settings, principles of

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      Citation Excerpt :

      However, this may not be borne out as most of the studies did not report on exact ventilator settings during NIV. Of course, the underlying cause of acute respiratory failure needs to be considered when planning the weaning process with NIV.33 An underlying obstructive or restrictive disease such as COPD or a neuromuscular respiratory failure require completely different NIV settings.

    Address reprint requests to Nicholas Hill, MD, Division of Pulmonary and Critical Care Medicine, Rhode Island Hospital, APC 475, 543 Eddy Street, Providence, RI 02903, e-mail: [email protected]

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    Division of Pulmonary and Critical Care Medicine, Rhode Island Hospital, Providence, Rhode Island

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