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Many patients need invasive ventilatory assistance via an endotracheal tube, but such therapy puts the patient at risk of ventilator-associated pneumonia, pneumothorax, and tracheal stenosis. With NIPPV, the patient wears a tightly fitting nasal or full facial mask, avoiding the need for an endotracheal tube, laryngeal mask, or tracheostomy (Figure 1).2 The mask can be connected to a standard mechanical ventilator or, more commonly, to a continuous positive airway pressure or bi-level airway pressure unit.
Several mechanisms may explain why noninvasive positive pressure ventilation is beneficial in acute exacerbations of COPD. Patients with decompensated respiratory failure lack sufficient alveolar ventilation, owing to abnormal respiratory mechanics and inspiratory muscle fatigue.10 For these patients, breathing faster does not fully compensate.
Several randomized trials have shown NIPPV to be beneficial in acute hypercapnic COPD exacerbations. NIPPV has been shown to be an effective adjunct in the treatment of acute hypercapnic respiratory failure secondary to a COPD exacerbation, reducing the need for endotracheal intubation, the length of hospital stay, and the mortality rate. 2 and decrease in PaCO2 and HCO3 after 1 hour of NIPPV application, which also persisted after successful weaning.
10.Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, et al Noninvaisve ventilation for acute exacerbations of chronic obstructive pulmonary disease. 31.Confalonieri M, Garuti G, Cattaruzza MS, Osborn JF, Antonelli M, Conti G, et al A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Correspondence Address:Jose Luis Lopez-CamposHospital Universitario Virgen del Rocio Avda. 1.Cabrera Lopez C, Julia Serda G, Cabrera Lacalzada C, Martin Medina A, Gullon Blanco JA, Garcia Bello MA, et al.
33.Fernandez Guerra J, Lopez-Campos Bodineau JL, Perea-Milla Lopez E, Pons Pellicer J, Rivera Irigoin R, Moreno Arrastio LF.
37.Carpe-Carpe B, Hernando-Arizaleta L, Ibanez-Perez MC, Palomar-Rodriguez JA, Esquinas-Rodriguez AM. 38.Lopez-Campos JL, Garcia Polo C, Leon Jimenez A, Arnedillo A, Gonzalez-Moya E, Fenandez Berni JJ.
55.Segrelles Calvo G, Zamora Garcia E, Giron Moreno R, Vazquez Espinosa E, Gomez Punter RM, Fernandes Vasconcelos G, et al. 56.Pozo-Rodriguez F, Lopez-Campos JL, Alvarez-Martinez CJ, Castro-Acosta A, Aguero R, Hueto J, et al. In selected patients with hypercapnic respiratory failure due to an acute exacerbation of chronic obstructive pulmonary disease (COPD), noninvasive positive pressure ventilation (NIPPV) is an effective adjunct to usual medical therapy. Noninvasive positive pressure ventilation decreases the pressure difference between the atmosphere and the alveoli, thereby reducing the inspiratory force needed for initiation of inspiratory effort, which may reduce the work of breathing. On the basis of controlled trials, NIPPV is now considered the ventilatory therapy of choice in selected patients with this condition. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure.
Early use of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Noninvasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure.
Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. Noninvasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis.
Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute respiratory failure.
Cost effectiveness of ward based noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease: economic analysis of randomised con-trolled trial.
A study of patients with type II respiratory failure put on non-invasive positive pressure ventilation. However, the use of artificial airways may lead to infectious complications and injury to the airways. Complications and consequences of endotracheal intubation and tracheotomy: A prospective study of 150 critically ill adult patients. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask.
Noninvasive face mask mechanical ventilation in patients with acute hypercapnic respiratory failure.
Non-invasive modalities of positive pressure ventilation improve the outcome of acute exacerbations in COLD patients. Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease.
Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: A multicentre randomised controlled trial. An evaluation of the role of noninvasive positive pressure ventilation in the management of acute respiratory failure in a developing country.
Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Efficacy of noninvasive pressure ventilation for the management of COPD with acute or acute on chronic respiratory failure: A randomized controlled trial.
Outcome predictors for non-invasive positive pressure ventilation in acute respiratory failure. Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure. Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: Long term survival and predictors of in-hospital outcome. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: A meta-analysis. European clinical audits have shown that 1) NIV is not invariably available, 2) its availability depends on countries and hospital sizes, and 3) numerous centers declare their inability to provide NIV to all of the eligible patients presenting throughout the year. Lights and shadows of non-invasive mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations.
Recently updated data on disease prevalence [1],[2],[3],[4] and mortality [5],[6] have shown that it is a major public health problem worldwide, causing substantial morbidity and mortality. A population-based cohort study on chronic obstructive pulmonary disease in Latin America: Methods and preliminary results.
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Continuing to Confront COPD International Patient Survey: Methods, COPD prevalence, and disease burden in 2012-2013. Underdiagnosis of chronic obstructive pulmonary disease in women: Quantification of the problem, determinants and proposed actions. Differences between physician and patient in the perception of symptoms and their severity in COPD.
Questionnaires in multidimensional assessment of chronic obstructive pulmonary disease: Two sides of the same coin. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.
Classification of chronic obstructive pulmonary disease severity according to the new global initiative for chronic obstructive lung disease 2011 guidelines: COPD assessment test versus modified medical research council scale. Distribution of clinical phenotypes in patients with chronic obstructive pulmonary disease caused by biomass and tobacco smoke.


The role of vitamin D in chronic obstructive pulmonary disease, asthma and other respiratory diseases. Prevalence of major comorbidities in subjects with COPD and incidence of myocardial infarction and stroke: A comprehensive analysis using data from primary care.
Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: A prospective, multicentre, randomised, controlled clinical trial. Noninvasive positive pressure ventilation for acute respiratory failure patients with chronic obstructive pulmonary disease (COPD): An evidence-based analysis.
Noninvasive ventilatory support does not facilitate recovery from acute respiratory failure in chronic obstructive pulmonary disease. A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure. Nasal ventilation in COPD exacerbations: Early and late results of a prospective, controlled study. Cost effectiveness of ward based non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease: Economic analysis of randomised controlled trial. Non invasive ventilation for acute exacerbation of chronic obstructive pulmonary disease: A meta-analysis. National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project implementation group. Evolution of the use of noninvasive mechanical ventilation in chronic obstructive pulmonary disease in a Spanish region, 1997-2010. Staff training influence on non-invasive ventilation outcome for acute hypercapnic respiratory failure. The utility and futility of non-invasive ventilation in non-designated areas: Can critical care outreach nurses influence practice?
Survey of non-invasive ventilation (NIPPV) in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) in the UK. Respiratory intermediate (high dependency) unit care in Europe: Models of service provision. GiViTI (Gruppo italiano per la Valutazione degli interventi in Terapia Intensiva) Group; Aipo (Associazione Italiana Pneumologi Ospedalieri) Group. Predicting survival following non-invasive ventilation for hypercapnic exacerbations of chronic obstructive pulmonary disease. Long-term survival in elderly patients with a do-not-intubate order treated with noninvasive mechanical ventilation. Non-invasive ventilation in an elderly population admitted to a respiratory monitoring unit: Causes, complications and one-year evolution. Frailty in people with COPD, using the National Health and Nutrition Evaluation Survey dataset (2003-2006).
Non-invasive mechanical ventilation in elderly patients: Moving towards a new strategy for hospital organization? Bronchoscopy during non-invasive mechanical ventilation: A review of techniques and procedures.
Non-invasive ventilation-aided transoesophageal echocardiography in high-risk patients: A pilot study. Should we follow ATLS guidelines for the management of traumatic pulmonary contusion: The role of non-invasive ventilatory support.
Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: A systematic review and meta-analysis. In controlled trials, it reduced the need for endotra-cheal intubation, the length of hospital stay, and the risk of death. However, caution should be used when using this therapy in tachypneic patients, in whom NIPPV may not fully overcome the auto-PEEP.
However, it should not be used as a substitute for intubation and mechanical ventilation if these are needed or if the patient is at risk of aspiration. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments).
Even with an established indication, the use of NIV in acute respiratory failure due to COPD exacerbations faces important challenges. Comorbidities and health status in individuals with and without COPD in five latin american cities: The PLATINO study.
European hospital adherence to GOLD recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions.
Clinical practice guideline for the use of noninvasive positive pressure ventilation in COPD patients with acute respiratory failure. Variability of hospital resources for acute care of COPD patients: The European COPD Audit. Shaheen Egyptian Journal of Chest Diseases and Tuberculosis.
Mostafa Egyptian Journal of Chest Diseases and Tuberculosis. Second, the use of NIV is not straightforward despite the availability of technologically advanced ventilators. Despite the overwhelming evidence justifying the use of non-invasive mechanical ventilatory support in COPD exacerbations, recent studies demonstrated that its application in real-life settings remains suboptimal. Third, NIV therapy of critically ill patients requires a thorough knowledge of both respiratory physiology and existing ventilatory devices.
If such treatments could be successful in reducing the requirements of invasive mechanical ventilation (IMV) in patients with respiratory failure, it could have a potentially favorable impact on the allocation of the sparse health resources to other reversible causes of respiratory failure.Three recent publications from India suggested that non-invasive positive pressure ventilation (NIPPV) was beneficial in cohorts of patients presenting with chronic obstructive pulmonary disease (COPD) as well as respiratory failure of varied etiology. Accordingly, an optimal team-training experience, the careful selection of patients, and special attention to the selection of devices are critical for optimizing NIV outcomes. Additionally, when applied, NIV should be closely monitored, and endotracheal intubation should be promptly available in the case of failure.
We attempt to provide a balanced view of the current use of NIV in COPD patients, identifying the lights and shadows of this treatment in the acute setting. The initial expiratory positive airway pressure (EPAP) was set at 4 cm H 2 O and was not altered unless clinically indicated. This patient population is particularly fragile, with several physiological and social characteristics requiring specific attention in relation to NIV.
Several other novel indications should also be critically examined, including the use of NIV during fiberoptic bronchoscopy or transesophageal echocardiography, as well as in interventional cardiology and pulmonology. Bronchodilators and corticosteroids as nebulisers and antibiotic agents were given where clinically indicated.Previous studies have suggested that clinical and oximetric improvements at 1 hour portend a favorable response.
The present narrative review aims to provide updated information on the use of NIV in acute settings to improve the clinical outcomes of patients hospitalized for COPD exacerbations. At that time, this type of ventilation was successful and it was the only such system in existence, other than positive pressure through a permanent tracheostomy, which was used in a few cases. During the weaning phase, the IPAP was decreased in gradations of 2-3 cm until the IPAP was 7-10 cm. However, negative pressure ventilation was complex and not without side effects, thus requiring a highly specialized management team.
NIV advanced in the late eighties with the advent of positive pressure non-invasive ventilation via a nasal mask to treat respiratory failure in patients with advanced neuromuscular disease, respiratory restrictive conditions, or sleep apnea.
Notably, NIV is currently considered the initial treatment of choice for acute respiratory failure. The ventilator serves as the energy source for inspiration, replacing the muscles of the diaphragm and chest wall. Despite the initial negative results, [28] subsequent trials clearly demonstrated the clinical usefulness of NIV for treating acute hypercapnic respiratory failure due to COPD. Expiration is passive, driven by the recoil of the lungs and chest wall; at the completion of inspiration, internal ventilator circuitry vents the airway to atmospheric pressure or a specified level of positive end expiratory pressure (PEEP).
The primary milestone was most likely the study by Plant et al.[29] This study included 236 patients, half of whom received standard therapy plus additional NIV.


The authors concluded that the early use of NIV for mildly and moderately acidotic COPD patients in the general ward results in a rapid improvement of physiological variables, reducing both the need for invasive mechanical ventilation and in-hospital mortality. Although the study participants were not spirometrically confirmed, the authors included patients who were admitted with a diagnosis of acute exacerbations of COPD and their results were consistent with those obtained in other trials. Clinical conditions associated with hypercarbic respiratory failure include neuromuscular diseases, such as myasthenia gravis, ascending polyradiculopathy, and myopathies, and diseases that cause respiratory muscle fatigue due to increased workload, such as asthma, chronic obstructive pulmonary disease, and restrictive lung disease. The positive nature of the pressure causes the gas to flow into the lungs until the ventilator breath is terminated.
As the airway pressure drops to zero, elastic recoil of the chest accomplishes passive exhalation by pushing the tidal volume out. In this regard, several issues remain to be addressed, including implementation of NIV, locations at which NIV should be utilized, the predictors of success, the use of NIV in elderly subjects, and novel indications for NIV in acute settings.
A clinical audit performed in the United Kingdom reported that COPD admissions treated with NIV in routine clinical practice involved severely ill patients. However, this audit raised concerns that challenged the respiratory community to develop appropriate clinical improvements. Specifically, numerous ventilated patients had mixed metabolic acidosis, some eligible subjects failed to receive NIV, whereas others received it inappropriately.
Moreover, in several cases, NIV appeared to be used as a last-ditch treatment in patients for whom its efficacy remains uncertain. The physiological effects of CPAP include augmentation of cardiac output and oxygen delivery, improved functional residual capacity, respiratory mechanics, reduced effort in breathing, [24] and decreased left ventricular afterload. In turn, 28.6% of patients who were treated with NIV did not meet the arterial blood gas criteria. It can be double-barreled or single-barreled with an expiratory valve.Interface (nasal or full face mask, nasal pillows, or less commonly a lip-seal mouthpiece) provides the connection to the user's airway. The interfaces can be removed intermittently to permit patient's meals and medications Flexible chin straps help in maintaining a closed pressure system, velcro-type adjustments allow quick sizing.
Additionally, when the investigators asked whether they had the capacity to noninvasively ventilate all of the eligible patients, 32.5% of the participating centers declared that they did not to have the resources to ventilate all of the eligible subjects presenting throughout the year. This response was independent of the size of the hospital, suggesting a similar effect across all types of centers.
In a recent investigation, the authors performed a time trend analysis of a retrospective observational study based on the minimum basic hospital discharge data aimed at evaluating the introduction of NIV in patients hospitalized for COPD at all public hospitals in the region of Murcia (Spain) between 1997 and 2010.
Additionally, by using a join point regression analysis, the authors demonstrated an upward trend in the use of NIV in the participating hospitals.
Care and maintenance Proper maintenance is essential for proper functioning, long unit life, and patient comfort. Because patients requiring NIV are critically ill, the progression of gas exchange abnormalities and the clinical conditions in the first few hours are paramount for determining the clinical outcomes after the initial acute episode. Accordingly, the use of NIV is not straightforward despite the availability of technologically advanced ventilators. In a prospective observational cohort study performed in conventional wards, a small group of consecutive patients requiring NIV due to acute hypercapnic respiratory failure were investigated. In this study, the most common caveats included: The lack of knowledge on how to operate the ventilator by the staff, An improper mask fitting leading to excessive leaks, and The inability of the personnel to control oxygen therapy or to address the ventilator alarms. Subsequently, Sumner et al.[39] demonstrated that the improper use of NIV in non-designated areas resulted in an increased patient mortality. However, it has been also argued that NIV can be safely administered in an adequately staffed and monitored ward when used to prevent intubation in otherwise stable patients. Accordingly, the debate on where to apply NIV is mainly related to the available hospital resources and the knowledge and experience of the staff rather than to the actual location of NIV use. In this regard, it would be desirable to establish a consensus document to help managers decide where to locate NIV facilities and to provide them with adequate resources. Accordingly, a substantial variability in both the availability and resources has been reported.
However, no information was available on the minimum number of hours used for training physicians to ensure proper implementation of ventilation. However, given the acute situation and the complexity of the management process (particularly in the first few hours), consensus guidelines on minimum requirements or conditions to ensure proper training are eagerly awaited.Appropriate staff training is guaranteed in ICUs. However, ICU cares are complex and expensive and are not invariably needed for all of the patients with exacerbated COPD requiring NIV. A relatively small number of patients, 10% and 6% respectively, also had fever and chest pain on presentation, which was clinically diagnosed as pneumonia.
Such so-called semi-critical, intermediate, or high-dependency units have recently emerged in industrialized countries as an alternative to ICUs, with the specific goal of providing non-invasive respiratory support without the complex environment and the costs of an ICU. The European COPD audit reported that 49.3% of European hospitals were equipped with such units.
Consequently, significant efforts have been made to identify the main predictors of successful NIV.
Specifically, it would be important to distinguish successful responders from patients requiring endotracheal intubation.
A failure is defined as early when it occurs within 1-48 h of NIV use (either with or without an initial success), whereas late failures occur 48 h after initiation of NIV, following an initial successful response.
Such variables might in turn be influenced by a patient's tolerance to NIV, which is directly related to the training and experience of the staff with this technique. Consequently, international guidelines recommend a second complete evaluation of the patient after a few hours of NIV use. In presence of NIV failure, a decision concerning intubation should be promptly made taking into account the severity of the underlying disease and the previous level of disability. This patient population is particularly fragile, with several physiological and social characteristics that require specific health care. In this population, NIV can be considered as a good alternative for treating respiratory acidosis even for those with a do-not-intubate order. However, elderly patients were more frequently re-admitted within 6-12 months after hospital discharge than the younger group.
Most explanations have involved the poorer functional states and the frailty of such patients following hospitalization. A novel indication for non-invasive mechanical ventilation is the use of NIV during invasive procedures, such as bronchoscopy. Bronchoscopy is a key technique in studying respiratory diseases, and it is necessary for acute and critical patients, often only after endotracheal intubation due to the possible complications of the technique. The use of NIV during bronchoscopy should be considered as an alternative to avoid the complications related to intubation and mechanical ventilation in patients in severe conditions, particularly in subjects with COPD with a tendency to develop hypercapnia. In these circumstances, NIV can reduce the need for deep sedation or general anesthesia and may prevent the respiratory depression that results from deep sedation. Moreover, its use can be considered in elderly patients with do-not-intubate orders and subjects who have exhausted all other treatment options. Notably, NIV may be clinically useful for improving outcomes in clinical situations other than COPD exacerbations.
Despite its efficacy, the implementation of NIV remains suboptimal, and managers should ensure the availability of trained staff and sufficient resources to guarantee its availability throughout the year.
NIV should be applied with close monitoring, and endotracheal intubation should be promptly available in cases of failure. An optimal team-training experience, the careful selection of patients, and special attention to the selection of devices are critical for optimizing NIV outcomes in critically ill patients presenting with COPD exacerbations.



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