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• W2056315037 abstract "Endotracheal intubation as a means for delivering mechanical ventilation has been the standard of care for the treatment of acute respiratory failure since the late 1960s. However, the use of noninvasive ventilation for this disorder has assumed increasing importance as nasal continuous positive airway pressure (CPAP) devices with comfortable and efficient masks were developed for the treatment of obstructive sleep apnea, and as new modes of ventilation, such as pressure support, have evolved.The concept of noninvasive ventilation is not new, as evidenced by the long history of negative pressure devices. In the early 1960s, we began to use noninvasive intermittent positive pressure via a positive pressure ventilator with a mouthpiece or facemask for the treatment of acute respiratory failure, particularly in COPD and asthma. This method required a skillful operator to manipulate the flow rate and pressure settings to achieve comfortable and adequate ventilation. In addition, the facemask was uncomfortable, and the mouthpiece was difficult to use, because patients frequently failed to maintain a tight seal. Unfortunately, pulmonologists used the modality indiscriminately, without specific controlled clinical studies to define the patient population for whom it could be beneficial. This lack of scientific information regarding the use of noninvasive ventilation resulted in its falling into disuse as the new era of endotracheal intubation and invasive ventilation ensued. Recently, the concept of pressure support and the technology to deliver this mode of ventilation via facemask have enabled us to have a much more comfortable and physiologically correct method of improving ventilation.In the late 1950s and early 1960s, oxygen could be administered via a tight fitting aviator facemask, which also had an expiratory retard device. We used this expiratory retard device in treating pulmonary edema with severe tachypnea. We now understand why it seemed to help when we consider the possibility of auto-positive end-expiratory pressure (PEEP) in such a patient. However, further development of these emerging concepts was abandoned as we all jumped on the endotracheal tube and invasive ventilation bandwagon. With the development of PEEP and the advent of CPAP, and subsequently the addition of bilevel positive airway pressure (BiPAP; Respironics Inc; Murrysville, Pa), we have moved on to another method of noninvasive ventilation.These developments led to a resurgence of interest in noninvasive ventilation, which had been used primarily to treat respiratory failure associated with neuromuscular diseases. Since that time, numerous authors1Brochard L. Isabey D. Piquet J. et al.Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask.N Engl J Med. 1990; 323: 1523-1530Crossref PubMed Scopus (564) Google Scholar, 2Bott J. Carroll M.P. Conway J.H. et al.Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease.Lancet. 1993; 341: 1555-1557Abstract PubMed Scopus (784) Google Scholar, 3Brochard L. Mancebo J. Wysocki M. et al.Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease.N Engl J Med. 1995; 333: 817-822Crossref PubMed Scopus (1700) Google Scholar have demonstrated its efficacy in alleviating the symptoms of breathlessness, normalizing arterial blood gases, reducing the length of hospital stay and the need for endotracheal intubation, and decreasing the hospital mortality rate in COPD. Similarly, its use as an adjunct in the treatment1Brochard L. Isabey D. Piquet J. et al.Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask.N Engl J Med. 1990; 323: 1523-1530Crossref PubMed Scopus (564) Google Scholar, 2Bott J. Carroll M.P. Conway J.H. et al.Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease.Lancet. 1993; 341: 1555-1557Abstract PubMed Scopus (784) Google Scholar, 3Brochard L. Mancebo J. Wysocki M. et al.Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease.N Engl J Med. 1995; 333: 817-822Crossref PubMed Scopus (1700) Google Scholar of pulmonary edema and chronic congestive heart failure has been confirmed.4Baratz D. Westbrook P. Shah P.K. et al.Effect of nasal continuous positive airway pressure on cardiac output and oxygen delivery in patients with congestive heart failure.Chest. 1992; 102: 1397-1401Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar We have found it to be particularly useful in patients with systolic dysfunction and low left ventricular ejection fractions, in whom it appears to improve performance by decreasing afterload (Thong H, DiBenedetto R, Nguyen AV; unpublished data; Savannah, Ga; 1995). Also, the use of noninvasive ventilation in acute respiratory failure, excluding COPD and heart failure, is receiving considerable attention.5Wysocki M. Tric L. Wolff M.A. et al.Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy.Chest. 1995; 107: 761-768Abstract Full Text Full Text PDF PubMed Scopus (344) Google ScholarIn addition, Meduri et al6Meduri G.U. Cook T.R. Turner R.E. et al.Noninvasive positive pressure ventilation in status asthmaticus.Chest. 1996; 110: 767-774Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar have recently reported that this modality is probably beneficial in status asthmaticus with respiratory failure. The state-of-the-art noninvasive ventilation in this group of patients reported by Meduri et al6Meduri G.U. Cook T.R. Turner R.E. et al.Noninvasive positive pressure ventilation in status asthmaticus.Chest. 1996; 110: 767-774Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar consists of a facemask, pressure support ventilation, and low-level PEEP. In 1972, Sheehy et al7Sheehy A.F. DiBenedetto R.J. Lefrak S. et al.Treatment of status asthmaticus: a report of 70 episodes.Arch Intern Med. 1972; 130: 37-42Crossref PubMed Scopus (22) Google Scholar suggested a similar approach for the inspiratory portion of noninvasive ventilation using an intermittent positive pressure ventilator via mouthpiece or facemask. Although it is certainly true that pressure support ventilation and intermittent positive pressure ventilation differ in the mechanics of ventilatory physiology, the basic concept of noninvasive ventilation in asthma was suggested many years ago, but it was also abandoned with the advent of invasive ventilation.In this issue of CHEST (see page 1639) Girault and colleagues provide us with a further extension of the concept of noninvasive ventilation by pointing out, as others have, that assist control ventilation can also be effectively utilized. These authors have nicely demonstrated that both assist control and pressure support utilized in the noninvasive mode provide respiratory muscle rest and improve breathing patterns and gas exchange. Assist control ventilation produced a lower respiratory workload, but with greater respiratory discomfort than pressure support ventilation. The authors have also provided us with settings as a guide for initiating noninvasive ventilation for both modes of ventilation, which should be helpful to the clinician. Apparently, pressure support and assist control are equally effective, except for the obvious advantage of assist control in patients with an unstable respiratory effort. This study provides us with the type of data regarding work of breathing and other variables that are required to make intelligent decisions about the use of both modes of noninvasive ventilation. We need similar controlled studies comparing BiPAP with these other modes in order for the clinician to select the optimal form of such therapy.Finally, we should be increasingly cautious as we rely more heavily on noninvasive ventilation. Historically, pulmonologists have been quick to become enamored with new techniques on theoretical grounds and in the absence of solid scientific physiologic and clinical studies. The noninvasive technique seems to have a major role in the treatment of neuromuscular causes of respiratory failure, acute exacerbations of COPD, cardiogenic pulmonary edema without hemodynamic instability, and possibly asthma. However, as we enter the era of managed care, it is vital that we identify patients in these categories and also those specific groups of patients with hypoxemic respiratory failure who will benefit from the noninvasive approach. Confalonieri et al8Confalonieri M. Aiolfi S. Gandola L. et al.Severe exacerbations of chronic obstructive pulmonary disease treated by BiPAP by nasal mask.Respiration. 1994; 61: 310-316Crossref PubMed Scopus (45) Google Scholar have demonstrated that an APACHE II score greater than 29 in patients with COPD is associated with a greater chance of failure with noninvasive ventilation. Wysocki et al5Wysocki M. Tric L. Wolff M.A. et al.Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy.Chest. 1995; 107: 761-768Abstract Full Text Full Text PDF PubMed Scopus (344) Google Scholar found no statistical difference between conventional therapy and noninvasive ventilation in patients with acute respiratory failure, excluding COPD. However, they did observe a significant reduction in the need for endotracheal intubation, length of ICU stay, and mortality rate in such patients with a PaCO2 greater than 45 mm Hg. This finding certainly merits further study for validation. It is this type of data, however, that will enable us to practice medicine effectively and economically as we encounter clinical practice guidelines and managed care. Let us not indiscriminately utilize this modality as we did in the 1960s, when noninvasive ventilation as we now know it was in its infancy, and let us not wait another 30 years before we move forward in the appropriate application of this exciting and very beneficial technique of therapy. Endotracheal intubation as a means for delivering mechanical ventilation has been the standard of care for the treatment of acute respiratory failure since the late 1960s. However, the use of noninvasive ventilation for this disorder has assumed increasing importance as nasal continuous positive airway pressure (CPAP) devices with comfortable and efficient masks were developed for the treatment of obstructive sleep apnea, and as new modes of ventilation, such as pressure support, have evolved. The concept of noninvasive ventilation is not new, as evidenced by the long history of negative pressure devices. In the early 1960s, we began to use noninvasive intermittent positive pressure via a positive pressure ventilator with a mouthpiece or facemask for the treatment of acute respiratory failure, particularly in COPD and asthma. This method required a skillful operator to manipulate the flow rate and pressure settings to achieve comfortable and adequate ventilation. In addition, the facemask was uncomfortable, and the mouthpiece was difficult to use, because patients frequently failed to maintain a tight seal. Unfortunately, pulmonologists used the modality indiscriminately, without specific controlled clinical studies to define the patient population for whom it could be beneficial. This lack of scientific information regarding the use of noninvasive ventilation resulted in its falling into disuse as the new era of endotracheal intubation and invasive ventilation ensued. Recently, the concept of pressure support and the technology to deliver this mode of ventilation via facemask have enabled us to have a much more comfortable and physiologically correct method of improving ventilation. In the late 1950s and early 1960s, oxygen could be administered via a tight fitting aviator facemask, which also had an expiratory retard device. We used this expiratory retard device in treating pulmonary edema with severe tachypnea. We now understand why it seemed to help when we consider the possibility of auto-positive end-expiratory pressure (PEEP) in such a patient. However, further development of these emerging concepts was abandoned as we all jumped on the endotracheal tube and invasive ventilation bandwagon. With the development of PEEP and the advent of CPAP, and subsequently the addition of bilevel positive airway pressure (BiPAP; Respironics Inc; Murrysville, Pa), we have moved on to another method of noninvasive ventilation. These developments led to a resurgence of interest in noninvasive ventilation, which had been used primarily to treat respiratory failure associated with neuromuscular diseases. Since that time, numerous authors1Brochard L. Isabey D. Piquet J. et al.Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask.N Engl J Med. 1990; 323: 1523-1530Crossref PubMed Scopus (564) Google Scholar, 2Bott J. Carroll M.P. Conway J.H. et al.Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease.Lancet. 1993; 341: 1555-1557Abstract PubMed Scopus (784) Google Scholar, 3Brochard L. Mancebo J. Wysocki M. et al.Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease.N Engl J Med. 1995; 333: 817-822Crossref PubMed Scopus (1700) Google Scholar have demonstrated its efficacy in alleviating the symptoms of breathlessness, normalizing arterial blood gases, reducing the length of hospital stay and the need for endotracheal intubation, and decreasing the hospital mortality rate in COPD. Similarly, its use as an adjunct in the treatment1Brochard L. Isabey D. Piquet J. et al.Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask.N Engl J Med. 1990; 323: 1523-1530Crossref PubMed Scopus (564) Google Scholar, 2Bott J. Carroll M.P. Conway J.H. et al.Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease.Lancet. 1993; 341: 1555-1557Abstract PubMed Scopus (784) Google Scholar, 3Brochard L. Mancebo J. Wysocki M. et al.Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease.N Engl J Med. 1995; 333: 817-822Crossref PubMed Scopus (1700) Google Scholar of pulmonary edema and chronic congestive heart failure has been confirmed.4Baratz D. Westbrook P. Shah P.K. et al.Effect of nasal continuous positive airway pressure on cardiac output and oxygen delivery in patients with congestive heart failure.Chest. 1992; 102: 1397-1401Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar We have found it to be particularly useful in patients with systolic dysfunction and low left ventricular ejection fractions, in whom it appears to improve performance by decreasing afterload (Thong H, DiBenedetto R, Nguyen AV; unpublished data; Savannah, Ga; 1995). Also, the use of noninvasive ventilation in acute respiratory failure, excluding COPD and heart failure, is receiving considerable attention.5Wysocki M. Tric L. Wolff M.A. et al.Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy.Chest. 1995; 107: 761-768Abstract Full Text Full Text PDF PubMed Scopus (344) Google Scholar In addition, Meduri et al6Meduri G.U. Cook T.R. Turner R.E. et al.Noninvasive positive pressure ventilation in status asthmaticus.Chest. 1996; 110: 767-774Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar have recently reported that this modality is probably beneficial in status asthmaticus with respiratory failure. The state-of-the-art noninvasive ventilation in this group of patients reported by Meduri et al6Meduri G.U. Cook T.R. Turner R.E. et al.Noninvasive positive pressure ventilation in status asthmaticus.Chest. 1996; 110: 767-774Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar consists of a facemask, pressure support ventilation, and low-level PEEP. In 1972, Sheehy et al7Sheehy A.F. DiBenedetto R.J. Lefrak S. et al.Treatment of status asthmaticus: a report of 70 episodes.Arch Intern Med. 1972; 130: 37-42Crossref PubMed Scopus (22) Google Scholar suggested a similar approach for the inspiratory portion of noninvasive ventilation using an intermittent positive pressure ventilator via mouthpiece or facemask. Although it is certainly true that pressure support ventilation and intermittent positive pressure ventilation differ in the mechanics of ventilatory physiology, the basic concept of noninvasive ventilation in asthma was suggested many years ago, but it was also abandoned with the advent of invasive ventilation. In this issue of CHEST (see page 1639) Girault and colleagues provide us with a further extension of the concept of noninvasive ventilation by pointing out, as others have, that assist control ventilation can also be effectively utilized. These authors have nicely demonstrated that both assist control and pressure support utilized in the noninvasive mode provide respiratory muscle rest and improve breathing patterns and gas exchange. Assist control ventilation produced a lower respiratory workload, but with greater respiratory discomfort than pressure support ventilation. The authors have also provided us with settings as a guide for initiating noninvasive ventilation for both modes of ventilation, which should be helpful to the clinician. Apparently, pressure support and assist control are equally effective, except for the obvious advantage of assist control in patients with an unstable respiratory effort. This study provides us with the type of data regarding work of breathing and other variables that are required to make intelligent decisions about the use of both modes of noninvasive ventilation. We need similar controlled studies comparing BiPAP with these other modes in order for the clinician to select the optimal form of such therapy. Finally, we should be increasingly cautious as we rely more heavily on noninvasive ventilation. Historically, pulmonologists have been quick to become enamored with new techniques on theoretical grounds and in the absence of solid scientific physiologic and clinical studies. The noninvasive technique seems to have a major role in the treatment of neuromuscular causes of respiratory failure, acute exacerbations of COPD, cardiogenic pulmonary edema without hemodynamic instability, and possibly asthma. However, as we enter the era of managed care, it is vital that we identify patients in these categories and also those specific groups of patients with hypoxemic respiratory failure who will benefit from the noninvasive approach. Confalonieri et al8Confalonieri M. Aiolfi S. Gandola L. et al.Severe exacerbations of chronic obstructive pulmonary disease treated by BiPAP by nasal mask.Respiration. 1994; 61: 310-316Crossref PubMed Scopus (45) Google Scholar have demonstrated that an APACHE II score greater than 29 in patients with COPD is associated with a greater chance of failure with noninvasive ventilation. Wysocki et al5Wysocki M. Tric L. Wolff M.A. et al.Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy.Chest. 1995; 107: 761-768Abstract Full Text Full Text PDF PubMed Scopus (344) Google Scholar found no statistical difference between conventional therapy and noninvasive ventilation in patients with acute respiratory failure, excluding COPD. However, they did observe a significant reduction in the need for endotracheal intubation, length of ICU stay, and mortality rate in such patients with a PaCO2 greater than 45 mm Hg. This finding certainly merits further study for validation. It is this type of data, however, that will enable us to practice medicine effectively and economically as we encounter clinical practice guidelines and managed care. Let us not indiscriminately utilize this modality as we did in the 1960s, when noninvasive ventilation as we now know it was in its infancy, and let us not wait another 30 years before we move forward in the appropriate application of this exciting and very beneficial technique of therapy." @default.
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