Correspondence
Noninvasive Ventilation
N Engl J Med 1998; 338:1388-1389May 7, 1998
- Article
To the Editor:
We are concerned about the implication in Hillberg and Johnson's review of noninvasive ventilation (Dec. 11 issue)1 that noninvasive pressure-cycled ventilation is more comfortable than volume-cycled ventilation and more desirable for patients with chronic respiratory failure. On the contrary, with bilevel positive airway pressure, the increased flows that compensate for leaks often cause patients to gag and can disrupt sleep. Indeed, when portable volume ventilators first became available, in 1978, many patients were switched from portable pressure to volume-cycled ventilators for reasons that included the comfort provided by the smoother flows and adjustable flow rates of the volume-cycled devices. In a recent review of the literature on noninvasive ventilation in patients with neuromuscular insufficiency, 15 of the 20 studies used volume-cycled ventilators.2 These ventilators have been used in many patients for long-term noninvasive ventilatory support.3
Hillberg and Johnson also mention that noninvasive pressure-support ventilation can be used to acclimate patients to the device for use during future emergencies. Although this is true, in the case of neuromuscular disorders, the emergencies are most often those due to mucus plugging during intercurrent respiratory tract infections.4 During these episodes, bilevel positive-airway-pressure machines cannot provide the deep insufflations needed for effective coughing. We believe that the more powerful volume-cycled ventilators are indicated for home mechanical ventilation in patients with neuromuscular disorders.
Portable volume-cycled ventilators have additional advantages. They can provide ventilation in patients with poor compliance; they use three to eight times less electricity for the same battery capacity, permitting longer periods of mobility for patients; they are quieter; they do not require expiratory positive airway pressure (to prevent rebreathing), resulting in lower mean thoracic pressures; and they can be used to operate abdominal exsufflation belts to ventilate the lungs.2 Acceptance by patients often follows the appropriate choice of ventilation, which is dictated by the clinical circumstances.
4 ReferencesVis Niranjan, M.D.
John Bach, M.D.
New Jersey Medical School, Newark, NJ 071031
Hillberg RE ,Johnson DC . Noninvasive ventilation. N Engl J Med 1997;337:1746-1752
Full Text | Web of Science | Medline2
Bach JR. Conventional approaches to managing neuromuscular ventilatory failure. In: Bach JR, ed. Pulmonary rehabilitation: the obstructive and paralytic conditions. Philadelphia: Hanley & Belfus, 1995:285-301.
3
Bach JR ,Alba AS ,Saporito LR . Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users. Chest 1993;103:174-182
CrossRef | Web of Science | Medline4
Bach JR ,Ishikawa Y ,Kim H . Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. Chest 1997;112:1024-1028
CrossRef | Web of Science | Medline
To the Editor:
We agree with Hillberg and Johnson that noninvasive ventilation has an established role in the care of patients with neuromuscular and rib-cage diseases, but its potential indications and benefits in patients with other disorders are much less well defined. In patients with stable chronic obstructive pulmonary disease (COPD), the long-term effects of noninvasive ventilation on the quality of life and prognosis have not been established.1 As Hillberg and Johnson mention, a prospective, randomized study found improvements in arterial-blood gases and in the quality of life in such patients after two months of noninvasive ventilation. However, this short period of time does not allow one to extrapolate the potential long-term effects of noninvasive ventilation in these patients.1 More important, Hillberg and Johnson do not mention that another prospective, controlled study showed the opposite results.2
Moreover, Hillberg and Johnson conclude that in patients hospitalized with acute exacerbations of COPD, noninvasive ventilation is an effective therapeutic alternative. Again, however, the authors do not mention a controlled trial showing that the use of noninvasive ventilation during recovery from an exacerbation of COPD does not add any significant effect to that obtained by standard medical care.3
Finally, Hillberg and Johnson conclude that noninvasive ventilation benefits patients with congestive heart failure and sleep-related breathing disorders. Yet there is evidence in the literature of the absence of improvement after noninvasive ventilation in such patients and even of potential hazards.4
4 ReferencesAlvar G.N. Agustí, M.D.
Ferran Barbé, M.D.
Bernat Togores, M.D.
Hospital Universitario Son Dureta, 07014 Palma de Mallorca, Spain1
Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease: official statement of the American Thoracic Society
Web of Science | Medline2
Lin C-C . Comparison between nocturnal nasal positive pressure ventilation combined with oxygen therapy and oxygen monotherapy in patients with severe COPD. Am J Respir Crit Care Med 1996;154:353-358
Web of Science | Medline3
Barbe F ,Togores B ,Rubi M ,Pons S ,Maimo A ,Agusti AG . Noninvasive ventilatory support does not facilitate recovery from acute respiratory failure in chronic obstructive pulmonary disease. Eur Respir J 1996;9:1240-1245
CrossRef | Web of Science | Medline4
Davies RJ ,Harrington KJ ,Ormerod OJ ,Stradling JR . Nasal continuous positive airway pressure in chronic heart failure with sleep-disordered breathing. Am Rev Respir Dis 1993;147:630-634
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Niranjan and Bach express their preference for the use of volume-cycled ventilators in patients with neuromuscular diseases. We agree that many studies have shown that volume-cycled noninvasive ventilation works well for long-term management in patients with neuromuscular diseases and kyphoscoliosis.1 These patients can benefit from training in the use of several types of noninvasive ventilators (e.g., bilevel devices, volume ventilators, cuirass negative-pressure devices, and intermittent abdominal-pressure devices). We agree that there are substantial advantages to portable, battery-operated, volume-cycled ventilators, and training for anticipated emergencies is a valuable clinical practice.
Agustí et al. properly state that the regular use of noninvasive ventilation in patients with stable COPD requires further documentation. We try this approach in patients with COPD and chronic, marked, persistent hypercapnia, but many patients do not tolerate long-term use of noninvasive ventilation. However, noninvasive ventilation has been shown to have an important role in managing selected cases of COPD with acute respiratory failure. In the study cited by Agustí et al. that found no improvement with noninvasive ventilation in patients with COPD and acute respiratory failure,2 none of the patients in either group required intubation. Other studies, possibly involving sicker patients, have found significant improvements, including lower intubation rates, with noninvasive ventilation.3,4 Data support the use of noninvasive ventilation in selected patients with sleep-disordered breathing and congestive heart failure.5 Further studies are needed to determine which patients with congestive heart failure may benefit from noninvasive ventilation.
5 ReferencesRobert E. Hillberg, M.D.
Spaulding Rehabilitation CenterDouglas C. Johnson, M.D.
Massachusetts General Hospital, Boston, MA 021141
Meyer TJ ,Hill NS . Noninvasive positive pressure ventilation to treat respiratory failure. Ann Intern Med 1994;120:760-770
Web of Science | Medline2
Barbe F ,Togores B ,Rubi M ,Pons S ,Maimo A ,Agusti AG . Noninvasive ventilatory support does not facilitate recovery from acute respiratory failure in chronic obstructive pulmonary disease. Eur Respir J 1996;9:1240-1245
CrossRef | Web of Science | Medline3
Brochard L ,Mancebo J ,Wysocki M , et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333:817-822
Full Text | Web of Science | Medline4
Kramer N ,Meyer TJ ,Meharg J ,Cece RD ,Hill NS . Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 1995;151:1799-1806
Web of Science | Medline5
Naughton MT ,Liu PP ,Bernard DC ,Goldstein RS ,Bradley TD . Treatment of congestive heart failure and Cheyne-Stokes respiration during sleep by continuous positive airway pressure. Am J Respir Crit Care Med 1995;151:92-97
Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Flávia MR Vital, Humberto Saconato, Magdaline T Ladeira, Ayan Sen, Claire A Hawkes, Bernardo Soares, Karen E. A. Burns, Álvaro N Atallah, Álvaro N Atallah. 2008. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema. .
CrossRef
