Correspondence

A Fatal Complication of Noninvasive Ventilation

N Engl J Med 2001; 344:533February 15, 2001

Article

To the Editor:

Noninvasive positive-pressure ventilation is widely used in patients with chronic respiratory failure due to neuromuscular diseases such as amyotrophic lateral sclerosis.1 Noninvasive positive-pressure ventilation can be used intermittently, the equipment is portable, and ventilation does not interfere with eating and speaking. It is considered safe, and most problems that occur are related to the fit of the mask and the risk of aspiration pneumonitis.2 We describe a complication we have not previously seen reported.

The patient was a previously healthy 53-year-old man with amyotrophic lateral sclerosis who was started on nocturnal noninvasive positive-pressure ventilation (inspiratory pressure, 10 cm of water; expiratory pressure, 2 cm of water). He tolerated this well and decided that he did not want invasive mechanical ventilation in the future. The patient's disease progressed, but he continued to work full-time and used noninvasive positive-pressure ventilation all night and most of the day. He obtained a second ventilator, which he kept at work.

More than a year after noninvasive ventilation was initiated, the patient's ventilating unit failed. The machine's error code indicated that there had been a power-supply failure. Respiratory distress quickly developed, and the patient was taken to a local hospital but died of respiratory failure before ventilation could be reinstituted.

This case demonstrates a problem that is likely to become more common as increasing numbers of patients with chronic respiratory failure use noninvasive positive-pressure ventilation. It is important to realize that technical failures of the machines in these cases can be catastrophic. Patients and their caregivers should be counseled that noninvasive positive-pressure ventilation is not a substitute for tracheostomy and mechanical ventilation. Patients need to be made aware of the consequences of ventilator failure. We recommend that our patients consider making the transition to tracheostomy if they require full-time ventilatory support. Although this event has not decreased our use of noninvasive positive-pressure ventilation, we have begun to teach caregivers how to provide bag-and-mask ventilation to patients in the event of an emergency. If the equipment is available, this simple technique may be lifesaving.

Noah Lechtzin, M.D., M.H.S.
Charles M. Weiner, M.D.
Lora Clawson, M.S.N., C.R.N.P.
Johns Hopkins University School of Medicine, Baltimore, MD 21287

2 References

1. 1

   Aboussouan LS, Khan SU, Meeker DP, Stelmach K, Mitsumoto H. Effect of noninvasive positive-pressure ventilation in amyotrophic lateral sclerosis. Ann Intern Med 1997;127:450-453
   Web of Science | Medline

2. 2

   Hill NS. Noninvasive ventilation: does it work, for whom, and how? Am Rev Respir Dis 1993;147:1050-1055
   Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Edward Anthony Oppenheimer. (2003) Treating respiratory failure in ALS: the details are becoming clearer. Journal of the Neurological Sciences 209:1-2, 1-4
   CrossRef