Nocturnal non-invasive ventilation for cardio-respiratory disorders in adults

Abstract

Following the classic ‘iron lung’ non-invasive negative pressure ventilator, non-invasive positive pressure ventilation (NIPPV), particularly used ‘nocturnally’ has developed a broad role in both the acute hospital setting and domiciliary long-term use for many cardio-respiratory disorders associated with acute and chronic ventilatory failure. This role is based in part upon the perceived relative ease of application and discontinuation of NIPPV, ability to avoid intubation or tracheostomy and their associated morbidities and availability of increasingly portable pressure and volume cycled NIPPV devices. Nevertheless, the many methodologies necessary for optimal NIPPV use are often underappreciated by health care workers and patients alike. This review focuses on the rationale, practice, and future directions for ‘nocturnal’ use of non-invasive positive pressure ventilation (nNIV) in cardio-respiratory disorders in adults which are commonly associated with sleep-related apnea, hypoventilation and hypoxemia: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), cystic fibrosis (CF) and neuromuscular disorders.

Keywords::

• amyotrophic lateral sclerosis
• Cheyne-Stokes breathing
• CHF
• COPD
• cystic fibrosis
• hypoventilation
• non-invasive ventilation
• OHS
• overlap syndrome

Financial & competing interests disclosure

RC Basner is the Principal Investigator of a Muscular Dystrophy Association grant, “Opto-Electronic Plethysmography (OEP): A Novel Noninvasive Quantitative Assessment of Lower Rib Cage Paradox and Use of Accessory Muscles in Patients With Amyotrophic Lateral Sclerosis”; Site Investigator and Sleep Protocol Subcommittee member of an NHLBI/NIH grant, “Sleep-Disordered Breathing During Pregnancy and Risks to Cardiovascular Health”; and co-investigator of the following: R01HL103676-01-A1 NIH/NHLBI; “Subclinical Interstitial Lung Disease in MESA”; R01HL093081 NIH/NHLBI; “Pulmonary Vascular Changes in Early COPD”; and “InterMune PIPF-016?: A Randomized, Double-Blind, Placebo-Controlled, Phase III Study of the Efficacy and Safety of Pirfenidone in Patients with Idiopathic Pulmonary Fibrosis (IPF).” The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Nocturnal non-invasive ventilation (nNIV) has a documented physiologic and clinical role in the treatment of many cardio-respiratory disorders, particularly those with clearly adverse and worsened physiology during sleep.

• • nNIV has been shown to improve gas exchange, oxyhemoglobin saturation and dyspnea or quality of life in a wide array of settings.

• • Current clinical practice demands that clinicians carefully consider the evidence-based indications for initiating and titrating nNIV based on the specific clinical, physiological and patient-oriented goals and needs of individual patients.

• • nNIV initiation must include careful monitoring for patient ventilatory dyssynchrony, air leak, mask interface compatibility and adherence.

• • Further research is much needed in nNIV titration modalities, identifying the patients most likely to benefit from nNIV, as well as patient-centered outcomes on nNIV use in the long term.

Notes