Modern Non-Invasive Mechanical Ventilation Turns 25

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(A) standard nasal mask (Respironics Inc., Murrysville, PA); (B) Sullivan nasal mask (Sullivan Bubble Mask, ResCare, San Diego, CA); (C) nasal pillows (Nellcor Puritan Bennett, ADAM circuit, Pleasanton, CA); (D) mini mask (Respironics Inc., Murrysville, PA); (E) lip seal (Nellcor Puritan Bennett, Pleasanton, CA); (F) total-face mask (Spectrum, Respironics Inc., Murrysville, PA)." ] ] ] "textoCompleto" => "It has been 25 years since the use of positive pressure ventilation with non-invasive interfaces became standardized. These have been 25 exciting years in which a succession of important events has significantly changed the history of pulmonology and contributed to the advancement and expansion of respiratory medicine. It is time to review the progress of non-invasive mechanical ventilation (NIMV) over this period.If the history of NIMV were plotted linearly, something similar to that shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> would be obtained. Just like a traditional history book, Ancient History, the Middle Ages, the Renaissance and the current or Modern Era can all be identified along this line. Nevertheless, NIMV is not a new technique. Its history and origins go back more than 100 years and are linked to the invention of the iron lung by Drinker and Shaw in 1927. This marks the beginning of the Ancient History of NIMV. The iron lung was used for the first time in 1928 in the Boston Children's Hospital (MA, USA) in an unconscious girl with respiratory problems. Her rapid recovery helped popularize the so-called “Drinker Respirator”. Some years later, Emerson improved the Drinker prototype, marketing an iron lung that was smaller, cheaper, lighter, more silent and more reliable than its predecessor. He was accused of infringing Drinker's patents, but the complaints were not upheld and hospitals were filled with Emerson's iron lung.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It played a crucial role during the poliomyelitis epidemics of the 1940s and 50s, keeping alive the 10% of polio patients who presented with acute respiratory failure and sustained ventilatory dependence.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> To avoid patients being shut away indefinitely in an institution, various hospitals decided to try to set up domiciliary mechanical ventilation programs. Iron lungs and their variants (ponchos and cuirasses) were the basic elements that supported the early home mechanical ventilation (HMV) programs.<a class="elsevierStyleCrossRef" href="#bib0015">3</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>In the 1950s, a series of events took place that limited the use of the iron lung. The eradication of poliomyelitis thanks to generalized vaccination programs, along with the surge in positive pressure mechanical ventilation administered with respiratory tract intubation, effectively led to the disappearance of the iron lung.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> At this point, we enter the NIMV Middle Ages. However, just as in the Middle Ages, when wisdom and knowledge were restricted to the monasteries, there were certain places where the NIMV flame continued to burn and many patients continued to benefit from negative pressure ventilation. One of these “ventilation monasteries” is the Hospital María Ferrer in Buenos Aires, which is still active today and survivors from those times can still be seen living in iron lungs. The room of one of these patients can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>From the 1960s until 1988, 990 cases of patients receiving home ventilation in various countries were reported, principally in France,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0030">6</a> and the United States.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Fourteen percent (14%) of these patients used negative pressure equipment (iron lung or poncho), 70% used volumetric respirators with tracheotomy and in the remaining 16% the airway was accessed via mouth or nose pieces.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> A classic study in the field of home ventilation, published by Robert et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> in 1983, reported 222 patients home-ventilated with tracheotomy since 1960, providing a survival curve for patients pooled according to disease type that was used as a reference throughout the years.In this modest setting of patients ventilated at home, primarily via tracheotomy, and to a lesser extent, in a non-invasive manner with negative pressure equipment or mouthpieces, Delaubier and Rideau introduced the technique of intermittent positive pressure ventilation via a nasal mask in patients with muscular dystrophy that they called NIPPV (non-invasive positive pressure ventilation). These French authors showed that a patient with Duchenne muscular dystrophy could be adequately ventilated with a nasal mask designed by Sullivan in 1980 for applying continuous pressure support to patients with sleep apnea.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The development of the first masks with which NIMV began to be applied was, as such, very closely associated with the development of continuous positive airway pressure (CPAP) for sleep apnea syndromes (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). An article published in 1987 in the journal Agressologie<a class="elsevierStyleCrossRef" href="#bib0055">11</a> was a historical milestone and a turning point in the history of NIMV, marking the transition between the Middle Ages and the Renaissance.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The confirmation that mechanical ventilation could be efficacious, comfortable and well-tolerated with the use of a nasal mask added to the exponential growth of patients on long-term ventilation in their own homes and the development of positive pressure NIMV in most respiratory medicine wards. Negative pressure ventilation techniques were practically abandoned and their use has been exceptional ever since.NIMV spread rapidly as the treatment of choice in patients with respiratory failure due to neuromuscular diseases, rib-cage defects and the sequelae of tuberculosis, which became known as restrictive respiratory failure, due to the spirometric and radiological characteristics of these patients. Other causes of hypoventilation, such as obesity, were added to the list of indications for NIMV.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> These patients were adapted to volumetric ventilators in a hospital setting and then sent home, and a new offer of domiciliary respiratory therapy appeared alongside oxygen therapy in the portfolio of treatment service providers: HMV delivered by mask. The number of patients treated with mechanical ventilation at home vastly exceeded the estimations made by Estopá in 1996,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> who calculated that by the year 2000 in Europe, over 7000 patients would be receiving home mechanical ventilation. This brings us to the heart of modern NIMV history.It is essential to mention the study by Leger et al., published in 1994,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> describing the first series of NIMV patients treated at home, with a 5-year follow-up of 276 patients. The results show the benefit in terms of survival provided by NIMV in patients with neuromuscular diseases, kyphoscoliosis and sequelae of tuberculosis, and to a lesser extent, patients with chronic obstructive pulmonary disease (COPD) and bronchiectasis.Restrictive respiratory failure, volumetric ventilators, the nasal mask, adaptation of patients in hospital and the use of nocturnal pulse oximetry as a basic monitoring tool were the cardinal points of NIMV in those early stages of modern NIMV, which culminated in 1999 in the publication in the journal Chest<a class="elsevierStyleCrossRef" href="#bib0080">16</a> of the Consensus Conference on the clinical indications for non-invasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD and nocturnal hypoventilation. This article established the criteria for indicating home NIMV which even today remain applicable to a large extent. The 1990s were the decade of NIMV and HMV.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>In the year 2000, De Lucas et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> analyzed HMV in Spain and demonstrated the variability in its use across this country, with a prevalence of patients ventilated at home ranging between 0.93/100000 in the region of Castilla-La Mancha and 10.11/100000 in the Community of Madrid. At that time, 1821 patients were receiving HMV in Spain, which was initiated here in 1987 by the Hospital de Bellvitge (Barcelona). This article documents the implementation of the HMV program in the Hospital San Pedro de Alcántara (Cáceres) in 1988, in the Hospital Clínico Universitario in Valencia in 1990 and in the hospitals La Paz (Madrid), Gregorio Marañón (Madrid) and Son Dureta (Mallorca) in 1992. In the year 2000, the number of hospitals offering HMV programs reached 43.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Two excellent reviews carried out by what were considered the pioneer groups in Spain, one on NIMV<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and one on HMV,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> were published in 1994, gathering all the knowledge in this area at the time in two articles which would become references for the groups contributing to the advancement of NIMV in Spain during the 1990s. Some years later, a European study, EUROVENT, analyzed data from 16 countries and more than 20000 patients, pointing out, like the Spanish study, a wide variability in indications and types of ventilators and interfaces used in the various countries studied. The prevalence of patients included in HMV programs also differed, with figures of 0.1/100000 in Poland compared to 17/100000 in France, with a mean prevalence of 6.6/100000.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>In 1992, BiPAP®, a ventilator originally designed for the treatment of patients with sleep apnea-hypopnea syndrome who could not tolerate the high pressures of CPAP, was introduced into the market by Respironics. With the philosophy of reducing pressure during expiration and intermittently reducing pressurization in the circuit, it rapidly became a new ventilatory modality in the field of NIMV: bi-level pressure ventilation.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In addition to the concepts of tidal volume, I/E ratio, respiratory rate, high and low pressure alarms and trigger, all normal parameters in volumetric ventilators, other terms, such as pressure support, inspiratory positive airway pressure (IPAP), expiratory positive airway pressure (EPAP) and positive end-expiratory pressure (PEEP), had to be assimilated, along with the concept that respiratory rate and I/E ratio was controlled by the patient himself, the trigger depended on the ventilator and the tidal volume was the result of all these factors and could not be determined previously by the physicians. Moreover, these ventilators did not have batteries or alarms (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Leaving aside the enthusiasm of some respiratory medicine specialists, it is really easy to understand how the appearance in the intensive care unit (ICU) of one of these tiny devices for transferring a complex patient labeled as difficult-to-wean to the general hospital ward would generate certain distrust in the eyes of intensive care physicians. In 1996, the following was published: “Recently we have begun to use the device known as BiPAP. This system should be called pressure support, and generates pressure through a constant airflow. […] There is still no general consensus on the usefulness of these devices, but in view of their simplicity and the low cost compared to volumetric ventilators, there is no doubt that they have a role in the area of home mechanical ventilation”,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> as was subsequently proven.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>In 1995, Brochard et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> published a study in the New England Journal of Medicine showing that applying pressure support to patients with exacerbations of COPD with respiratory acidosis reduced the need for orotracheal intubation, ICU admission, hospital mortality and mean length of stay, and improved blood gases and pH. A few years later, bi-level pressure NIMV had become the gold standard for the treatment of this type of patient.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The Global Initiative for Chronic Obstructive Lung Diseases (GOLD) established the criteria for this indication with level A scientific evidence.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> In 2002, the British Thoracic Society Standards of Care Committee established an incidence of 70 patients with COPD treated with NIMV per 250000 population per year.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Plant et al.,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> for their part, clarified which patients could be treated in the general hospital ward and which could not. Other authors concerned themselves with determining the predictive factors for success in the acute patient setting, thus placing blood gases firmly in the awareness of physicians everywhere when initiating ventilation.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> Evidence of the efficacy of NIMV emerged, not only in patients with COPD, but also in other situations of acute respiratory failure, both hypercapnic and hypoxemic,<a class="elsevierStyleCrossRef" href="#bib0145">29</a> and the emphasis of NIMV use switched from the chronic patient to the acute patient, from the volumetric ventilator to the bi-level pressure ventilator, from the nose mask to other interfaces with greater facial cover (oronasal, total, helmet) and from the home to the hospital. In 2001, the American Thoracic Society published the International Consensus Conference on NIMV in acute respiratory failure,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> which was a new historical milestone establishing recommendations which have served as guidelines for other standards and subsequent revisions.<a class="elsevierStyleCrossRefs" href="#bib0155">31,32</a>New fronts have been opened in the NIMV revolution in recent years. One of these has been the location in which patients should be treated. Far from the initial binomial of the respiratory medicine ward or ICU, the concept of intermediate respiratory care units has emerged, although this has not spread as widely as might be desired.<a class="elsevierStyleCrossRefs" href="#bib0165">33,34</a> It has become clear that NIMV in acute patients requires a specific infrastructure and specially dedicated personnel with the appropriate training, experience and 24-h availability.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> The increased complexity of ventilated patients and the greater investment in nursing time required for their care has produced significant changes in the organization of pulmonology departments.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> Patient care has gone beyond these units, and experience is growing in the successful application of NIMV in hospital and out-of-hospital emergency departments.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> The type of home-ventilated patients has expanded to include acute respiratory failure survivors, those impossible to wean and patients with frequent exacerbations. In parallel, NIMV is increasingly demanded for the growing number of hospitalized patients with hypercapnic respiratory failure in situations with a lower level of evidence, related with advanced progressive stages of many diseases and degenerative processes. NIMV and HMV are increasingly proposed in elderly patients, patients with a do-not-intubate order or with serious concomitant diseases, and with palliative intent; data are available on its utility in these critical situations.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>From a technological point of view, ventilators have evolved considerably with the progressive incorporation, depending on the manufacturer, of different ventilatory modes, sophisticated alarms, functions for regulating trigger, cycling, volumes and pressures, ability to ensure or guarantee volumes, and, more recently, the provision of monitoring tools. Screens with FiO2 curves, estimations, measurements or regulation, and integrated recording of hemoglobin saturation or expired CO2 are only some of the possibilities offered by latest-generation ventilators, thus making NIMV a little more complex (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>NIMV also has its limitations. Against the setting of the uncontrolled expansion of its use, discussions are often raised about whether or not it should be initiated in critical situations, thus highlighting ethical dilemmas in an area with little scientific evidence and doubtful verifiable experience of the medical team.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> Similarly, the scarcity of standardized training and education in ventilation and the wide variability of the existing organizational models combined with a lack of data on the resources necessary for applying NIMV are other aspects highlighting the limitations of NIMV. Questions about whether or not a duty pulmonologist is required, if ventilation procedures should be concentrated in a specific hospital area or if the patients should be distributed according to their underlying disease, all await response.It has been 25 years since that patient with Duchenne muscular dystrophy was successfully ventilated with a nasal mask and made known in the literature, and 25 years since the first patient was ventilated at home in Spain. The history of modern NIMV has been exciting and fast-paced. All the initial predictions have been surpassed. Nowadays young doctors have to deal with NIMV with top-of-the-range ventilators, often without the necessary historical perspective that everyone working with NIMV should have. What does the future hold for NIMV? Technological developments, monitoring, patient types, indications, infrastructures, new ventilatory modes and telemedicine all have to be taken on board. In coming years, research will focus on areas such as patient-ventilator asynchrony and sleep disorders in NIMV patients. For now, we should celebrate 25 years of modern NIMV, sing “Happy Birthday”, and make a wish for this therapeutic modality that has contributed so much to the advancement of respiratory medicine over the last 25 years to continue to help advancements in our specialist area for many years to come.Conflict of InterestsThe authors declare that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "xres287808" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec271295" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres287807" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec271296" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interests" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-08-18" "fechaAceptado" => "2012-11-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec271295" "palabras" => array:4 [ 0 => "Non invasive ventilation" 1 => "History" 2 => "Intermediate care units" 3 => "Respiratory failure" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec271296" "palabras" => array:4 [ 0 => "Ventilación no invasiva" 1 => "Historia" 2 => "Cuidados intermedios" 3 => "Insuficiencia respiratoria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The history of non-invasive mechanical ventilation goes back more than 100 years, but it was not until 1987 when what we could call “modern” non-invasive mechanical ventilation was developed. The description of Delaubier and Rideau of a patient with Duchenne's disease who had been effectively ventilated through a nasal mask marked the start of a new era in the history of non-invasive mechanical ventilation. Over these last 25years, we have witnessed exponential growth in its use, field of activity and technological advances on an exciting fast-paced track. We believe that it is time to review the main milestones that have marked the development of non-invasive mechanical ventilation to date, while paying homage to this therapeutic method that has contributed so much to the advancement of respiratory medicine in the last 25years." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La historia de la ventilación mecánica no invasiva se remonta más de 100años en el tiempo, pero no fue hasta 1987 cuando entramos en lo que podemos llamar la ventilación mecánica no invasiva moderna. La descripción de Delaubier y Rideau de un paciente con enfermedad de Duchenne ventilado eficazmente a través de una mascarilla nasal marcó el inicio de una nueva era en la historia de la ventilación mecánica no invasiva. En estos 25años hemos asistido a un crecimiento exponencial de su utilización, de su campo de actuación y de su desarrollo tecnológico, en una carrera apasionante y vertiginosa. Consideramos que es oportuno realizar una revisión de los principales hitos que han marcado el desarrollo de la ventilación mecánica no invasiva hasta llegar al momento actual, y aprovechamos para rendir tributo a esta modalidad terapéutica que tanto ha contribuido al desarrollo de la neumología en los últimos 25años." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Díaz Lobato S, Mayoralas Alises S. La ventilación mecánica no invasiva moderna cumple 25 años. Arch Bronconeumol. 2013;49:475–479." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1820 "Ancho" => 2684 "Tamanyo" => 266228 ] ] "descripcion" => array:1 [ "en" => "Timeline of the first 25 years of the history of non-invasive mechanical ventilation (NIMV)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 781 "Ancho" => 1045 "Tamanyo" => 115215 ] ] "descripcion" => array:1 [ "en" => "Room in the Ferrer Home in Buenos Aires. The iron lung can be seen in the foreground." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 636 "Ancho" => 900 "Tamanyo" => 112210 ] ] "descripcion" => array:1 [ "en" => "Non-invasive mechanical ventilation masks. (A) standard nasal mask (Respironics Inc., Murrysville, PA); (B) Sullivan nasal mask (Sullivan Bubble Mask, ResCare, San Diego, CA); (C) nasal pillows (Nellcor Puritan Bennett, ADAM circuit, Pleasanton, CA); (D) mini mask (Respironics Inc., Murrysville, PA); (E) lip seal (Nellcor Puritan Bennett, Pleasanton, CA); (F) total-face mask (Spectrum, Respironics Inc., Murrysville, PA)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1003 "Ancho" => 900 "Tamanyo" => 104763 ] ] "descripcion" => array:1 [ "en" => "BiPAP S/T (Respironics Inc., Murrysville, PA)." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1061 "Ancho" => 1380 "Tamanyo" => 156466 ] ] "descripcion" => array:1 [ "en" => "Non-invasive mechanical ventilation (NIMV) ventilators. 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Modern Non-Invasive Mechanical Ventilation Turns 25

La ventilación mecánica no invasiva moderna cumple 25 años

Salvador Díaz Lobato

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sdiazlobato@gmail.com

Corresponding author.

, Sagrario Mayoralas Alises

Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It has been 25 years since the use of positive pressure ventilation with non-invasive interfaces became standardized&#46; These have been 25 exciting years in which a succession of important events has significantly changed the history of pulmonology and contributed to the advancement and expansion of respiratory medicine&#46; It is time to review the progress of non-invasive mechanical ventilation &#40;NIMV&#41; over this period&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">If the history of NIMV were plotted linearly&#44; something similar to that shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> would be obtained&#46; Just like a traditional history book&#44; Ancient History&#44; the Middle Ages&#44; the Renaissance and the current or Modern Era can all be identified along this line&#46; Nevertheless&#44; NIMV is not a new technique&#46; Its history and origins go back more than 100 years and are linked to the invention of the iron lung by Drinker and Shaw in 1927&#46; This marks the beginning of the Ancient History of NIMV&#46; The iron lung was used for the first time in 1928 in the Boston Children&#39;s Hospital &#40;MA&#44; USA&#41; in an unconscious girl with respiratory problems&#46; Her rapid recovery helped popularize the so-called &#8220;Drinker Respirator&#8221;&#46; Some years later&#44; Emerson improved the Drinker prototype&#44; marketing an iron lung that was smaller&#44; cheaper&#44; lighter&#44; more silent and more reliable than its predecessor&#46; He was accused of infringing Drinker&#39;s patents&#44; but the complaints were not upheld and hospitals were filled with Emerson&#39;s iron lung&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It played a crucial role during the poliomyelitis epidemics of the 1940s and 50s&#44; keeping alive the 10&#37; of polio patients who presented with acute respiratory failure and sustained ventilatory dependence&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> To avoid patients being shut away indefinitely in an institution&#44; various hospitals decided to try to set up domiciliary mechanical ventilation programs&#46; Iron lungs and their variants &#40;ponchos and cuirasses&#41; were the basic elements that supported the early home mechanical ventilation &#40;HMV&#41; programs&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In the 1950s&#44; a series of events took place that limited the use of the iron lung&#46; The eradication of poliomyelitis thanks to generalized vaccination programs&#44; along with the surge in positive pressure mechanical ventilation administered with respiratory tract intubation&#44; effectively led to the disappearance of the iron lung&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> At this point&#44; we enter the NIMV Middle Ages&#46; However&#44; just as in the Middle Ages&#44; when wisdom and knowledge were restricted to the monasteries&#44; there were certain places where the NIMV flame continued to burn and many patients continued to benefit from negative pressure ventilation&#46; One of these &#8220;ventilation monasteries&#8221; is the Hospital Mar&#237;a Ferrer in Buenos Aires&#44; which is still active today and survivors from those times can still be seen living in iron lungs&#46; The room of one of these patients can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">From the 1960s until 1988&#44; 990 cases of patients receiving home ventilation in various countries were reported&#44; principally in France&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Fourteen percent &#40;14&#37;&#41; of these patients used negative pressure equipment &#40;iron lung or poncho&#41;&#44; 70&#37; used volumetric respirators with tracheotomy and in the remaining 16&#37; the airway was accessed via mouth or nose pieces&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A classic study in the field of home ventilation&#44; published by Robert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in 1983&#44; reported 222 patients home-ventilated with tracheotomy since 1960&#44; providing a survival curve for patients pooled according to disease type that was used as a reference throughout the years&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this modest setting of patients ventilated at home&#44; primarily via tracheotomy&#44; and to a lesser extent&#44; in a non-invasive manner with negative pressure equipment or mouthpieces&#44; Delaubier and Rideau introduced the technique of intermittent positive pressure ventilation via a nasal mask in patients with muscular dystrophy that they called NIPPV &#40;non-invasive positive pressure ventilation&#41;&#46; These French authors showed that a patient with Duchenne muscular dystrophy could be adequately ventilated with a nasal mask designed by Sullivan in 1980 for applying continuous pressure support to patients with sleep apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The development of the first masks with which NIMV began to be applied was&#44; as such&#44; very closely associated with the development of continuous positive airway pressure &#40;CPAP&#41; for sleep apnea syndromes &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; An article published in 1987 in the journal <span class="elsevierStyleItalic">Agressologie</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> was a historical milestone and a turning point in the history of NIMV&#44; marking the transition between the Middle Ages and the Renaissance&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The confirmation that mechanical ventilation could be efficacious&#44; comfortable and well-tolerated with the use of a nasal mask added to the exponential growth of patients on long-term ventilation in their own homes and the development of positive pressure NIMV in most respiratory medicine wards&#46; Negative pressure ventilation techniques were practically abandoned and their use has been exceptional ever since&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">NIMV spread rapidly as the treatment of choice in patients with respiratory failure due to neuromuscular diseases&#44; rib-cage defects and the sequelae of tuberculosis&#44; which became known as restrictive respiratory failure&#44; due to the spirometric and radiological characteristics of these patients&#46; Other causes of hypoventilation&#44; such as obesity&#44; were added to the list of indications for NIMV&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> These patients were adapted to volumetric ventilators in a hospital setting and then sent home&#44; and a new offer of domiciliary respiratory therapy appeared alongside oxygen therapy in the portfolio of treatment service providers&#58; HMV delivered by mask&#46; The number of patients treated with mechanical ventilation at home vastly exceeded the estimations made by Estop&#225; in 1996&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> who calculated that by the year 2000 in Europe&#44; over 7000 patients would be receiving home mechanical ventilation&#46; This brings us to the heart of modern NIMV history&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It is essential to mention the study by Leger et al&#46;&#44; published in 1994&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> describing the first series of NIMV patients treated at home&#44; with a 5-year follow-up of 276 patients&#46; The results show the benefit in terms of survival provided by NIMV in patients with neuromuscular diseases&#44; kyphoscoliosis and sequelae of tuberculosis&#44; and to a lesser extent&#44; patients with chronic obstructive pulmonary disease &#40;COPD&#41; and bronchiectasis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Restrictive respiratory failure&#44; volumetric ventilators&#44; the nasal mask&#44; adaptation of patients in hospital and the use of nocturnal pulse oximetry as a basic monitoring tool were the cardinal points of NIMV in those early stages of modern NIMV&#44; which culminated in 1999 in the publication in the journal <span class="elsevierStyleItalic">Chest</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> of the Consensus Conference on the clinical indications for non-invasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease&#44; COPD and nocturnal hypoventilation&#46; This article established the criteria for indicating home NIMV which even today remain applicable to a large extent&#46; The 1990s were the decade of NIMV and HMV&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the year 2000&#44; De Lucas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> analyzed HMV in Spain and demonstrated the variability in its use across this country&#44; with a prevalence of patients ventilated at home ranging between 0&#46;93&#47;100<span class="elsevierStyleHsp" style=""></span>000 in the region of Castilla-La Mancha and 10&#46;11&#47;100<span class="elsevierStyleHsp" style=""></span>000 in the Community of Madrid&#46; At that time&#44; 1821 patients were receiving HMV in Spain&#44; which was initiated here in 1987 by the Hospital de Bellvitge &#40;Barcelona&#41;&#46; This article documents the implementation of the HMV program in the Hospital San Pedro de Alc&#225;ntara &#40;C&#225;ceres&#41; in 1988&#44; in the Hospital Cl&#237;nico Universitario in Valencia in 1990 and in the hospitals La Paz &#40;Madrid&#41;&#44; 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a wide variability in indications and types of ventilators and interfaces used in the various countries studied&#46; The prevalence of patients included in HMV programs also differed&#44; with figures of 0&#46;1&#47;100<span class="elsevierStyleHsp" style=""></span>000 in Poland compared to 17&#47;100<span class="elsevierStyleHsp" style=""></span>000 in France&#44; with a mean prevalence of 6&#46;6&#47;100<span class="elsevierStyleHsp" style=""></span>000&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In 1992&#44; BiPAP<span class="elsevierStyleSup">&#174;</span>&#44; a ventilator originally designed for the treatment of patients with sleep apnea-hypopnea syndrome who could not tolerate the high pressures of CPAP&#44; was introduced into the market by Respironics&#46; With the philosophy of reducing pressure during expiration and intermittently reducing pressurization in the circuit&#44; it rapidly became a new ventilatory modality in the field of NIMV&#58; bi-level pressure ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In addition to the concepts of tidal volume&#44; I&#47;E ratio&#44; respiratory rate&#44; high and low pressure alarms and trigger&#44; all normal parameters in volumetric ventilators&#44; other terms&#44; such as pressure support&#44; inspiratory positive airway pressure &#40;IPAP&#41;&#44; expiratory positive airway pressure &#40;EPAP&#41; and positive end-expiratory pressure &#40;PEEP&#41;&#44; had to be assimilated&#44; along with the concept that respiratory rate and I&#47;E ratio was controlled by the patient himself&#44; the trigger depended on the ventilator and the tidal volume was the result of all these factors and could not be determined previously by the physicians&#46; Moreover&#44; these ventilators did not have batteries or alarms &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Leaving aside the enthusiasm of some respiratory medicine specialists&#44; it is really easy to understand how the appearance in the intensive care unit &#40;ICU&#41; of one of these tiny devices for transferring a complex patient labeled as difficult-to-wean to the general hospital ward would generate certain distrust in the eyes of intensive care physicians&#46; In 1996&#44; the following was published&#58; &#8220;Recently we have begun to use the device known as BiPAP&#46; This system should be called pressure support&#44; and generates pressure through a constant airflow&#46; &#91;&#8230;&#93; There is still no general consensus on the usefulness of these devices&#44; but in view of their simplicity and the low cost compared to volumetric ventilators&#44; there is no doubt that they have a role in the area of home mechanical ventilation&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> as was subsequently proven&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In 1995&#44; Brochard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> published a study in the <span class="elsevierStyleItalic">New England Journal of Medicine</span> showing that applying pressure support to patients with exacerbations of COPD with respiratory acidosis reduced the need for orotracheal intubation&#44; ICU admission&#44; hospital mortality and mean length of stay&#44; and improved blood gases and pH&#46; A few years later&#44; bi-level pressure NIMV had become the gold standard for the treatment of this type of patient&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The <span class="elsevierStyleItalic">Global Initiative for Chronic Obstructive Lung Diseases</span> &#40;GOLD&#41; established the criteria for this indication with level A scientific evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> In 2002&#44; the <span class="elsevierStyleItalic">British Thoracic Society Standards of Care Committee</span> established an incidence of 70 patients with COPD treated with NIMV per 250<span class="elsevierStyleHsp" style=""></span>000 population per year&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Plant et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> for their part&#44; clarified which patients could be treated in the general hospital ward and which could not&#46; Other authors concerned themselves with determining the predictive factors for success in the acute patient setting&#44; thus placing blood gases firmly in the awareness of physicians everywhere when initiating ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> Evidence of the efficacy of NIMV emerged&#44; not only in patients with COPD&#44; but also in other situations of acute respiratory failure&#44; both hypercapnic and hypoxemic&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and the emphasis of NIMV use switched from the chronic patient to the acute patient&#44; from the volumetric ventilator to the bi-level pressure ventilator&#44; from the nose mask to other interfaces with greater facial cover &#40;oronasal&#44; total&#44; helmet&#41; and from the home to the hospital&#46; In 2001&#44; the American Thoracic Society published the International Consensus Conference on NIMV in acute respiratory failure&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> which was a new historical milestone establishing recommendations which have served as guidelines for other standards and subsequent revisions&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">New fronts have been opened in the NIMV revolution in recent years&#46; One of these has been the location in which patients should be treated&#46; Far from the initial binomial of the respiratory medicine ward or ICU&#44; the concept of intermediate respiratory care units has emerged&#44; although this has not spread as widely as might be desired&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a> It has become clear that NIMV in acute patients requires a specific infrastructure and specially dedicated personnel with the appropriate training&#44; experience and 24-h availability&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The increased complexity of ventilated patients and the greater investment in nursing time required for their care has produced significant changes in the organization of pulmonology departments&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Patient care has gone beyond these units&#44; and experience is growing in the successful application of NIMV in hospital and out-of-hospital emergency departments&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The type of home-ventilated patients has expanded to include acute respiratory failure survivors&#44; those impossible to wean and patients with frequent exacerbations&#46; In parallel&#44; NIMV is increasingly demanded for the growing number of hospitalized patients with hypercapnic respiratory failure in situations with a lower level of evidence&#44; related with advanced progressive stages of many diseases and degenerative processes&#46; NIMV and HMV are increasingly proposed in elderly patients&#44; patients with a do-not-intubate order or with serious concomitant diseases&#44; and with palliative intent&#59; data are available on its utility in these critical situations&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">From a technological point of view&#44; ventilators have evolved considerably with the progressive incorporation&#44; depending on the manufacturer&#44; of different ventilatory modes&#44; sophisticated alarms&#44; functions for regulating trigger&#44; cycling&#44; volumes and pressures&#44; ability to ensure or guarantee volumes&#44; and&#44; more recently&#44; the provision of monitoring tools&#46; Screens with FiO<span class="elsevierStyleInf">2</span> curves&#44; estimations&#44; measurements or regulation&#44; and integrated recording of hemoglobin saturation or expired CO<span class="elsevierStyleInf">2</span> are only some of the possibilities offered by latest-generation ventilators&#44; thus making NIMV a little more complex &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">NIMV also has its limitations&#46; Against the setting of the uncontrolled expansion of its use&#44; discussions are often raised about whether or not it should be initiated in critical situations&#44; thus highlighting ethical dilemmas in an area with little scientific evidence and doubtful verifiable experience of the medical team&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Similarly&#44; the scarcity of standardized training and education in ventilation and the wide variability of the existing organizational models combined with a lack of data on the resources necessary for applying NIMV are other aspects highlighting the limitations of NIMV&#46; Questions about whether or not a duty pulmonologist is required&#44; if ventilation procedures should be concentrated in a specific hospital area or if the patients should be distributed according to their underlying disease&#44; all await response&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It has been 25 years since that patient with Duchenne muscular dystrophy was successfully ventilated with a nasal mask and made known in the literature&#44; and 25 years since the first patient was ventilated at home in Spain&#46; The history of modern NIMV has been exciting and fast-paced&#46; All the initial predictions have been surpassed&#46; Nowadays young doctors have to deal with NIMV with top-of-the-range ventilators&#44; often without the necessary historical perspective that everyone working with NIMV should have&#46; What does the future hold for NIMV&#63; Technological developments&#44; monitoring&#44; patient types&#44; indications&#44; infrastructures&#44; new ventilatory modes and telemedicine all have to be taken on board&#46; In coming years&#44; research will focus on areas such as patient-ventilator asynchrony and sleep disorders in NIMV patients&#46; For now&#44; we should celebrate 25 years of modern NIMV&#44; sing &#8220;Happy Birthday&#8221;&#44; and make a wish for this therapeutic modality that has contributed so much to the advancement of respiratory medicine over the last 25 years to continue to help advancements in our specialist area for many years to come&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of Interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres287808"
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          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres287807"
          "titulo" => "Resumen"
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    "fechaRecibido" => "2012-08-18"
    "fechaAceptado" => "2012-11-26"
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          "clase" => "keyword"
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            0 => "Non invasive ventilation"
            1 => "History"
            2 => "Intermediate care units"
            3 => "Respiratory failure"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Ventilaci&#243;n no invasiva"
            1 => "Historia"
            2 => "Cuidados intermedios"
            3 => "Insuficiencia respiratoria"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The history of non-invasive mechanical ventilation goes back more than 100 years&#44; but it was not until 1987 when what we could call &#8220;modern&#8221; non-invasive mechanical ventilation was developed&#46; The description of Delaubier and Rideau of a patient with Duchenne&#39;s disease who had been effectively ventilated through a nasal mask marked the start of a new era in the history of non-invasive mechanical ventilation&#46; Over these last 25<span class="elsevierStyleHsp" style=""></span>years&#44; we have witnessed exponential growth in its use&#44; field of activity and technological advances on an exciting fast-paced track&#46; We believe that it is time to review the main milestones that have marked the development of non-invasive mechanical ventilation to date&#44; while paying homage to this therapeutic method that has contributed so much to the advancement of respiratory medicine in the last 25<span class="elsevierStyleHsp" style=""></span>years&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La historia de la ventilaci&#243;n mec&#225;nica no invasiva se remonta m&#225;s de 100<span class="elsevierStyleHsp" style=""></span>a&#241;os en el tiempo&#44; pero no fue hasta 1987 cuando entramos en lo que podemos llamar la ventilaci&#243;n mec&#225;nica no invasiva moderna&#46; La descripci&#243;n de Delaubier y Rideau de un paciente con enfermedad de Duchenne ventilado eficazmente a trav&#233;s de una mascarilla nasal marc&#243; el inicio de una nueva era en la historia de la ventilaci&#243;n mec&#225;nica no invasiva&#46; En estos 25<span class="elsevierStyleHsp" style=""></span>a&#241;os hemos asistido a un crecimiento exponencial de su utilizaci&#243;n&#44; de su campo de actuaci&#243;n y de su desarrollo tecnol&#243;gico&#44; en una carrera apasionante y vertiginosa&#46; Consideramos que es oportuno realizar una revisi&#243;n de los principales hitos que han marcado el desarrollo de la ventilaci&#243;n mec&#225;nica no invasiva hasta llegar al momento actual&#44; y aprovechamos para rendir tributo a esta modalidad terap&#233;utica que tanto ha contribuido al desarrollo de la neumolog&#237;a en los &#250;ltimos 25<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; D&#237;az Lobato S&#44; Mayoralas Alises S&#46; La ventilaci&#243;n mec&#225;nica no invasiva moderna cumple 25 a&#241;os&#46; Arch Bronconeumol&#46; 2013&#59;49&#58;475&#8211;479&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Room in the Ferrer Home in Buenos Aires&#46; The iron lung can be seen in the foreground&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Non-invasive mechanical ventilation masks&#46; &#40;A&#41; standard nasal mask &#40;Respironics Inc&#46;&#44; Murrysville&#44; PA&#41;&#59; &#40;B&#41; Sullivan nasal mask &#40;Sullivan Bubble Mask&#44; ResCare&#44; San Diego&#44; CA&#41;&#59; &#40;C&#41; nasal pillows &#40;Nellcor Puritan Bennett&#44; ADAM circuit&#44; Pleasanton&#44; CA&#41;&#59; &#40;D&#41; mini mask &#40;Respironics Inc&#46;&#44; Murrysville&#44; PA&#41;&#59; &#40;E&#41; lip seal &#40;Nellcor Puritan Bennett&#44; Pleasanton&#44; CA&#41;&#59; &#40;F&#41; total-face mask &#40;Spectrum&#44; Respironics Inc&#46;&#44; Murrysville&#44; PA&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Non-invasive mechanical ventilation &#40;NIMV&#41; ventilators&#46; Early NIMV ventilators&#58; &#40;1&#41; Monnal D &#40;Vitalaire&#41;&#59; &#40;2&#41; Airox Home1 &#40;France&#41;&#59; &#40;3&#41; Bipap S&#47;T &#40;Respironics Inc&#46;&#44; Murrysville&#44; PA&#41;&#59; &#40;4&#41; Harmony &#40;Respironics Inc&#46;&#44; Murrysville&#44; PA&#41;&#46; Second generation NIMV ventilators&#58; &#40;5&#41; PV 501 &#40;Breas Medical&#41;&#59; &#40;6&#41; VIVO 40 &#40;Breas Medical&#41;&#59; &#40;7&#41; Synchrony &#40;Respironics Inc&#46;&#44; Murrysville&#44; PA&#41;&#46; Modern NIMV ventilators&#58; &#40;8&#41; VIVO 50 &#40;Breas Medical&#41;&#59; &#40;9&#41; Trilogy 100 &#40;Respironics Inc&#46;&#44; Murrysville&#44; PA&#41;&#59; &#40;10&#41; Elisee 150 &#40;ResMed SA&#41;&#59; &#40;11&#41; Stellar 150 &#40;ResMed SA&#41;&#46;</p>"
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2013.09.004

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2024 November	18	1	19
2024 October	193	45	238
2024 September	206	48	254
2024 August	183	47	230
2024 July	160	33	193
2024 June	129	38	167
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2024 March	121	37	158
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2022 December	130	54	184
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2022 May	191	48	239
2022 April	260	70	330
2022 March	237	63	300
2022 February	259	72	331
2022 January	228	63	291
2021 December	134	61	195
2021 November	134	70	204
2021 October	100	68	168
2021 September	124	72	196
2021 August	117	46	163
2021 July	133	52	185
2021 June	156	65	221
2021 May	198	61	259
2021 April	339	113	452
2021 March	182	56	238
2021 February	167	42	209
2021 January	157	50	207
2020 December	125	57	182
2020 November	144	31	175
2020 October	107	40	147
2020 September	162	33	195
2020 August	121	36	157
2020 July	141	46	187
2020 June	155	36	191
2020 May	181	39	220
2020 April	287	72	359
2020 March	232	56	288
2020 February	130	42	172
2020 January	133	53	186
2019 December	158	25	183
2019 November	133	46	179
2019 October	156	35	191
2019 September	220	32	252
2019 August	137	36	173
2019 July	154	40	194
2019 June	168	50	218
2019 May	188	65	253
2019 April	200	45	245
2019 March	244	54	298
2019 February	105	38	143
2019 January	107	30	137
2018 December	100	34	134
2018 November	190	62	252
2018 October	367	53	420
2018 September	139	20	159
2018 May	104	1	105
2018 April	225	3	228
2018 March	200	11	211
2018 February	101	11	112
2018 January	320	6	326
2017 December	324	7	331
2017 November	129	10	139
2017 October	87	7	94
2017 September	79	9	88
2017 August	107	8	115
2017 July	82	9	91
2017 June	124	30	154
2017 May	131	16	147
2017 April	114	40	154
2017 March	130	41	171
2017 February	93	46	139
2017 January	58	16	74
2016 December	89	11	100
2016 November	172	14	186
2016 October	214	30	244
2016 September	293	43	336
2016 August	206	26	232
2016 July	99	61	160
2016 June	1	0	1
2016 March	2	0	2
2016 February	1	0	1
2015 December	3	0	3
2015 October	117	7	124
2015 September	138	34	172
2015 August	127	38	165
2015 July	162	31	193
2015 June	103	30	133
2015 May	157	55	212
2015 April	142	46	188
2015 March	129	16	145
2015 February	120	24	144
2015 January	118	25	143
2014 December	95	42	137
2014 November	87	19	106
2014 October	116	21	137
2014 September	88	24	112
2014 August	75	17	92
2014 July	101	14	115
2014 June	87	28	115
2014 May	97	28	125
2014 April	104	17	121
2014 March	87	16	103
2014 February	38	19	57
2013 December	0	2	2
2013 November	2	4	6

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