Journal Information
Vol. 40. Issue 11.
Pages 508-517 (November 2004)
Share
Share
Download PDF
More article options
Vol. 40. Issue 11.
Pages 508-517 (November 2004)
Original Articles
Full text access
Leak Monitoring in Noninvasive Ventilation
Visits
7697
C.A. Rabec
Corresponding author
claudio.rabec@chu-dijon.fr

Correspondence: Dr. C.A. Rabec. Service de Pneumologie et Réanimation Respiratoire. Centre Hospitalier et Universitaire de Dijon. 2 Bd Marechal de Lattre de Tassigny. 21079 Dijon Cedex France
, O. Reybet-Degat, P. Bonniaud, A. Fanton, P. Camus
Service de Pneumologie et Réanimation Respiratoire, Centre Hospitalier et Universitaire de Dijon, Dijon, France
This item has received
Article information

Nasal mask ventilation has been shown to be effective, but outcomes do not always match expectations because of mouth leaks, patient-ventilator asynchrony, or decreased upper airway patency. These developments are detected when they lead ultimately to circuit leaks that lower the effectiveness of ventilation through pressure loss, poor inspiratory triggering, and prolonged inspiratory time. The quality of sleep is affected, and adverse effects and treatment intolerance may arise.

A number of ways to detect leaks and their practical consequences are proposed in this article.

We applied 310 leak-detection procedures to 177 patients who had disappointing clinical, gasometric, or polysomnographic outcomes of ventilation. The leak-detection procedures varied according to the type of ventilation and the supposed underlying pathophysiological mechanism. Significant leaks were detected in 132 patients (76%); therapeutic changes were then prescribed to optimize outcomes.

We present a practical method to apply in patients with suboptimal ventilation outcomes. If leaks can be detected during treatment, the probable cause of treatment failure can sometimes be established and possible pathophysiological mechanisms better understood. With this knowledge, it may be possible to improve ventilation.

Key Words:
Noninvasive ventilation
Monitoring
Leaks
Respiratory insufficiency
Sleep apnea-hypopnea syndrome

La ventilación por mascarilla nasal ha dado sobradas pruebas de su eficacia. Sin embargo, en ciertos casos los re-sultados no son los esperados. Tres mecanismos pueden ex-plicar estos fallos: apertura bucal, desincronización pacien-te-respirador y disminución de la permeabilidad de la vía respiratoria superior. Éstos pueden detectarse por su mani-festación última: las fugas en el circuito, que reducen la eficacia de la ventilación (fallo de presurización, disfunción del trigger inspiratorio y prolongación del tiempo inspiratorio), alteran la calidad del sueño y producen efectos adversos e intolerancia al tratamiento.

Proponemos aquí varias técnicas de detección de fugas y sus consecuencias prácticas.

Se sometió a 177 pacientes, con resultados de la ventilación inferiores a los esperados (clínicos, gasométricos o poligráfi-cos), a 310 procedimientos de detección de fugas, con montajes que variaron según la modalidad ventilatoria y el mecanismo fisiopatológico juzgado como responsable. Se detectaron fugas significativas en 132 pacientes (76%), lo cual impuso modifica-ciones terapéuticas para optimizar los resultados.

Presentamos un método de aplicación práctica en casos en que se asista a resultados insuficientes de la ventilación. La detección de fugas bajo tratamiento ofrece la posibilidad de establecer la causa probable del fracaso, comprender el mecanismo fisiopatológico potencialmente responsable e inter-venir en consecuencia.

Palabras clave:
Ventilación no invasiva
Monitorización
Fugas
Insuficiencia respiratoria
Síndrome de apnea del sueño
Full text is only aviable in PDF
REFERENCES
[1]
Heather S, Simmonds A, Ward S. Problem solving in acute NIPPV. In: Simmonds A, editor. Non invasive respiratory support. London: 2001; p. 76-83.
[2]
V Jounieaux, V Parreira, P Delguste, G Aubert, D Rodenstein.
Nasal mask pressure waveform and inspiratory muscle rest during nasal assisted ventilation.
Am J Respir Crit Care Med, 155 (1997), pp. 2096-2101
[3]
V Jounieaux, G Aubert, M Dury, P Delguste, DO Rodenstein.
Effects of nasal positive-pressure hyperventilation on the glottis in normal sleeping subjects.
J Appl Physiol, 79 (1995), pp. 186-193
[4]
B Langevin, P Leger, M Gerard, F Sukkar, A Guez, D Robert.
Monitoring nasal ventilation.
Eur Respir Rev, 3 (1993), pp. 260-265
[5]
V Jounieaux, G Aubert, M Dury, P Delguste, DO Rodenstein.
Effects of nasal positive-pressure hyperventilation on the glottis in normal awake subjects.
J Appl Physiol, 79 (1995), pp. 176-185
[6]
VF Parreira, P Delguste, V Jounieaux, G Aubert, M Dury, DO Rodenstein.
Glottic aperture and effective minute ventilation during nasal two-level positive pressure ventilation in spontaneous mode.
Am J Respir Crit Care Med, 154 (1996), pp. 1857-1863
[7]
VF Parreira, V Jounieaux, G Aubert, M Dury, PE Delguste, DO Rodenstein.
Nasal two-level positive-pressure ventilation in normal subjects. Effects of the glottis and ventilation.
Am J Respir Crit Care Med, 153 (1996), pp. 1616-1623
[8]
DI Loube, PC Gay, KP Strohl, AI Pack, DP White, NA Collop.
Indications for positive airway pressure treatment of adult obstructive sleep apnea patients: a consensus statement.
Chest, 115 (1999), pp. 863-866
[9]
DC Flenley.
Sleep in chronic obstructive lung disease.
Clin Chest Med, 6 (1985), pp. 651-661
[10]
C Rabec, T Ulukavak, M Merati, F Massin, N Baudouin, P Foucher, et al.
One night computerized self-setting CPAP (Autoset™) in determining optimal nasal CPAP pressure.
Eur Respir J, 10 (1997), pp. S745
[11]
M Molina, L Hernández, J Durán, R Farré, R Rubio, D Navajas, et al.
Protocol to evaluate automatic continuous positive airway pressure. Assessment of the usefulness of the Autoset-T device to determine optimal pressure for treating sleep apnea/hypopnea syndrome.
Arch Bronconeumol, 39 (2003), pp. 118-125
[12]
P Lloberes, E Ballester, JM Montserrat, E Botifoll, A Ramírez, A Reolid, et al.
Comparison of manual and automatic CPAP titration in patients with sleep apnea/hypopnea syndrome.
Am J Respir Crit Care Med, 154 (1996), pp. 1755-1758
[13]
H Teschler, M Berthon-Jones, AB Thompson, A Henkel, J Henry, N Konietzko.
Automated continuous positive airway pressure titration for obstructive sleep apnea syndrome.
Am J Respir Crit Care Med, 154 (1996), pp. 734-740
[14]
RA Pauwels, AS Buist, PM Calverley, CR Jenkins, SS Hurd.
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary.
Am J Respir Crit Care Med, 163 (2001), pp. 1256-1276
[15]
C Rabec, M Merati, N Baudouin, P Foucher, T Ulukavac, O Reybet Degat.
Management of obesity and respiratory insufficiency. The value of dual-level pressure nasal ventilation.
Rev Mal Respir, 15 (1998), pp. 269-278
[16]
CA Rabec.
Obesity hypoventilation syndrome: what's in a name?.
Chest, 122 (2002), pp. 1498
[17]
R Kessler, A Chaouat, P Schinkewitch, M Faller, S Casel, J Krieger, et al.
The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases.
Chest, 120 (2001), pp. 369-376
[18]
J Bach, D Robert, P Leger, B Langevin.
Sleep fragmentation in kyphoscoliotic individuals with alveolar hypoventilation treated by NIPPV.
Chest, 107 (1995), pp. 1552-1558
[19]
T Meyer, M Pressman, J Benditt, F McCool, R Millman, R Natarajan, et al.
Air leaking through the mouth during nasal ventilation: effect on sleep quality.
Sleep, 20 (1997), pp. 561-569
[20]
H Teschler, J Stampa, R Ragette, N Konietzko, M Berthon-Jones.
Effect of mouth leak on effectiveness of nasal bilevel ventilatory assistance and sleep architecture.
Eur Respir J, 14 (1999), pp. 1251-1257
[21]
VF Parreira, V Jounieaux, P Delguste, G Aubert, M Dury, DO Rodenstein.
Determinants of effective ventilation during nasal intermittent positive pressure ventilation.
Eur Respir J, 10 (1997), pp. 1975-1982
[22]
H Teschler.
Monitoring of the home mechanical ventilated patient.
Eur Respir Mon, 16 (2001), pp. 274-280
[23]
P Delguste, G Aubert-Tulkens, DO Rodenstein.
Upper airway obstruction during nasal intermittent positive pressure hyperventilation in sleep.
Lancet, 338 (1991), pp. 1295-1297
[24]
M Highcock, J Shneerson, I Smith.
Functional differences in bilevel pressure ventilators.
Eur Respir J, 17 (2001), pp. 268-273
[25]
Robert D, Langevin B, Sab J, Le Q. Utilisation des modes en régulation de volume ou en régulation de pression au cours de la VNI. In: Robert D, Muir J, Editors. Ventilation non invasive. Paris: 1996; p. 189-96.
[26]
E Calderini, M Confalonieri, PG Puccio, N Francavilla, L Stella, C Gregoretti.
Patient-ventilator asynchrony during noninvasive ventilation: the role of expiratory trigger.
Intensive Care Med, 25 (1999), pp. 662-667
[27]
GP Schettino, MR Tucci, R Sousa, CS Valente Barbas, MB Passos Amato, CR Carvalho.
Mask mechanics and leak dynamics during noninvasive pressure support ventilation: a bench study.
Intensive Care Med, 27 (2001), pp. 1887-1891
[28]
Elliott M. Domiciliary non-invasive ventilation in chronic obstructive pulmonary disease. In: Simmonds A, editor. Non invasive respiratory support. London: 2001; p. 146-59.
[29]
JR Hotchkiss, AB Adams, DJ Dries, JJ Marini, PS Crooke.
Dynamic behavior during noninvasive ventilation: chaotic support?.
Am J Respir Crit Care Med, 163 (2001), pp. 374-378
[30]
S Mehta, F McCool, N Hill.
Leak compensation in positive pressure ventilators: a lung model study.
Eur Respir J, 17 (2001), pp. 259-267
[31]
DO Rodenstein, P Levy.
To sleep, perchance to leak.
Eur Respir J, 14 (1999), pp. 1241-1243
[32]
GN Richards, PA Cistulli, RG Ungar, M Berthon-Jones, CE Sullivan.
Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance.
Am J Respir Crit Care Med, 154 (1996), pp. 182-186
[33]
MJ Hayes, FB McGregor, DN Roberts, RC Schroter, NB Pride.
Continuous nasal positive airway pressure with a mouth leak: effect on nasal mucosal blood flux and nasal geometry.
Thorax, 50 (1995), pp. 1179-1182
[34]
Stiller R, Sanders M, Kern N, Constantino J, Strollo P. Monitorage non invasive de la PCO2 au cours du sommeil. In: Robert D, editor. Assistance ventilatoire à domicile. Paris: 1994; p. 119-39.
Copyright © 2004. Sociedad Española de Neumología y Cirugía Torácica (SEPAR)
Archivos de Bronconeumología
Article options
Tools

Are you a health professional able to prescribe or dispense drugs?