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Contemporary Reviews in Sleep MedicineInitiation of Noninvasive Ventilation for Sleep Related Hypoventilation Disorders: Advanced Modes and Devices
Section snippets
Hardware
In minimally monitored hospital areas and at home, the most common NIV devices being used are bilevel positive airway pressure (BPAP) devices exclusively designed to interact with a mask. They are basically composed of a blower (or turbine), a respiratory circuit (generally a single limb), heated humidity, and a mask. Based on flow and pressure sensors located in the device, a microprocessor-based controller is constantly adjusting the turbine speed (dynamic blower) to reach a preset device
Effective Ventilation by Synchronization With NIV Devices
The effective ventilation of a patient is attained only by reaching a synchronous interaction between the “mechanical pump” (settings) and the “respiratory pump” (the patient’s ability and desire to breathe). Effective synchrony requires optimized mask fitting to reduce flow and other comfort features such as heat and humidity adjustments. Finally, synchrony requires the respiratory specialist to harmonize settings to the unique features of each patient’s physiology.
NIV for Sleep-Related Alveolar Hypoventilation in Non-ICU Hospital Settings/Sleep Laboratory and at Home
Selection of the appropriate mode of NIV and the adjustment of NIV settings are of crucial importance to reach optimal synchronization with the patient.23 However, hospital or sleep laboratory initiation and titration of BPAP devices in patients with complex cardiopulmonary comorbidities could be challenging. Therefore, it is recommended that this titration (modes/settings) be performed in a monitored environment (monitored bed in a hospitalized patient or sleep laboratory setting for chronic
Troubleshooting Asynchronies
Multiple asynchronies may emerge during titration of NIV devices. Similar to invasive mechanical ventilation, these asynchronies could be identified at initiation of inhalation (eg, ineffective inspiratory effort, double triggering or auto-triggering), or at the end of it (eg, premature or late cycling). Before adjusting any setting on the device, a thorough mask fitting should take high priority toward minimizing any pressure leak. If not compensated, a mask leak may (1) increase or decrease
Conclusions
In the past 2 decades, the role of NIV in the management of acute and chronic sleep-related alveolar hypoventilation syndromes has dramatically changed medical practice in hospitals as well as in outpatient settings. However, a growing knowledge gap exists in the way to adjust these devices’ settings to achieve synchrony and match the patient’s unique respiratory failure physiology. Unfortunately, there are several shortcomings in this area. In the NIV literature, the objective testing (bench
Acknowledgments
Financial/nonfinancial disclosures: None declared.
Additional information: The e-Tables can be found in the Supplemental Materials section of the online article.
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