title: The appropriate setting of noninvasive pressure support ventilation in stable COPD patients.
abstract: OBJECTIVE
  To evaluate the short-term physiologic effects of two settings of nasal pressure-support ventilation (NPSV) in stable COPD patients with chronic hypercapnia.
  
  
  METHODS
  Randomized controlled physiologic study.
  
  
  METHODS
  Lung function units and outpatient clinic of two affiliated pulmonary rehabilitation centers.
  
  
  METHODS
  Twenty-three patients receiving domiciliary nocturnal NPSV for a mean (+/- SD) duration of 31 +/- 20 months.
  
  
  METHODS
  Evaluation of arterial blood gases, breathing pattern, respiratory muscles, and dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn) during both unassisted and assisted ventilation. Two settings of NPSV were randomly applied for 30 min each: (1) usual setting (U), the setting of NPSV actually used by the individual patient at home; and (2) physiologic setting (PHY), the level of inspiratory pressure support (IPS) and external positive end-expiratory pressure (PEEPe) tailored to patient according to invasive evaluation of respiratory muscular function and mechanics.
  
  
  RESULTS
  All patients tolerated NPSV well throughout the procedure. Mean U was IPS, 16 +/- 3 cm H(2)O and PEEPe, 3.6 +/- 1.4 cm H(2)O; mean PHY was IPS, 15 +/- 3 cm H(2)O and PEEPe, 3.1 +/- 1.6 cm H(2)O. NPSV was able to significantly (p < 0.01) improve arterial blood gases independent of the setting applied. When compared with spontaneous breathing, both settings induced a significant increase in minute ventilation (p < 0.01). Both settings were able to reduce the diaphragmatic pressure-time product, but the reduction was significantly greater with PHY (by 64%; p < 0.01) than with U (56%; p < 0.05). Eleven of 23 patients (48%) with U and 7 of 23 patients (30%) with PHY showed ineffective efforts (IE); the prevalence of IE (20 +/- 39% vs 6 +/- 11% of their respiratory rate with U and PHY, respectively) was statistically different (p < 0.05).
  
  
  CONCLUSIONS
  In COPD patients with chronic hypercapnia, NPSV is effective in improving arterial blood gases and in unloading inspiratory muscles independent of whether it is set on the basis of patient comfort and improvement in arterial blood gases or tailored to a patient's respiratory muscle effort and mechanics. However, setting of inspiratory assistance and PEEPe by the invasive evaluation of lung mechanics and respiratory muscle function may result in reduction in ineffective inspiratory efforts. These short-term results must be confirmed in the long-term clinical setting.
authors.affiliation: Pulmonary Department, Scientific Institute of Gussago, Fondazione Salvatore Maugeri IRCCS, Gussago, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Vitacca
authors.forename: S
authors.initials: S
authors.lastname: Nava
authors.forename: M
authors.initials: M
authors.lastname: Confalonieri
authors.forename: L
authors.initials: L
authors.lastname: Bianchi
authors.forename: R
authors.initials: R
authors.lastname: Porta
authors.forename: E
authors.initials: E
authors.lastname: Clini
authors.forename: N
authors.initials: N
authors.lastname: Ambrosino
mesh_terms: D000368:Aged; D002245:Carbon Dioxide / Q000097:blood; D002908:Chronic Disease; D003964:Diaphragm / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006699:Home Care Services; D006801:Humans; D006935:Hypercapnia / Q000503:physiopathology / Q000628:therapy; D001239:Inhalation / Q000502:physiology; D008168:Lung / Q000503:physiopathology; D008173:Lung Diseases, Obstructive / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008451:Maximal Voluntary Ventilation / Q000502:physiology; D009666:Nose; D010100:Oxygen / Q000097:blood; D011175:Positive-Pressure Respiration / Q000379:methods*; D018467:Positive-Pressure Respiration, Intrinsic / Q000503:physiopathology; D011312:Pressure; D012119:Respiration; D015656:Respiratory Mechanics / Q000502:physiology; D012132:Respiratory Muscles / Q000503:physiopathology
chemical_list: D002245:Carbon Dioxide; D010100:Oxygen