The growing role of noninvasive ventilation in patients requiring prolonged mechanical ventilation.
For many patients with chronic respiratory failure requiring ventilator support, noninvasive ventilation (NIV) is preferable to invasive support by tracheostomy. Currently available evidence does not support the use of nocturnal NIV in unselected patients with stable COPD. Several European  studies have reported benefit for high intensity NIV, in which setting of inspiratory pressure and respiratory rate are selected to achieve normocapnia. There have also been studies reporting benefit for the use of NIV as an adjunct to exercise training. NIV may be useful as an adjunct to  airway clearance techniques in patients with cystic fibrosis. Accumulating evidence supports the use of NIV in patients with obesity hypoventilation syndrome. There is considerable observational evidence supporting the use of NIV in patients with chronic respiratory failure related to neuromuscular  disease, and one randomized controlled trial reported that the use of NIV was life-prolonging in patients with amyotrophic lateral sclerosis. A variety of interfaces can be used to provide NIV in patients with stable chronic respiratory failure. The mouthpiece is an interface that is unique  in this patient population, and has been used with success in patients with neuromuscular disease. Bi-level pressure ventilators are commonly used for NIV, although there are now a new generation of intermediate ventilators that are portable, have a long battery life, and can be used for NIV  and invasive applications. Pressure support ventilation, pressure controlled ventilation, and volume controlled ventilation have been used successfully for chronic applications of NIV. New modes have recently become available, but their benefits await evidence to support their widespread use.  The success of NIV in a given patient population depends on selection of an appropriate patient, selection of an appropriate interface, selection of an appropriate ventilator and ventilator settings, the skills of the clinician, the motivation of the patient, and the support of the family.
Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. dhess@partners.org
Dean R
DR
Hess
D000690:Amyotrophic Lateral Sclerosis / Q000503:physiopathology / Q000628:therapy; D003550:Cystic Fibrosis / Q000453:epidemiology / Q000628:therapy; D004867:Equipment Design; D006801:Humans; D019458:Insurance Coverage; D006278:Medicare / Q000191:economics; D020388:Muscular Dystrophy, Duchenne / Q000503:physiopathology / Q000628:therapy; D009468:Neuromuscular Diseases / Q000503:physiopathology / Q000628:therapy*; D010845:Obesity Hypoventilation Syndrome / Q000503:physiopathology / Q000628:therapy; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D012121:Respiration, Artificial / Q000379:methods* / Q000706:statistics & numerical data; D012891:Sleep Apnea Syndromes / Q000453:epidemiology / Q000503:physiopathology; D013990:Tidal Volume / Q000502:physiology; D013997:Time Factors; D014481:United States; D012122:Ventilators, Mechanical