Content

Recent Advance in BiPAP Care

Speaker: Leung Kwok Cheung APN, ICU/PMH

Introduction Breathing mode Indication Contra-indication Nursing care of NIV Complication Updates of NIV

Introduction

NIV = Non Invasive Ventilation Delivery ventilatory support that without the need for invasive artificial airway
Non invasive Negative Pressure Ventilation Iron Lung Non invasive Positive Pressure Ventilation CPAP/BiPAP

Introduction
st

1 trial of NIV in 1930s, and successful treatment documented in1960s Does not require a tracheal tube

Wysocki M et al, Eur respir J 2001

Require nasal, oral or oronasal interface and a device capable of delivering gas with sustained high-flow and positive air pressure.

Introduction

Breathing mode

A significant increase in use of NIV over the 88-years study.

Implementing use of NIV in patient with COAD and CPE Outcome: 1.improved survival 2.reduction of nosocomial infection.

Most common use NIV in PMH

BiPAP Vision

CPAP BiPAP

S mode T mode S/T mode

Girou, E.2003

Continuous Positive Airway Pressure

CPAP

CPAP

Single level breathing mode Patient breathes at an elevated positive pressure level

The purpose is to keep the airway patent and alveoli open for improving oxygenation.
Positive pressure

Alveoli

BiPAP = Bi-level Patient breathes between 2 elevated positive pressure level IPAP resembles PS(pressure support) which helps to enhance breathing effort EPAP resembles CPAP/PEEP for keeping the alveoli open
IPAP (Inspiratory positive airway pressure) EPAP (Expiratory positive airway pressure)

BiPAP

Lung Volume

Tidal volume

EPAP PEEP Functional residue capacity

Lung Volume

IPAP

the work of breathing

T
V

IPAP

EPAP

alveolar ventilation dead space ventilation respiratory rate related to auto PEEP gas exchange
Hypoxemia and hypercapnia
Antonelli M et al, Crit Care, 2000

respiratory distress unloads respiratory muscles Improves respiratory muscle function

FRC

EPAP

gas exchange alveolar recruitment corrects hypoxemia FRC prevent alveolar collapse in end-expiratory phase. lung compliance + TV respiratory muscle fx Enhances the delivery of bronchodilators to distal bronchial tree
Antonelli M et al, Crit Care, 2000

BiPAP Mode

S (Spontaneous) T (Timed)

Flow sensors detect spontaneous inspiratory effort triggers IPAP cycles back to EPAP IPAP/EPAP cycling is purely machine-triggered, at a set rate, typically expressed in breaths per minute (BPM)

dynamic hyperinflation effort to trigger ventilator.

BiPAP Mode

S/T (Spontaneous/Timed)

How does NIV work?

Similar S mode the device triggers to IPAP on patient inspiratory effort a "backup" rate is also set to ensure that patients still receive a minimum number of breaths per minute if they fail to breathe spontaneously
CPAP EPAP S IPAP EPAP S/T IPAP EPAP RR T IPAP EPAP RR I:E

work of breathing (WOB) Avoid respiratory muscle fatigue TV CPAP counterbalances the inspiratory threshold work related to intrinsic PEEP Reversing microatelectasis of lung
improve compliance

Advantages

Advantages

Improve clinical outcomes e.g morbidity, mortality, LOS, Cost effective Avoid complications of endotracheal intubation Reduces the need for sedation

Significantly reduce infection rate and VILI

Early (local trauma, aspiration) Late (injury to the the hypopharynx, larynx, and trachea, nosocomial infections)

VAP, LOS, Mortality

Antonelli M et al, Crit Car, 2000

Advantages

Maintain Oral patency preserves speech, swallowing, cough Patient comfort, also participates in decision making, better communication with health care professional.

Disadvantages

System Mask

Increased initial time commitment Gastric distension (occurs in <2% patients) Air leakage Transient hypoxemia from accidental removal Eye irritation Facial skin necrosis most common complication Difficulty in suctioning of secretions risk of aspiration

Lack of airway access and protection

Antonelli M et al, Crit Car, 2000

Sleep apnea syndrome Neuromuscular disorders Central hypoventilation syndrome Severe chest deformities Immunosuppression COPD Actue Cardiogenic Pulmonary Edema Hypoxic Respiratory Failure Promote early extubation Extubation failure

Indication

Contraindication

Unconscious patient Require large amount of sedation Tend to vomit Have poor cough or gag reflex Uncooperative or agitated status Have pre-existing pathologies

Common indication in ICU

Pnemothorax Pulmonary emphysema Severe epistaxis Recent upper airway or upper GI surgery

Ensure a safe and effective NIV therapy

Familiar with the interface Familiar with the ventilator

Nursing care of NIV

Interface
Nasal mask

Interface

Total face mask

Facial mask

Nasal pillow Helmet Nasal prong

Helmet

Facial mask vs Nasal mask

Advantages (+) and disadvantages (-) of face and nasal mask Clinical Aspect Mouth leak and mouth breathing Influence of dental status Airway pressure Dead space Communication Eating, drinking Expectoration Risk of aspiration Comfort Eating or drinking via preset pot Risk of gastric distention Facial mask Nasal mask + + + + + + + + + +

Rare complications in Helmet Skin necrosis Gastric distention Eye irritation LOS, intubation rates, Mortality rate similar Patient tailor makes and more expensive
Intensive Care Med. 2003:29 Crit Care Med. 2002:30; Chest. 200:126

Helmet vs facial mask

Most common use in ICU

Total face mask

Facial mask vs Total face mask

Outcome Early NIV discontinuations Failure to improve Mask intolerance Agitation Copious secretions Claustrophobia Intubation rate Mean LOS Mortality Facial mask (n=31) 12 (38.0) 7 (23.3) 5 (16.7) 0 (0.0) 2 (6.7) 3 (10.0) 9 (29.0) 19.2 (5-92) 6 (19.4) Total mask (n=29) 16 (55.2) 5 (17.9) 11 (39.3) 1 (3.6) 0 (0.0) 5 (17.9) 6 (20.7) 10.9 (1-77) 3 (10.3)

Facial mask vs Total face mask

Weaning, intubation rate, LOS, Mortality Mean vital signs (HR, RR, SaO2) NO significant differences between facial mask and total face mask

CHEST 2011; 139(5):10341041

Availability of masks in your unit NIV ventilator type Comfort vs Effectiveness Patient head shape and face contour

Mask selection

Mask Fitting Golden Rule:

All Noses Are Not Created Equal!

Place chin in mask first Rotate upward Internal sealing flap should be below the lower lip Lightly press against face Secure headgear straps Minimal tension should be applied Connect circuit

How to fitting Total Face Mask

Mask Cleaning Instructions

Every Day Wash in hot soapy water No alcohol or lotions Disassembly not necessary Air dry Allergy to Mask Material Know composition of mask Change to mask with other material Irritation to Skin Soak in hot soapy water for one hour
CELKI

Ten Tips For Mask Usage

Accessories

1. Clean face and mask thoroughly before each use. 2. Remove mask by pulling over head or use quick release. 3. Mark the straps with permanent marker where fastened. 4. Tight fit is not necessary. The mask can be loose as long as a seal is maintained. (Overtightening may create folds that may result in leaks.) 5. Straps can be adjusted to prevent air leaks. 6. Small leaks are acceptable. 7. Eliminate all leaks into the eyes. 8. Do not over tighten the headgear. 9. Check for proper sizing of the mask and spacer. 10.Do not block the openings on the exhalation device.
CELKI

Entrainment valve

Whisper-Swivel + Whisper-Swivel II

Air entrainment valve

Inspiratory valve Knife-edge seat, disc and spring Requires a very small ve pressure to be exerted the disc to lift allowing air to be entrained

Exhalation devices

In mask-Full face mask In circuit

Whisper-Swivel Whisper-Swivel II Plateau expiratory valve Better removal of CO2 in COPD patient

Exhalation devices

Exhalation devices

Different position in different type of masks Less rebreathed CO2 for mask with exhalation port

Whisper Swivel / Disposable Exhalation Port / Built-in Exhalation Port Plateau Valve Alert on use of Plateau Valve with EPAP setting above 8 cmH2O
The blue diaphragm will be depressed by high pressure level of EPAP in the expiratory phase towards the valve cap and hinder the CO2 washout from the exhaust vent.

Minimum EPAP Setting

Using Bacteria Filter

EPAP settings of 4 cmH2O should be used (insure CO2 wash out and prevent build up)

Use a HIGH Flow / LOW Resistant Filter Filter Use in the hospital prevent cross contamination If Using a heated humidifier, the filter will also act as a barrier to prevent water from entering the unit
Bacteria filter

Nebulizer during NIV

Place Nebulizer in-line at the end of hose using a Teepiece adapter and mouth piece Keep flow to drive Nebulizer less than 15 LPM
Most Nebulizer use 6 - 10 LPM

Humidification during NIV

Humidification not normally necessary, unless

Drying of nasal mucosa Airway resistance poor Compliance

Allow patient to use BiPAP w/ Nebulizer at Will

Take a couple of breaths at a time followed by short break until patient adapts to treatment

HME significantly

Resistance Compliance Impair function of inspiratory and expiratory triggers

Hess DR, Respir Care 2004

Ventilator setting

Ventilator setting
Mode FiO2 IPAP

EPAP

Rate

Tidal Volume
(Estimated exhaled tidal volume)

Minute Ventilation
(Estimated)

Peak Inspiratory Pressure

Parameters

Ventilator setting

Determine the level of CPAP and EPAP 5-8 cmH2O Determine the level of IPAP Oxygen Backup RR + I:E ratio (1:2,1:3)

CPAP: Single pressure level BiPAP: IPAP + EPAP, 2 pressure level

Clinical assessment

Nursing care - monitoring

10-20cmH2O achieve TV 8-10ml/kg Not recommended >20cmH2O overcome esophageal pressure Gas mixing and leaking FiO2 >0.5 is difficult to achieve even using maximal flow of 15L/min

Continue SpO2 ABG Monitoring: Within 1 2-6 hr after start to determine success, and afterwards when indicated
st

Chest wall movement Co-ordination of respiratory effort with ventilator Accessory muscle recruitment HR RR Patient comfort Mental status

Monitoring - Ventilator function

Air leak

IPAP

EPAP

Universally accepted to have some air leak Monitored determinant of success of NIV BiPAP compensates up to 60 LPM Leak Mouth or Mask Leaks < 25 LPM are Ok

Rate

AirLeak 60 L/min

Tidal Volume Minute Ventilation

Peak Inspiratory Pressure

Nasal mask

Air leak

Air leak

Oro-nasal masks Applied in those in respiratory distress with mouth breathing. Comfort Flap will help stop leaks into Eyes. If bothersome Mouth Leaks continue, use Full Face Mask.

Mouth leakdue to nasal resistance as a result of unidirectional flow. Minimized by mouth closure or use chin straps

Caution with air leak over ~60 L/min

Air leak enhances :

Prevention of CO2 retention the chance of re-breathing

But not excessive air leak!

Air leak

Significant air leak for most BiPAP is 0.4L/sec above intentional leak (exhalation port)
effectiveness of ventilation (excessive air leak) Inability to maintain optimal pressures Sleep fragmentation Inability to trigger ventilator Prolonged inspiratory time (increased time taken for flow compensation) Air Leak Guidelines Greater oxygen consumption 0 - 6 lpm = Too tight
7 - 25 lpm 26 - 60 lpm > 60 lpm = Just right = Adjust = Caution

Monitoring

Rabec CA et al, Arch Bronconeumol 2004

Alarms warn of events An event is condition/occurrence requiring clinical awareness/action Events are related to: Technical performance of ventilator or Change in patients clinical condition that ventilator can detect

Alarm Overview

Types of Vision System Alarms

System

Preset by manufacturer Monitor technical performance of ventilator Monitor patients clinical condition that can be detected by ventilator with adjustable alarm to facilitate monitoring.

Adjustable

System Alarms

Pressure Regulation Low Battery for new model Proximal Pressure Line Disconnection Oxygen Flow Low Leak

Low Internal Battery Alarm

Lo Int. Batt. message illuminates /audible alarm Alarm activates when internal battery voltage is low. Plug in AC supply and start battery charging.

Pressure Regulation Alarm

Activated when proximal pressure +/- 5 cmH 0 of set pressure P. Regulation message illuminates /audible alarm Ventilator sends available flow to achieve set pressure Audible self cancels when measured prox. pressure within specification.
2

Proximal Line Disconnect Alarm

Activated by proximal pressure line disconnect Prox. Line Disc. message illuminates /audible alarm. Possible causes:
Pressure line disconnection or obstruction.

O Flow message illuminates/audible alarm.

Possible cause:
2
2

Low Oxygen Flow Alarm

Low Flow Alarm

1. Insufficient oxygen supply pressure. 2. Obstructed oxygen inlet filter

. Audible self cancels O /air ratio within range for set FIO
2

Activated when average baseline flow decreases by > 25% or 4 L/min, for a period of one minute Low Flow message illuminates /audible alarm Audible self cancels when baseline flow returns to within range Averaged baseline leak calculated when:

Unit is turned on and begins operation Mode change Learn soft key selected by user

Adjustable Alarms

Standard Optional

High Pressure Alarm

High Pressure Low Pressure with Low Pressure Delay control Apnea Low Rate High Rate Low Minute Ventilation

1. Inappropriate alarm limit setting 2. Patient coughing during inspiratory cycle.

Activated proximal pressure > high pressure limit for 0.5 sec. Hi P message illuminates/audible alarm. Possible cause:

Set according to proximal pressures Warns of events occurring proximal to patient

Ventilator immediately terminates breath (added safety feature) Audible self cancels if proximal pressure < high pressure limit on next breath

Low Pressure Alarm

Proximal pressure < low pressure limit for set time delay

Apnea Alarm
Activated if spontaneous trigger not detected within set interval

Lo P message illuminates/audible alarm.

Possible cause:
1. Large leak 2. Patient and circuit disconnection. 3. Patient inspiratory demand flow > machine delivered flow.

Apnea message illuminates/ audible alarm. Possible causes:

1. Patient not breathing, unable to trigger. 2. Circuit may be disconnected.

Audible self cancels if proximal pressure > low pressure limit on next breath

Low Rate Alarm

Activated total respiratory rate < low rate BPM limit

High Rate Alarm

Activated total respiratory rate > high rate BPM limit

Lo RATE message illuminates/audible alarm

Possible causes:
1. decreased in RR 2. Unable to trigger ventilator. 3. Inappropriate alarm limit setting.

Hi RATE message illuminates/audible alarm Possible causes:

1. Increase in patient breathing rate. 2. Improperly set alarm limit.

Audible self cancels total respiratory rate > low rate BPM limit

Audible self cancels total respiratory rate < high rate BPM limit

Activated when minute ventilation < set low minute ventilation limit Low Min Vent message illuminates/audible alarm. Possible causes:
Large leak or patient and circuit disconnection RR decreased or tidal volume decreased

Low Minute Ventilation Alarm

Nursing care of NIV

Maintain adequate oxygenation & ventilation

Audible self cancels minute ventilation > set low minute ventilation limit

Observation ABG, SpO2 Respiratory rate & pattern Signs of exhaustion or respiratory distress Standby Bag & mask Suction Intubation equipment Mechanical Ventilator

Nursing care of NIV

Reduce patient anxiety & physical discomfort Anxiety Explanation, reassurance Physical discomfort Nasal abrasion Skin irritation Eye irritation Dryness of mucous membrane Gastric distension Muscle cramps

Nursing care of NIV

Detect lifelife-threatening complications

Aspiration Cardio-pulmonary complications Decrease in conscious level Desaturation

Rare Cx

Gastric distension Nosocomial pneumonia Pneumothorax Pneumonmeidastinum Air embolism stroke Esophageal perforation Esophago-pleural fistula Upper airway obstruction inspirated secretion
Hung SC et al , Eur Respir J, 1998; Hurst JR et al, Thorax, 2003; Hill NS, Resp Care 2000

Inability to tolerate the mask because of discomfort or pain Inability to improve gas exchange or dyspnea Need for endotracheal intubation to manage secretions or protect airway Hemodynamic instability ECG ischemia/arrhythmia Failure to improve mental status in those with CO2 narcosis.
Gay, 2008

When to discontinue NIV?

New model:BiPAPmodel:BiPAP- V60

Bipap V60 -additional mode

Bipap V60: PC mode

The PCV (pressure controlled ventilation) ventilation) - delivers pressurepressure-controlled mandatory breaths, either triggered by the ventilator (Timed) or the patient (spont).

Bipap V60: Ramp time

The Ramp time

- helps patient adapt to ventilation by gradually increasing inspiratory (IPAP) and expiratory pressure (EPAP) from subtherapeutic to user-set interval.

Bipap V60: AVAPS mode (Average volumevolume-assured pressure support)

Bipap V60 : CC-flex for CPAP

AVAPS Maintain a target tidal volume in a pressure limited mode -It achieves the target volume by regulating the pressure applied.

*If the calculated target pressure is outside of the minimum and maximum pressure range, the target volume will not be achieved.

CPAP with CC-Flex

-offer 3 levels of flow based expiratory pressure relief at the beginning of exhalation. - improved patient comfort and improved sleep quality

Bipap V60 for transport

1. Ensure O2 cylinder are full. 2. Whenever possible, reduce the O2 setting before transport. 3. Minimize all inadvertent leak 4. Be aware O2 is rapidly depleted at high leak rate. 5. Ensure fully charged backup battery power for transport. transport.

Oxygen depletion at various rate of leak

COAD patient
Oxygen (N=20) Intubation 7(35) 2.72.0 7.9 4.1 4 (20) NIV (N=19) 0 (0) 1.20.4 8.78.3 2 (10) P value 0.005 0.006 0.68 0.36

Is NIV effective in COAD patient?

ICU Stay LOS Mortality

Bersten NEJM 1991; 325: 1825

COAD patient
Five centers in Europe
Intubated

COAD patient
NIV (N=43)
11 (26%)

Control (N=42)
31 (74%)

Hospital Stay

23 + 17 days

35 + 33 days

Mortality

4 (9%)

12 (29%)

Brochard NEJM 1995; 333:817 Chin Med J, 2005

MetaMeta-analysis NIV

Success rate 80- 85% mortality +LOS significantly intubation rate significantly Nosocomial infection and pneumonia rate significantly pH, PaCO2 , reduces the severity of breathlessness in first 4 hr of treatment Insufficient data to confer benefit of NIPPV to other patients
Keenen CCM 1997; 25:1685; Girou JAMA 2000; 284; 2361;GOLD 2003

Is NIV effective in COAD patient?

Asthma patient
A total of 26 patients completed the study in the NPPV group. significantly improved after 40 minutes in the high-pressure group compared with that in the control group (p<0.0001).

Is NIV effective in Asthma patient?

Soma et al., 2008

Asthma patient

Is NIV effective in Asthma patient?

Soroksky et al., 2003

CAP patient
Intubation rate

Is NIV effective in CAP patient?

Antonelli et al., 2001

Study involved 64 severe CAP patient 36 patients (56%) failed on NIV 28 patients (43%) succeeded All patient had lower pH before NIV BUT no significant data proven effectiveness of NIV on CAP patient

CAP patient

Is NIV effective in CAP patient?

Guerin et al., 1997; Nourdine et al., 1999

Hypoxemic ARF

Is NIV effective in Hypoxiemia ARF patient?

Antonelli et al, 1998

Hypoxemic ARF
Risk of Intubation rate in difference type of ARF

Hypoxemic ARF
Compare with baseline and NIV after2 Hrs
100
No difference PaCO2, pH Respiratory Rate Does not support the routine use of NIV in all patients with acute hypoxemic respiratory failure

Log Odds Ratio 0.01

COPD Cardiogenic P. Edema Acute Hypoventilation Post-Extubation Failure Hypoxemic Respiratory Failure

0.1

0.5 1 2

10

Antonelli el at, 1998

Martin et al, 2000; Keenan et al, 2004

Is NIV effective in Hypoxiemia ARF patient?

Is NIV effective in CPE patient?

Cardiogenic Pulmonary edema (CPE)

Effects of NIV on Mortality Effects of NIV on Intubation

CPE

Oxygenation need for intubation mortality rate Hypercapnia patients

more rapid relief of respiratory distress better gas exchange intubation rate
Masip et al, 2005; Mehta, et al, 1997; Peter et al, 2006; Nava et al, 2003

Masip et al., 2005; Peter et al, 2006

Is NIV effective in CPE patient?

Is NIV effective in Chest trauma patient?

Chest trauma patient

RCT of NIV vs IPPV

Nosocomial infection mortality Lower PaO2 in first 2 days Same ICU stay Less intubation rate LOS shorter Same survival

Is NIV effective in Chest trauma patient?

RCT of NIV vs O2 mask

Gunduz et al., 2003; Hernandez et al., 2010

Immunosuppressed patient

Is NIV effective in Immunosuppressed patient?

Early initiation of NIV is associated with significant intubation rate and serious complications and improved LOS.
Conti et al., 1998; Hilber et al., 2004

Is NIV effective in Immunosuppressed patient?

Is NIV effective in ALI/ARDS patient?

ARDS/ALI patient
Not significant improved

ARDS/ALI patient
Intubation rate

Delclaux et al., 2000

Antonelli et al., 2001

ARDS/ALI patient

70.3% failed on NIV 19 patients shock or metabolic acidosis. mortality rate in NIV NIV should be tried very cautiously or not at all in ARDS/AIL patients
Garpestad & Hill, 2006; Rana et al., 2006

Is NIV effective in ALI/ARDS patient?

PostPost-extubation patient

Is NIV effective in postpost-extubation ARF patient?

Does not improve outcome in patients who develop respiratory distress during the first 48 hours after extubation

Esteban et al., 2004; Ferrer et al., 2006; Keenan et al., 2002

Is NIV effective in postpost-extubation ARF patient?

Is NIV effective in weaning?

Weaning
Duration/day

Weaning

11 RCT of NIV vs IPPV

Mortality VAP ICU stay LOS total duration MV support

Use of NIV facilitate weaning in MV patients with predominantly COPD is significant benefit
Ferrer et al., 2009 Burns et al., 2006

Summary
Condition COPD Asthma CAP Suggestion NIV More study More study NIV depend on case NIV More study NIV Avoid NIV NIV but still more study Avoid NIV NIV LOE(Level of evidence) A C C A A B/C A C B C A

Is NIV effective in weaning?

Hypoxemic ARF CPE Chest trauma Immunosuppesed ARF ALI/ARDS Post-operation ARF Post extubation ARF Weaning from MV

Keenan et al., 2011

NIV provides ventilatory support to patient but less complications compared with mechanical ventilation. Provide as a first line therapy in a wide variety of conditions causing respiratory failure. Use cautiously and depend on case Early initiation of NIV is associated with good outcome in appropriately selected individuals

Take Home message

References
Alasdair G, Steve G, David E N, Moyra M, Fiona S, Jon N. Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema ,The New England Journal of Medicine. Boston:Jul 10, 2008. Vol. 359, Iss. 2, p. 142-51 Ambrosino, N; Foglio, K; Rubini, F; Clini, E; Nava, S; Vitacca, M, Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax. 50(7):755-757, July 1995. Ambrosino N & Vagheggini G. Noninvasive positive pressure ventilation in the acute care setting: where are we? Eur Respir J , 2008; 31: 874-886. American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Socit de Ranimation de Langue Franaise, and approved by the ATS. International Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. Am. J. Respir. Crit. Care Med., Volume 163, Number 1, January 2001, 283-291 . Andres E, Fernando FV, Niall DF et al., Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation. N Engl J Med 2004;350: 2452-60. Antonelli M, Conti G, Moro ML et al., Predictors of failure of noninvasive positive pressure ventialtion in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med, 2001; 27: 17181728. Antonelli M; Conti G; Bufi M; Costa MG; Lappa A; Rocco M; Gasparetto A; Meduri GU, Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 283(2):235-41, 2000 Jan 12.

References
Antonelli, M; Conti, G; Bufi, M; Costa, M; Lappa, A; Rocco, M; Gasparetto, A; Meduri, Gi, Noninvasive Ventilation for Treatment of Acute Respiratory Failure in Patients Undergoing Solid Organ Transplantation: A Randomized Trial. JAMA. 283(2):235-241, January 12, 2000. Antonelli M, Conti G, Rocco M, et al: A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429, 1998.

References
Conti G, Marino P, Cogliati A, et al: Noninvasive ventilation for the treatment of acute respiratory failure in patients with hematologic malignancies: a pilot study. Intensive Care Med 24:1283, 1998. Conti G, Antonelli M, Navalesi P et al., Noninvasive vs conventional mechankical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med, 2002; 28: 1701-1707. Cuvelier A, Viacroze C, Benichou J et al., Dependency on mask ventilation after acute respiratory failure in the intermediate care unit. Eur Respir J 2005, 26: 289-297. Domenighetti G, Gayer R & Gentilini R. Noninvasive pressure support ventilation in non-COPD patients with acute cardiogenic pulmonary edema and severe community-acquired pneumonia: acute effects and outcome. Intensive Care Med, 2002; 28: 1226-1232. Esteban A, Frutos-Vivar F, Ferguson ND, et al: Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004, 350:2452. Ferrer M, Esquinas A, Leon M et al., Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure: A Randomized Clinical Trial. Am J Respir Crit Care Med, 2003; 168: 1438-1444. Ganesan R, Watts DK, Lestrud S. Noninvasive Mechanical Ventilation. Clin Ped Emerg Med, 2007; 8:139-144 Garpestad E & Hill NS. Noninvasive ventilation for acute lung injury: how often should we try, how often should we fail? Critical Care, 2006; 10 ($): 147.

Antonelli M; Conti G; Rocco M; Bufi M; De Blasi RA; Vivino G; Gasparetto A; Meduri GU, A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. New England Journal of Medicine. 339(7):429-35, 1998 Aug 13. Bach, J.R. (2002). Noninvasive Mechanical ventilation. Hanley & Belgus, INC, Philadelphia. BiPAP Vision Clinical Manual Celikel T, Sungur M, Ceyhan B, Karakurt S: Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. Chest 114:1636, 1998. Cheung TM, Yam LY, So LK, et al: Effectiveness of noninvasive positive pressure ventilation in the treatment of acute respiratory failure in severe acute respiratory syndrome. Chest 126:845, 2004. Confalonieri M, Potena A, Carbone G, et al: Acute respiratory failure in patients with severe communityacquired pneumonia. Am J Respir Crit Care Med 160:1585, 1999.

References
Guerin C, Girard R, Chemorin C, et al: Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia: a prospective epidemiological survey from a single ICU. Intensive Care Med 23:1024, 1997. Hilbert G, Gruson D, Vargas F, et al: Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481, 2001. Hilbert G, Gruson D, Portel L, et al: Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J 11:1349, 1998. Hilbert, G; Gruson, D; Vargas, F; Valentino, R; Gbikpi-Benissan, G; Dupon, M; Reiffers, J; Cardinaud, J, Noninvasive Ventilation in Immunosuppressed Patients with Pulmonary Infiltrates, Fever, and Acute Respiratory Failure. New England Journal of Medicine. 344(7):481-487, February 15, 2001. In a randomized trial of asthma treatment: Can Bayesian statisticalanalysis explain the results? Acad Emerg Med 2001;8:1128-35. Jaber S; Delay JM; Chanques G; Sebbane M; Jacquet E; Souche B; Perrigault PF; Eledjam JJ, Outcomes of patients with acute respiratory failure after abdominal surgery treated with noninvasive positive pressure ventilation., Chest. 128(4):2688-95, 2005 Oct. Jolliet P, Abajo B, Pasquina P, et al: Non-invasive pressure support ventilation in severe communityacquired pneumonia. Intensive Care Med 27:812, 2001.

References
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