What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation
Abstract
:1. Introduction
2. Circuits and Expiratory Valves
2.1. Double Limb System
2.1.1. Implications for Monitoring
2.1.2. Implications for Ventilator Performance
2.2. Single Limb with Active Valve
Effects on Monitoring
2.3. Single Limb with Intentional Leakage
2.3.1. Effectiveness in Preventing Rebreathing
2.3.2. Influence on Monitoring
- Both parameters (tidal volume and leakage) are closely related, as the total flow is the sum of tidal volume plus the leakage. Therefore, if one is underestimated, the other will also be overestimated.
- The reference point commonly used to determine leakage (and indirectly tidal volume) is usually the transition between expiration and inspiration, because at that point, the patient’s flow is zero and therefore all circulating flow will correspond to leakage. In fact, it is analogous to a single equation with two unknowns, in which the total amount of flow is known for the entire cycle, but their components (patient’s flow and leaks) are not known. Only in two points of the cycle (transitions from inspiration to expiration and vice versa) one of the values (leakage) is known since the patient’s flow is zero. The choice of the expiratory–inspiratory transition as a reference is related to the flatter slope in the flow waveform at this point. Then, small deviations in the curve would not represent a big error in the estimations.
- If the leak flow and the pressure (EPAP/PEEP) are known, the resistance of the system during the expiratory phase can be estimated by means of the Poiseuille’s law for fluids. Usually, the leakage during inspiration is calculated by applying the resistance value to the inspiratory phase. In other words, a linear or near-linear relationship is assumed. However, there are some situations in clinical practice that do not fulfil this linearity (asymmetric leaks). For example, a poorly attached interface can produce leakage in the system only during inspiratory phase. In this case, the leakage (and the tidal volume) can be wrongly estimated [17].
- Based mainly on this single datum (resistance during expiratory phase), an attempt is made to determine what happens for the whole respiratory cycle. Therefore, if this point is taken as a reference (at the end of the cycle), the analysis must be applied to the next cycle, not to the same cycle that generated this datum. This can be misleading in very heterogeneous cycles.
- The estimation of leakage (and therefore tidal volume) must consider that the actual data (pressure and flow) are obtained inside the ventilator, and that there is a pressure loss through the system dependent on the outlet flow and the properties of the tubing (resistance and compliance, by Poiseuille’s law). Some manufacturers have incorporated tests for the correction of the pressure values (pre-use tests) for greater reliability in the estimation of the tidal volume [18]. Another option would be the placement of a proximal pressure sensor, such as in some acute care ventilators.
2.3.3. Influences on Ventilator Performance
3. Interfaces
- Nasal masks: cover the nasal structure, with support on the nasal bridge and upper jaw area, especially.
- Nasal pillows: cover only the nasal orifices.
- Oronasal masks, whey can be classified into two subtypes: the conventional oronasal mask, with support on the nasal bridge and lower jaw, and the subnasal (“hybrid”) mask, with support on the lower jaw but respecting the nasal bridge by means of support on the cartilaginous area of the nose.
- Full-face masks: nose and mouth coverage and forehead support.
- Oral-only interfaces: mouthpiece and lip-seal masks.
4. Filters and Other Items
5. Conclusions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Item | Types | Advantages | Disadvantages |
---|---|---|---|
Limb systems | Double limb system | Accuracy in monitoring. only compressible volume needs correction | Bulky system |
Single limb with active valve | PEEP not strictly necessary | Flow expiratory waveform not displayed. Semiology may be confusing. | |
Single limb with intentional leakage | Simple system | Rebreathing under certain conditions should be considered. Leakage and tidal volume estimation are challenging. | |
Masks | Nasal | Less instrumental dead space | Oral leakage. |
Oronasal | No oral leakage | Can worsen upper airway obstructions. | |
Filters | Protective effect | Interferences in trigger function and pressurization. |
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Luján, M.; Flórez, P.; Pomares, X. What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation. J. Clin. Med. 2023, 12, 2692. https://doi.org/10.3390/jcm12072692
Luján M, Flórez P, Pomares X. What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation. Journal of Clinical Medicine. 2023; 12(7):2692. https://doi.org/10.3390/jcm12072692
Chicago/Turabian StyleLuján, Manel, Pablo Flórez, and Xavier Pomares. 2023. "What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation" Journal of Clinical Medicine 12, no. 7: 2692. https://doi.org/10.3390/jcm12072692
APA StyleLuján, M., Flórez, P., & Pomares, X. (2023). What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation. Journal of Clinical Medicine, 12(7), 2692. https://doi.org/10.3390/jcm12072692