Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine—Volume I

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Pulmonology".

Deadline for manuscript submissions: closed (22 February 2023) | Viewed by 28417

Special Issue Editor


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Guest Editor
1. Department of Clinical, Integrated and Experimental Medicine (DIMES), University of Bologna, Bologna, Italy
2. Respiratory and Critical Care Unit, St. Orsola University Hospital, Bologna, Italy
Interests: non invasive ventilatory support techniques; respiratory palliative care; weaning from mechanical ventilation
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Special Issue Information

Dear Colleagues,

The importance of non-invasive respiratory therapies has been highlighted during the COVID-19 pandemic. The use of this treatment in all areas of the hospital has rapidly increased. Despite the increased use of these technologies within the hospital, there is an increased need to improve education and experience in this field, especially with regard to patients requiring long-term treatment at home.

This Special Issue titled “Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine—Volume I” aims to collect the latest approaches and findings, as well discuss current challenges in the provision of respiratory support (non-invasive ventilation with or without oxygen and high flow therapy) with regard to patient selection, initiation and telemedicine applications. Where applicable, case examples will be presented in addition to real data, aiming to assist the reader with their clinical practice. The focus is on getting it right in patient diagnosis and should include a focus on new modes and strategies of respiratory support such as autotitration modes and monitoring. (The Special Issue "Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine—Volume II" can be found here: https://www.mdpi.com/journal/jcm/special_issues/8A29H4I764)

We expect this Special Issue to promote the state of the art in this field, increase the visibility and importance of this area and promote research in areas where there are gaps. Potential topics include, but are not limited to:

  • Domiciliary high flow therapy;
  • Monitoring requirements for home mechanical ventilation;
  • The ventilator, modes and settings for home mechanical ventilation;
  • What circuit, mask and filters should be used in home mechanical ventilation;
  • Oxygen distribution with respiratory support devices in the hospital and home;
  • Hospital versus outpatient versus home initiation of ventilatory support.

Prof. Dr. Stefano Nava
Guest Editor

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Keywords

  • non-invasive ventilation (NIV)
  • continuous positive airway pressure (CPAP)
  • high flow therapy (HFT)
  • mouthpiece ventilation (MPF)
  • sleep studies
  • mechanical insufflation–exsufflation (MI-E)
  • chronic obstructive pulmonary disease (COPD)
  • neuromuscular disease (NMD)
  • amyotrophic lateral sclerosis (ALS)
  • home mechanical ventilation (HMV)
  • auto-EPAP monitoring
  • weaning

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Published Papers (11 papers)

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Editorial

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3 pages, 198 KiB  
Editorial
Non-Invasive Respiratory Support: How to Get It Right in Clinical Medicine
by Stefano Nava
J. Clin. Med. 2023, 12(16), 5243; https://doi.org/10.3390/jcm12165243 - 11 Aug 2023
Viewed by 687
Abstract
It is with great pleasure and enthusiasm that I introduce this Special Issue of the Journal of Clinical Medicine, entitled “Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine” [...] Full article

Review

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15 pages, 330 KiB  
Review
COPD Exacerbation: Why It Is Important to Avoid ICU Admission
by Irene Prediletto, Gilda Giancotti and Stefano Nava
J. Clin. Med. 2023, 12(10), 3369; https://doi.org/10.3390/jcm12103369 - 9 May 2023
Cited by 6 | Viewed by 2911
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD [...] Read more.
Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD causing acute respiratory failure (ARF) often requires admission to an intensive care unit (ICU) with endotracheal intubation and invasive mechanical ventilation. AECOPD also acts as comorbidity in critically ill patients; this condition is associated with poorer prognoses. The prevalence reported in the literature on ICU admission rates ranges from 2 to 19% for AECOPD requiring hospitalization, with an in-hospital mortality rate of 20–40% and a re-hospitalization rate for a new severe event being 18% of the AECOPD cases admitted to ICUs. The prevalence of AECOPD in ICUs is not properly known due to an underestimation of COPD diagnoses and COPD misclassifications in administrative data. Non-invasive ventilation in acute and chronic respiratory failure may prevent AECOPD, reducing ICU admissions and disease mortality, especially when associated with a life-threating episode of hypercapnic ARF. In this review, we report on up to date evidence from the literature, showing how improving the knowledge and management of AECOPD is still a current research issue and clinical need. Full article
11 pages, 1441 KiB  
Review
Getting It Right in Restrictive Lung Disease
by Annalisa Carlucci and Barbara Fusar Poli
J. Clin. Med. 2023, 12(10), 3353; https://doi.org/10.3390/jcm12103353 - 9 May 2023
Cited by 1 | Viewed by 2898
Abstract
Restrictive lung disease (predominantly in patients with neuromuscular disease (NMD) and ribcage deformity) may induce chronic hypercapnic respiratory failure, which represents an absolute indication to start home NIV (HNIV). However, in the early phases of NMD, patients may present only diurnal symptoms or [...] Read more.
Restrictive lung disease (predominantly in patients with neuromuscular disease (NMD) and ribcage deformity) may induce chronic hypercapnic respiratory failure, which represents an absolute indication to start home NIV (HNIV). However, in the early phases of NMD, patients may present only diurnal symptoms or orthopnoea and sleep disturbances with normal diurnal gas exchange. The evaluation of respiratory function decline may predict the presence of sleep disturbances (SD) and nocturnal hypoventilation that can be respectively diagnosed with polygraphy and PCO2 transcutaneous monitoring. If nocturnal hypoventilation and/or apnoea/hypopnea syndrome are detected, HNIV should be introduced. Once HNIV has been started, adequate follow-up is mandatory. The ventilator’s built-in software provides important information about patient adherence and eventual leaks to correct. Detailed data about pressure and flow curves may suggest the presence of upper airway obstruction (UAO) during NIV that may occur with or without decrease in respiratory drive. Etiology and treatment of these two different forms of UAO are different. For this reason, in some circumstances, it might be useful to perform a polygraph. PtCO2 monitoring, together with pulse-oximetry, seem to be very important tools to optimize HNIV. The role of HNIV in neuromuscular disease is to correct diurnal and nocturnal hypoventilation with the consequence of improving quality of life, symptoms, and survival. Full article
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10 pages, 243 KiB  
Review
Moving from Inpatient to Outpatient or Home Initiation of Non-Invasive Home Mechanical Ventilation
by Mike J. Kampelmacher
J. Clin. Med. 2023, 12(8), 2981; https://doi.org/10.3390/jcm12082981 - 19 Apr 2023
Cited by 2 | Viewed by 1583
Abstract
Home mechanical ventilation (HMV) is an effective treatment for patients with chronic hypercapnic respiratory failure caused by restrictive or obstructive pulmonary disorders. Traditionally, HMV is initiated in the hospital, nowadays usually on a pulmonary ward. The success of HMV, and especially non-invasive home [...] Read more.
Home mechanical ventilation (HMV) is an effective treatment for patients with chronic hypercapnic respiratory failure caused by restrictive or obstructive pulmonary disorders. Traditionally, HMV is initiated in the hospital, nowadays usually on a pulmonary ward. The success of HMV, and especially non-invasive home mechanical ventilation (NIV), has led to a steep and ongoing increase in the incidence and prevalence of HMV, in particular for patients with COPD or obesity hypoventilation syndrome. Consequently, the number of available hospital beds to accommodate these patients has become insufficient, and models of care that minimize the use of (acute) hospital beds need to be developed. At present, the practices for initiation of NIV vary widely, reflecting the limited research on which to base model-of-care decisions, local health system features, funding models, and historical practices. Hence, the opportunity to establish outpatient and home initiation may differ between countries, regions, and even HMV centres. In this narrative review, we will describe the evidence regarding the feasibility, effectiveness, safety, and cost savings of outpatient and home initiation of NIV. In addition, the benefits and challenges of both initiation strategies will be discussed. Finally, patient selection and execution of both approaches will be examined. Full article
14 pages, 2040 KiB  
Review
Ventilators, Settings, Autotitration Algorithms
by Manel Luján and Cristina Lalmolda
J. Clin. Med. 2023, 12(8), 2942; https://doi.org/10.3390/jcm12082942 - 18 Apr 2023
Cited by 2 | Viewed by 1447
Abstract
The choice of a ventilator model for a single patient is usually based on parameters such as size (portability), presence or absence of battery and ventilatory modes. However, there are many details within each ventilator model about triggering, pressurisation or autotitration algorithms that [...] Read more.
The choice of a ventilator model for a single patient is usually based on parameters such as size (portability), presence or absence of battery and ventilatory modes. However, there are many details within each ventilator model about triggering, pressurisation or autotitration algorithms that may go unnoticed, but may be important or may justify some drawbacks that may occur during their use in individual patients. This review is intended to emphasize these differences. Guidance is also provided on the operation of autotitration algorithms, in which the ventilator is able to take decisions based on a measured or estimated parameter. It is important to know how they work and their potential sources of error. Current evidence on their use is also provided. Full article
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18 pages, 19802 KiB  
Review
Optimizing Tracheal Oxygen Tension and Diffusion Ratio When Choosing High-Flow Oxygen Therapy or CPAP for the Treatment of Hypoxemic Respiratory Failure: Insights from Ex Vivo Physiologic Modelling
by Bill Truschel and Michael I. Polkey
J. Clin. Med. 2023, 12(8), 2878; https://doi.org/10.3390/jcm12082878 - 14 Apr 2023
Cited by 2 | Viewed by 1395
Abstract
This article is a review of the physiological and technological processes underpinning high-flow nasal therapy with oxygen (HFNT or HFOT) for the treatment of hypoxemic respiratory failure. A mathematical model was carefully built to represent the relationships between the settings on the HFNT [...] Read more.
This article is a review of the physiological and technological processes underpinning high-flow nasal therapy with oxygen (HFNT or HFOT) for the treatment of hypoxemic respiratory failure. A mathematical model was carefully built to represent the relationships between the settings on the HFNT device and the resultant diffusion of oxygen into hypoxemic, arterial blood. The analysis was used to recommend a strategy for setting the flow rate at or above the patient’s peak inspiratory flow when HFNT is used with a blender and equal to the patient’s peak inspiratory rate when bleed-in oxygen is used. The analysis also teaches how to titrate the settings to achieve a desired fraction of inhaled oxygen, (FiO2), in the trachea using a simple ratio when bleed-in oxygen is used. The model was used to compare HFNT as a method to improve oxygen diffusion efficacy with other forms of oxygen therapy. The analysis in this article relates the efficacy of HFOT/HFNT to that of CPAP with supplemental oxygen by computing the diffusion ratio of oxygen therapy versus breathing room air. We predicted that in non-atelectatic lungs, when considering oxygenation, HFNT can be equally effective as CPAP with supplemental oxygen therapy for treating hypoxemic respiratory failure. Full article
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12 pages, 4189 KiB  
Review
What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation
by Manel Luján, Pablo Flórez and Xavier Pomares
J. Clin. Med. 2023, 12(7), 2692; https://doi.org/10.3390/jcm12072692 - 4 Apr 2023
Cited by 1 | Viewed by 1644
Abstract
Most of the published reviews about non-invasive home ventilation mainly reflect the technical aspects of ventilators. There is much less information about the consumables most used at home. However, the choice of a good interface or tubing system can lead to physiological changes [...] Read more.
Most of the published reviews about non-invasive home ventilation mainly reflect the technical aspects of ventilators. There is much less information about the consumables most used at home. However, the choice of a good interface or tubing system can lead to physiological changes in the patient–ventilator interaction that the clinician should be aware of. These physiological changes may affect the performance of the ventilator itself, the reliability of monitoring and, of course, the comfort of the patient. The use of different circuits, masks or filters is therefore related to the concepts of rebreathing, compressible volume, instrumental dead space or leak estimation and tidal volume. Through certain bench experiments, it is possible to determine the implications that each of these elements may have in clinical practice. Full article
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15 pages, 295 KiB  
Review
Home High-Flow Therapy in Patients with Chronic Respiratory Diseases: Physiological Rationale and Clinical Results
by Maria Laura Vega Pittao, Gioacchino Schifino, Lara Pisani and Stefano Nava
J. Clin. Med. 2023, 12(7), 2663; https://doi.org/10.3390/jcm12072663 - 3 Apr 2023
Cited by 6 | Viewed by 2864
Abstract
High-flow therapy (HFT) is the administration of gas flows above 15 L/min. It is a non-invasive respiratory support that delivers heated (up to 38 °C), humidified (100% Relative Humidity, RH; 44 mg H2O/L Absolute Humidity, AH), oxygen-enriched air when necessary, through [...] Read more.
High-flow therapy (HFT) is the administration of gas flows above 15 L/min. It is a non-invasive respiratory support that delivers heated (up to 38 °C), humidified (100% Relative Humidity, RH; 44 mg H2O/L Absolute Humidity, AH), oxygen-enriched air when necessary, through a nasal cannula or a tracheostomy interface. Over the last few years, the use of HFT in critically ill hypoxemic adults has increased. Although the clinical benefit of home high-flow therapy (HHFT) remains unclear, some research findings would support the use of HHFT in chronic respiratory diseases. The aim of this review is to describe the HFT physiological principles and summarize the published clinical findings. Finally, we will discuss the differences between hospital and home implementation, as well as the various devices available for HHFT application. Full article
14 pages, 2392 KiB  
Review
Mechanical Insufflation-Exsufflation: Considerations for Improving Clinical Practice
by Michelle Chatwin and Ruth Helen Wakeman
J. Clin. Med. 2023, 12(7), 2626; https://doi.org/10.3390/jcm12072626 - 31 Mar 2023
Cited by 6 | Viewed by 5769
Abstract
The provision of mechanical insufflation-exsufflation (MI-E) devices to enhance cough efficacy is increasing. Typically, MI-E devices are used to augment cough in patients with neuromuscular disorders but also in patients who are weak in an acute care setting. Despite a growing evidence base [...] Read more.
The provision of mechanical insufflation-exsufflation (MI-E) devices to enhance cough efficacy is increasing. Typically, MI-E devices are used to augment cough in patients with neuromuscular disorders but also in patients who are weak in an acute care setting. Despite a growing evidence base for the use of these devices, there are barriers to the provision of MI-E, including clinician lack of knowledge and confidence. Enhancing clinician education and confidence is key. Individualized or protocolized approaches can be used to initiate MI-E. Evaluation of MI-E efficacy is critical. One method to evaluate effectiveness of MI-E is the MI-E-assisted cough peak flow (CPF). However, this should always be considered alongside other factors discussed in this review. The purpose of this review is to increase the theoretical understanding of the provision and evaluation of MI-E and provide insight into how this knowledge can be applied into clinical practice. Approaches to initiation and titration can be selected based on the clinical situation, patient diagnosis (including and beyond neuromuscular disorders), and clinician’s confidence. Full article
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18 pages, 5305 KiB  
Review
Monitoring Systems in Home Ventilation
by Jean-Michel Arnal, Mathilde Oranger and Jésus Gonzalez-Bermejo
J. Clin. Med. 2023, 12(6), 2163; https://doi.org/10.3390/jcm12062163 - 10 Mar 2023
Cited by 4 | Viewed by 3767
Abstract
Non-invasive ventilation (NIV) is commonly used at home for patient with nocturnal hypoventilation caused by a chronic respiratory failure. Monitoring NIV is required to optimize the ventilator settings when the lung condition changes over time, and to detect common problems such as unintentional [...] Read more.
Non-invasive ventilation (NIV) is commonly used at home for patient with nocturnal hypoventilation caused by a chronic respiratory failure. Monitoring NIV is required to optimize the ventilator settings when the lung condition changes over time, and to detect common problems such as unintentional leaks, upper airway obstructions, and patient–ventilator asynchronies. This review describes the accuracy and limitations of the data recorded by the ventilator. To efficiently interpret this huge amount of data, clinician assess the daily use and regularity of NIV utilization, the unintentional leaks and their repartition along the NIV session, the apnea–hypopnea index and the flow waveform, and the patient–ventilator synchrony. Nocturnal recordings of gas exchanges are also required to detect nocturnal alveolar hypoventilation. This review describes the indication, validity criteria, and interpretation of nocturnal oximetry and transcutaneous capnography. Polygraphy and polysomnography are indicated in specific cases to characterize upper airway obstruction. Telemonitoring of the ventilator is a useful tool that should be integrated in the monitoring strategy. The technical solution, information, and limitations are discussed. In conclusion, a basic monitoring package is recommended for all patients complemented by advanced monitoring for specific cases. Full article
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Other

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8 pages, 453 KiB  
Brief Report
Getting It Right in Obstructive Lung Disease
by Annalisa Carlucci and Barbara Fusar Poli
J. Clin. Med. 2023, 12(8), 3032; https://doi.org/10.3390/jcm12083032 - 21 Apr 2023
Cited by 1 | Viewed by 1148
Abstract
Chronic hypercapnic respiratory failure in obstructive lung diseases may benefit from nocturnal Home non-invasive ventilation (HNIV). It has been shown that in patients with persistence of hypercapnia after an acute episode of chronic obstructive pulmonary disease (COPD) exacerbation requiring mechanical ventilation, HNIV may [...] Read more.
Chronic hypercapnic respiratory failure in obstructive lung diseases may benefit from nocturnal Home non-invasive ventilation (HNIV). It has been shown that in patients with persistence of hypercapnia after an acute episode of chronic obstructive pulmonary disease (COPD) exacerbation requiring mechanical ventilation, HNIV may improve the risk for new admission and survival. The ability to reach these aims depends on the correct timing of enrolling patients, as well as a correct definition of ventilatory needing and setting of the ventilator. This review tries to define a possible home treatment path of hypercapnic respiratory failure in COPD by analyzing the main studies published in recent years. Full article
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