Nocturnal Nasal Ventilation for Treatment of Patients With Hypercapnic Respiratory Failure

https://doi.org/10.1016/S0025-6196(12)62081-3Get rights and content

We reviewed the Mayo Clinic experience with nocturnal nasal ventilation (NNV) and retrospectively assessed the clinical benefits, patient compliance, and complications. NNV had been instituted in 26 patients with daytime hypercapnia and nocturnal hypoventilation due to neuromuscular diseases or chronic obstructive pulmonary disease. After initiation of NNV, 21 of 26 patients continued to use this treatment regularly (81% compliance rate) and considered their life-style improved. In this subset of patients, the arterial partial pressure of carbon dioxide during unassisted breathing decreased from 64 ± 13 to 51 ± 7 mm Hg, and the arterial partial pressure of oxygen increased from 58 ± 12 to 68 ± 8 mm Hg. No significant change was noted in the forced vital capacity or maximal respiratory pressures. Four of the five patients in whom NNV had been discontinued cited discomfort related to the mask or severity and poor prognosis of the underlying illness as reasons for cessation of treatment. We conclude that NNV is well tolerated by most patients and may improve alveolar ventilation and arterial oxygenation in patients with chronic respiratory failure.

Section snippets

Patient Population and Selection Criteria.

Both ambulatory and hospitalized patients with hypercapnic ventilatory failure (arterial partial pressure of carbon dioxide [PaCO2] of more than 45 mm Hg) and nocturnal oxygen desaturation were considered for this protocol. All patients had undergone polysomnography or overnight pulse oximetry monitoring and demonstrated recurrent nocturnal hypoxemia refractory to supplemental oxygen therapy or alternative types of ventilatory support (or both). We excluded patients who required intubation for

Characterization of Study Group.

The 22 male and 4 female patients had a mean age of 58.4 (range, 17 to 76) years (Table 1). Unsuccessful treatment attempts before NNV included nasally administered continuous positive airway pressure in 11 patients, supplemental oxygen alone without augmented ventilation in 10, negative pressure ventilation with a cuirass in 2, and pharmacotherapy (medroxyprogesterone acetate) in 1. One patient with nocturnal hypoventilation syndrome had received conventional mechanical ventilation through a

REFERENCES (39)

  • SM Garay et al.

    Sustained reversal of chronic hypercapnia in patients with alveolar hypoventilation syndromes: long-term maintenance with noninvasive nocturnal mechanical ventilation

    Am J Med

    (1981)
  • JG Martin

    Clinical intervention in chronic respiratory failure

    Chest

    (1990)
  • C Guilleminault et al.

    Central alveolar hypoventilation and sleep: treatment by intermittent positive-pressure ventilation through nasal mask in an adult

    Chest

    (1989)
  • Z Carrey et al.

    Ventilatory muscle support in respiratory failure with nasal positive pressure ventilation

    Chest

    (1990)
  • D Segall

    Noninvasive nasal mask-assisted ventilation in respiratory failure of Duchenne muscular dystrophy

    Chest

    (1988)
  • ER Ellis et al.

    Noninvasive ventilatory support during sleep improves respiratory failure in kyphoscoliosis

    Chest

    (1988)
  • WT McNicholas et al.

    Nocturnal deaths among patients with chronic bronchitis and emphysema

    Br Med J

    (1984)
  • J Fleetham et al.

    Sleep, arousals, and oxygen desaturation in chronic obstructive pulmonary disease: the effect of oxygen therapy

    Am Rev Respir Dis

    (1982)
  • PTP Bye et al.

    Role of sleep in the development of respiratory failure in neuromuscular disease (abstract)

    Am Rev Respir Dis

    (1985)
  • Cited by (78)

    • Non-Invasive Ventilation in Acute, Post-Acute and Stable COPD

      2021, Encyclopedia of Respiratory Medicine, Second Edition
    • Management of Pulmonary Complications in Neuromuscular Disease

      2012, Physical Medicine and Rehabilitation Clinics of North America
      Citation Excerpt :

      The more common presentation, with insidious onset of respiratory failure in patients with NMD, can be improved by early intervention to prevent respiratory complications and prolong life. Noninvasive forms of both positive and negative ventilation and the rocking bed have been used effectively in reversing, at least temporarily, progressive chronic respiratory failure.30–33 Initially, patients may require ventilator support for only part of the day.

    • Current issues in home mechanical ventilation

      2007, Chest
      Citation Excerpt :

      Portable, lightweight, single-circuit flow generators that are capable of delivering bilevel pressure support with mask leak compensation can actually provide high levels of pressure support near 30 cm H2O. This treatment initially emerged and quickly proliferated with the successful application of nocturnal NPPV in the population of patients with neuromuscular disease (NMD) that has been described mostly in the European literature6 but also in the United States.7 Although one randomized trial89 suggested that patients with Duchenne muscular dystrophy who were introduced to NPPV as preventive therapy did not do as well as those patients receiving conservative treatment, the study was thought to be flawed, and NPPV has now become the standard of care for patients with NMD and hypoventilation.

    • Respiratory support of individuals with Duchenne muscular dystrophy: Toward a standard of care

      2005, Physical Medicine and Rehabilitation Clinics of North America
      Citation Excerpt :

      Respiratory insufficiency and pneumonia is the most frequent cause of death in individuals with DMD [1,2,4,5]. Numerous studies of NPPV using volume ventilators have shown that daytime Paco2 can be improved and symptoms of fatigue, daytime hypersomnolence, and morning headaches can be reduced significantly by nocturnal ventilation in patients with neuromuscular restrictive thoracic disorders, including many patients with DMD [57–65]. Application of nocturnal ventilation when appropriate also improves survival.

    View all citing articles on Scopus
    View full text