Resp Care
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Noninvasive ventilation (NIV) is under-utilized, despite robust evidence supporting its use in appropriately selected patients with acute respiratory failure. Diffusion of NIV into practice requires that clinicians view it as better than invasive ventilation, that it is perceived as compatible with existing approaches to mechanical ventilation, that it is not too difficult to apply, that it is trialable, and that its results are visible. Barriers to NIV use include lack of awareness of the evidence, lack of agreement with the evidence, lack of self-efficacy, unrealistic outcome expectations, and the inertia of previous practice. ⋯ For optimum success the multidisciplinary nature of NIV application must be recognized. The NIV program should be a quality-improvement initiative. Following these principles, a successful program can be initiated in any acute-care setting.
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This conference brought together experts on noninvasive ventilation (NIV) to discuss and debate the advances in evidence and technology over the past decade. A major impetus for the conference was that many institutions have not systematically integrated NIV into their clinical practice, despite mounting, high-level evidence supporting its effectiveness. ⋯ The papers in this and last month's special issue of the Journal provide an informative guide for clinicians attempting to implement NIV in their institutions. This paper summarizes the major findings from each presentation and the discussions that followed.
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Acute cardiogenic pulmonary edema (ACPE) is a common cause of respiratory failure that necessitates endotracheal intubation. In some patients intubation and its attendant complications can be avoided with noninvasive ventilation (NIV). Both continuous positive airway pressure (CPAP) and NIV have been evaluated in patients with ACPE. ⋯ Initial concern that NIV may be associated with a greater risk of myocardial infarction than CPAP was laid to rest by later studies. Despite a physiologic rationale that NIV should offer greater benefit than CPAP, NIV has not been found to offer any advantages regarding intubation rate or mortality compared with CPAP. We review the randomized controlled trials and summarize the evidence on NIV and CPAP in patients with ACPE.
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The use of noninvasive ventilation (NIV) for acute respiratory failure has become widespread, but with the newfound beneficial treatments come complications. There is credible although somewhat disparate evidence to support the concept that, compared to invasive ventilation, NIV can reduce the incidence of infectious complications. In selected populations, nosocomial pneumonia appears to be significantly less common with NIV than with endotracheal intubation. ⋯ Despite apparently similar costs of treatment for patients with equivalent severity of illness, there is substantially less reimbursement for NIV than for intubation. The use of sedation in NIV patients has not been systematically studied, and sedation is generally underutilized, to avoid complications. Do-not-intubate patients pose a special ethical dilemma with regard to NIV, because NIV may conflict with a preexisting directive not to use life-support measures in the terminally ill patient.
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Noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been used in various unusual settings to assist breathing. NIV is now frequently used to treat exacerbations of chronic obstructive pulmonary disease and chronic respiratory failure in neuromuscular disease. This paper discusses CPAP and NIV for postoperative hypoxemia, preventing intubation in high-risk bronchoscopy, respiratory failure in pandemics, obesity hypoventilation syndrome, and respiratory support during percutaneous endoscopic gastrostomy tube placement.