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Editor
Antonio M. Esquinas
Noninvasive Mechanical Ventilation
Theory, Equipment, and Clinical Applications
3rd ed. 2023
Editor
Antonio M. Esquinas
Murcia, Spain
ISBN 978-3-031-28962-0 e-ISBN 978-3-031-28963-7
https://doi.org/10.1007/978-3-031-28963-7
© The Editor(s) (if applicable) and The Author(s), under exclusive
license to Springer Nature Switzerland AG 2010, 2016, 2023
This work is subject to copyright. All rights are solely and exclusively
licensed by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in
any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks,
service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.
The publisher, the authors, and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
material contained herein or for any errors or omissions that may have
been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer
Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham,
Switzerland
Preface
The 3rd edition of “Noninvasive Ventilation, Theory, Equipment and
Clinical Practice” was born 6 years ago as a written reference on the
three fundamental aspects that define an adequate and complete vision
of noninvasive ventilation. This book has been able to achieve a 3rd
edition, thanks to all the researchers and scientific contributions that
continue to confirm that noninvasive ventilation remains one of the
major advances in clinical practice, of a multidisciplinary scope and of
major contribution to the improvement of the most common and
atypical situations of chronic acute respiratory failure in the pre-
hospital, hospital and home care setting.
In this 3rd edition, there is a selection of the most important
controversial top topics of the past two years, since together with a
valuable panel of authors, the concept of noninvasive ventilation in a
wide variety of situations has been analyzed.
The reader who is new to noninvasive ventilation and a senior of
this technique can find a solid and well-defined reference on the
definition, equipment advances (ventilatory modes, interpretation of
noninvasive ventilation-asynchrony; mask interfaces technology),
advances in monitoring, indications, classes and emerging indications
of noninvasive ventilation.
The book encompasses and structures the concepts in specific
sections and chapters, linked for a correct conclusion of noninvasive
ventilation.
The index offers a sequence of concepts and applications from
physiology and pathophysiology, physical basis of the equipment and
ventilatory modes. In the section on clinical indications, there is a
logical sequence of all possible indications in the hospital setting.
Finally, the book concludes with a section on prognosis, ethical aspects,
and quality of life of the patient, which allows a global vision and
application of noninvasive ventilation.
Antonio M. Esquinas
Murcia, Spain
Acknowledgements
To all the authors who gave their time and made this 3rd edition
possible.
To our patients, the essence of the realization of this book.
To our families
Abbreviations
ACPE Acute cardiogenic pulmonary edema
ACRF Acute on chronic respiratory failure
AHI Apnea-hypopnea index
AI Asynchrony index
ALS Amyotrophic lateral sclerosis
ANN American Academy of Neurology
ARDS Acute respiratory distress syndrome
ARF Acute respiratory failure
AVAPS Average volume-assured pressure support ventilation
Bilevel NPV Bilevel negative pressure ventilation
BiPAP Bilevel positive airway pressure
BMI Body mass index
BPAP Bilevel positive airway pressure
CARDS Covid-19 acute respiratory distress syndrome
CNAPV Continuous negative abdominal pressure ventilation
CNPV Continuous negative pressure ventilation
CO Cardiac output
CO2 Carbon dioxide
COPD Chronic obstructive pulmonary disease
COT Conventional oxygen therapy
COVID-19 Coronavirus disease 2019
CPAP Continuous positive airway pressure
CPPV Continuous positive pressure ventilation
ENPV External negative-pressure ventilation
EP Expiratory port
EPAP Expiratory positive airway pressure
ERV Expiratory reserve volume
ETI Endotracheal intubation
FF Full face
FiO2 Fraction of inspired oxygen
FOSQ Functional Outcomes of Sleep Questionnaire
FRC Functional residual capacity
FVC Forced vital capacity
HF Heart Failure
HFNOT High flow nasal oxygen therapy
HFOT High flow oxygen therapy
HRQoL Health related quality of life
I:E Inspiration to expiration ratio
IBW Ideal body weight
ICU Intensive care unit
IHT Intra-hospital transport
IMV Invasive mechanical ventilation
IPAP Inspiratory positive airway pressure
IPPV Intermittent positive pressure ventilation
ITPP Intra-thoracic positive pressure
iVAPS Intelligent volume assured pressure support
LV Left ventricle
MIP Maximal inspiratory pressure
MV Mechanical ventilation
NIPPV Non-invasive positive pressure ventilation
NIV Noninvasive ventilation
NRS Noninvasive respiratory support
OHS Obesity hypoventilation syndrome
ON Oronasal
OSA Obstructive sleep apnea
OSAS Obstructive sleep apnea syndrome
PaCO2 Partial carbon dioxide pressure
PaO2 Partial oxygen pressure
PaO2/FiO2 Arterial oxygen pressure/inspiratory fraction of oxygen
ratio
PEEP Positive end expiratory pressure
Pres-NIV Pressure-preset noninvasive ventilation pressure
PS Pressure support
PSV Pressure support ventilation
Ptm Trans-mural pressure
pts Patients
PVA Patient–ventilator asynchrony
PVR Pulmonary vascular resistance
QOL Quality of life
RCT Randomized controlled trial
REM Rapid eye movement
RV Right ventricle
SNIP Sniff nasal inspiratory pressure
SpO2− Pulse oxygen saturation
SRI Severe respiratory insufficiency
Te Expiratory time
Ti Inspiratory time
TLC Total lung capacity
TPP Trans-pulmonary pressure
TST Total sleep time
TV Tidal volume
Vol NIV Volume-preset noninvasive ventilation
VR Venous return
VT Tidal volume
VTPCV Volume-targeted pressure-controlled ventilation
WOB Work of breathing
Contents
Part I Physiology
1 Rationale of Noninvasive Ventilation
Teresa Michi, Tommaso Rosà , Michael C. Sklar and
Domenico Luca Grieco
1.1 The Physio-Pathological Mechanism Underlying NIV
1.1.1 NIV and Gas Exchange Improvement
1.1.2 NIV and Work of Breathing Reduction
1.1.3 Cardiovascular effects of NIV
1.2 Clinical Benefits and Negative Effects of NIV
1.2.1 Clinical Benefits of NIV
1.2.2 NIV Side Effects
1.3 Mode of Ventilation
1.4 Interfaces
1.4.1 High-PEEP Helmet NIV
1.5 Ventilators and Humidification
1.6 Pharmacological Agents
References
Part II Interface, Ventilatory Modes and Ventilators
2 Interfaces for Noninvasive Mechanical Ventilation:Different
Types and Mask Ventilation
Bruno Mendes, Carlos Figueiredo, Mariana Cabral and
Alexandra Mineiro
2.1 Introduction
2.2 Interface Selection
2.3 Facial Interface
2.3.1 Oronosal Mask
2.3.2 Total-Face/Full-Face Mask
2.3.3 Helmet
2.4 Nasal Interface
2.4.1 Nasal Mask
2.4.2 Nasal Pillow
2.5 Other Interfaces
2.5.1 Mouthpiece
2.5.2 Custom-Built
2.6 Conclusion
References
3 Ventilatory modes of Noninvasive Mechanical Ventilation:
Technology and Clinical Implications
S. Aneesa Shahul and Nishant Kumar Chauhan
3.1 Contraindications for NIV
3.2 Advantages
3.3 Modes of Noninvasive Ventilation
3.4 Advantages of Pressure-Targeted Ventilation
3.5 Ventilator Modes
3.5.1 Continuous Positive Airway Pressure Ventilation
(CPAP)
3.5.2 Bilevel Positive Pressure Ventilation (BiPAP)
3.5.3 Proportional Assist Ventilation
3.5.4 Volume Preset Ventilation/Volume Targeted
Ventilation
3.5.5 Volume Assured Pressure Support (VAPS)
3.5.6 Adaptive Servo Ventilation
3.6 Clinical Implications of NIV
3.6.1 Hypercapnic Respiratory Failure
3.6.2 Obstructive Sleep Apnea
3.6.3 Obesity Hypoventilation Syndrome
3.6.4 Central Sleep Apnea
3.6.5 Pulmonary Edema
3.7 Limitations
References
4 Noninvasive Ventilation-Leaks Compensation and Clinical
Implications
Beatriz Ferraz, Bruno Gomes and Antonio M. Esquinas
4.1 Introduction
4.1.1 Air Leaks
4.1.2 Mouth Leak
4.1.3 Internal Air Leaks
4.2 Air Leaks Clinical Implications
4.2.1 Volume vs Pressure Ventilators
4.2.2 Asynchrony
References
5 New Ventilatory Modes of Noninvasive Mechanical Ventilation
Umberto Vincenzi
5.1 Positive + Negative Synchronized Ventilation
5.1.1 Ventilatory Mechanics
5.2 Intermittent Abdominal Pressure Ventilation (IAPV)
References
6 Ventilators for Noninvasive Mechanical Ventilation:Theory and
Technology
Raffaele Scala, Teresa Renda and Luca Guidelli
6.1 Introduction
6.2 Classification of Ventilators
6.3 Technologic Issues
6.3.1 Source of Gas and Oxygen Supply
6.3.2 Circuit
6.3.3 Pressurization rate or inspiratory flow
6.3.4 Back-Up Respiratory Rate
6.3.5 Air Leak Compensation
6.3.6 Battery
6.3.7 Alarm and Monitoring System
6.4 Controversial Issues
References
7 Continuous Positive Airway Pressure (CPAP)
Giovanni Ferrari, Elena Rindone, Roberta Di Tria and Roberto Prota
7.1 Introduction
7.2 Devices to Deliver CPAP
7.2.1 High Flow Generators
7.3 Respiratory and Cardiovascular Effects of CPAP
7.3.1 Respiratory Effects of CPAP
7.3.2 Hemodynamic Effects of CPAP
7.4 CPAP Indications and Contraindications
7.4.1 Contraindications
7.4.2 Absolute
7.4.3 Relative
7.5 Conclusions
References
8 Negative Noninvasive Mechanical Ventilation:External Negative
Pressure Ventilation (ENPV)
Corrado Mollica and Umberto Vincenzi
8.1 Introduction
8.1.1 Operation of External Ventilators (ENPV)
8.1.2 Ventilation “Mode”
8.1.3 Favorable and Adverse Side Effects of ENPV
8.2 Discussion and Analysis:Main Topic
8.2.1 Why and When ENPV Is to Be Used
8.2.2 In ARDS Patients
8.2.3 As a Bridge to Lung Transplant
8.3 Conclusions and Take Home
References
Part III Nasal High Flow
9 High Flow Nasal Oxygen Therapy
Michalis Agrafiotis, Marija Hadjimitrova and Asterios Tzinas
9.1 Introduction
9.2 Design and Technology of High Flow Nasal Oxygen Therapy
Devices
9.3 Mechanisms and Physiologic Effects of High Flow Nasal
Oxygen Therapy
9.4 Practicalities in the Implementation of High-Flow Nasal
Oxygen Therapy
9.5 Contraindications, Side Effects and Concerns Regarding
High Flow Nasal Oxygen Therapy
9.6 Monitoring of High Flow Nasal Oxygen Treatment
9.7 Clinical Applications of High Flow Nasal Oxygen Therapy
References
Part IV Complementary Technologies in NIV
10 Humidification and Airway Secretions Management
Pinar Atagun Guney
10.1 Introduction
10.2 Humidification Requirements in NIMV
10.3 Types of Humidification in NIMV
10.4 Problems of Humidification in NIMV
10.5 Management of Mucociliary Activity
10.6 Recommendations
References
11 Aerosol Therapy
Michalis Agrafiotis, Dimosthenis Fletsios and Electra Karypidou
11.1 Introduction
11.2 Aerosol Mechanics
11.3 Aerosol Generating Devices
11.4 Aerosol Therapy During Noninvasive Ventilation
11.4.1 Technical Aspects
11.4.2 Lung Function Variables
11.5 Conclusions and Key Points
References
Part V Methodology; Patient-Ventilator Interaction
12 How to Start Noninvasive Ventilation:Preparation of the
Patient, Interface, and Primary Ventilator Setting
Andreas Perren, Alessandro F. Chiesa and Cristian Fusi
12.1 Introduction
12.2 Ventilators and Interfaces
12.3 How to Approach the Patient
12.4 Primary and Secondary Ventilator Settings
12.5 Monitoring of the First NIV Session
12.6 Preventing and Solving Problems
12.7 Conclusion
References
13 Pressure/Airflow and Volume Waveforms
Laura Fagetti
13.1 Introduction
13.2 Pressure Versus Time Scalar
13.3 Flow Versus Time Scalar (Fig.13.3)
13.4 Volume Versus Time Scalar (Fig.13.4)
13.5 Monitoring Noninvasive Mechanical Ventilation Using
Ventilator Waveforms
13.5.1 Ineffective Triggering or Ineffective Effort
13.5.2 Autotriggering
13.5.3 Double Trigger
13.5.4 Rise Time
13.5.5 Hang-Up
13.5.6 Expiratory Cycling
13.5.7 Hyperdynamic Inflation
13.5.8 Volume Scalar
References
14 Basic Patient Ventilator Interaction:Pressure–Volume–Flow
María Sevilla Martinez and Dionisio Guillamon Fernandez
14.1 Introduction
14.2 Patient–Ventilator Interaction
14.3 Causes that Affect Asynchrony
14.4 Asynchrony Groups
14.4.1 Asynchrony in the Trigger Phase
14.4.2 Asynchrony During the Pressurization Phase
14.4.3 Asynchrony of Cycling:Asynchronous Expiration
14.4.4 Asynchrony Related to Interfaces
14.5 Conclusion
References
15 Non Invasive Ventilation Asynchrony:Diagnosis and Treatment
Rahul Roshan and Sanjeev Singhal
15.1 Introduction
15.2 Diagnosis of Asynchrony
15.3 Ventilator Waveform Analysis and Terminologies in
Asynchrony in NIV (Fig.15.1)
15.3.1 Ineffective Triggering
15.3.2 Auto-Triggering
15.3.3 Double Triggering
15.3.4 Premature &Prolonged Cycling
15.4 Determinants of Asynchrony in NIV
15.4.1 Patient–Ventilator Interface
15.4.2 Rebreathing
15.4.3 Leaks
15.4.4 Humidification Devices
15.5 Key Practical Recommendations
15.5.1 Type of Ventilator
15.5.2 Trigger
15.5.3 Flow Synchrony
15.5.4 Cycling
15.5.5 Patient–Ventilator Interface
15.5.6 Humidification
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