Non-invasive Ventilation in the Post-Acute Care Setting

Editor’s note: This text-based course is an edited transcript of the webinar, Non-invasive Ventilation in the Post-Acute Care Setting, presented by Claire Aloan, MS, RRT-NPS, FAARC.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Describe the patients who may benefit from non-invasive ventilation in the post-acute care setting
• List the available methods of non-invasive ventilation for post-acute care
• Explain the advantages and disadvantages of each method

Terminology

• Non-invasive ventilation (NIV) is a form of mechanical ventilation where positive pressure is provided to the airway and lungs through a mask or cannula, or mouthpiece
• Negative pressure ventilation (NPV) is a form of ventilation that promotes air flow using negative pressure applied to the chest wall
• POV® proportional open ventilation, a technology that augments inspired tidal volume
• TAV®: Tidal assist ventilator. Adds bolus to spontaneous tidal volume
• Post-acute care settings: usually home but may also include long-term care facilities and rehab settings

During this presentation, I will be using certain terminology. Hopefully, most of it is familiar, although some might be new to you. We will be referring to non-invasive ventilation as NIV, which involves mechanical ventilation providing positive pressure to the airway lungs through a mask, cannula, or mouthpiece. Sometimes, you will see this abbreviated as NPPV, denoting non-invasive positive pressure ventilation.

There are a couple of other abbreviations to keep in mind. However, when discussing non-invasive ventilation, our main focus will be on positive pressure. This sets the tone for our discussion. We will also touch upon NPV, which stands for negative pressure ventilation—a method where airflow is encouraged by applying negative pressure to the chest wall.

We will delve into the concept of proportional open ventilation, a technology that boosts inspired tidal volume. We will discuss the tidal assist ventilator (TAV), which essentially supplements spontaneous tidal volume with a bolus.

To clarify, post-acute care primarily refers to the home setting. Usually, when we talk about non-invasive ventilation beyond acute care, whether short-term or long-term, we are considering patients transitioning to home care. However, these interventions may also be relevant in long-term care facilities and rehabilitation settings, catering to the diverse needs of our patients.

Why NIV in Post-Acute Care?

Why do we want to even think about non-invasive ventilation in post-acute care? Well, when we use this, especially in the appropriately selected patients, we can do a number of things. One of the most important things we can do is to improve the quality of life of our patients. Many of our patients with disorders that affect the respiratory system are very limited in what they can do their quality of life tends to go downhill fairly rapidly.

Being able to reverse that and improve their quality of life is such a huge benefit of non-invasive ventilation. If you are involved in this at all with these patients, it is really a very feel-good place to be as a respiratory therapist. We also like the idea of reducing hospital admissions. That is a good thing for a number of reasons. Obviously, the expense of being in the hospital also affects your quality of life. Patients really do not want to be in the hospital, and it is not a great place for them to be. Reducing mortality is something that we work on patients can live longer, better lives with non-invasive ventilation. Oftentimes, we are looking at reducing dyspnea. We will talk specifically about how with some devices improving patients' exercise capacity, non-invasive ventilation has been shown to be helpful in all of those things.

Patients Who May Need NIV 

• COPD
• Thoracic restrictive disorders
• Obesity hypoventilation syndrome
• ? Interstitial lung disease

When considering patients who might benefit from non-invasive ventilation beyond the acute care setting, we often think of individuals with a variety of respiratory conditions. While non-invasive ventilation is commonly utilized in acute care for COPD patients to avoid invasive intubation and its associated complications, its potential extends well beyond this setting.

As patients transition from hospitalization to home, rehabilitation facilities, or long-term care, the need for non-invasive ventilation may persist. This includes COPD patients who require ongoing respiratory support beyond the acute phase. However, it is essential to broaden our perspective to encompass other respiratory conditions such as thoracic restrictive disorders, obesity hypoventilation syndrome, and possibly interstitial lung disease.

Thoracic restrictive disorders encompass a range of conditions characterized by reduced lung expansion, potentially leading to hypercapnic respiratory failure. Similarly, obesity hypoventilation syndrome, defined by obesity, daytime hypercapnia, and coexisting obstructive sleep apnea, may necessitate non-invasive ventilation to address respiratory insufficiency.

While the role of non-invasive ventilation in interstitial lung disease remains somewhat uncertain, it is an area that warrants further exploration. By considering these diverse patient populations, we can better recognize the potential benefits of non-invasive ventilation and ensure its appropriate utilization beyond the acute care setting.

COPD

In discussions regarding COPD, there has been considerable controversy in recent years regarding its efficacy. However, the most recent study by William et al. (2021), which serves as the cornerstone publication summarizing various aspects of non-invasive ventilation by Williams and other pulmonologists, presents compelling evidence.

The prevailing belief now is that non-invasive ventilation indeed enhances survival and reduces healthcare utilization. This focus is increasingly favored. Often, in intensive care or step-down units, patients initially on invasive ventilation can be transitioned to non-invasive ventilation as a bridge to home respiratory support. This approach evolves alongside advancements in non-invasive ventilation technology. We can consider weaning non-invasive ventilation patients to settings conducive to home use.

Frequently, we administer non-invasive ventilation at relatively high settings during exacerbations, gradually tapering down but not necessarily discontinuing it entirely. Instead, we adjust the settings to accommodate home use. The timing of initiating non-invasive ventilation is crucial for COPD patients during exacerbations, particularly for those persistently hypercapnic, as they demonstrate the most significant benefits. It is important to note that non-invasive ventilation is not universally applicable to all COPD patients. It is most beneficial for those persistently hypercapnic.

There is evidence suggesting the need for more aggressive settings. Research indicates that patients receiving high-intensity pressure support fare better than those receiving low-intensity pressure support. When prescribing settings for home use, it may be advantageous to opt for slightly higher pressure differentials between inhalation and exhalation, defining pressure support. This calls for a reconsideration of our approach, perhaps leaning towards a more proactive stance than previously adopted.

Hypercapnic COPD patients constitute a distinct phenotype driven by specific physiological factors, such as air trapping, which imposes a significant mechanical disadvantage. Many of these individuals experience nocturnal hyperventilation and are prone to sleep apnea, placing them at heightened risk for adverse health outcomes. They represent a priority target for intervention, as highlighted in the latest GOLD guidelines, which offer a comprehensive discussion of COPD phenotypes worth exploring.

Home non-invasive ventilation holds promise in addressing the underlying physiological issues contributing to hypercapnia. While older literature yielded mixed results regarding its efficacy in various populations, recent clinical trials have demonstrated significant benefits, including improvements in quality of life, reduced hospitalizations, and mortality rates. This emerging body of literature supports a more assertive approach towards its utilization. Additionally, advancements in non-invasive ventilation technology, particularly in optimizing inspiratory pressure, may account for the observed success in home settings.

Effective implementation necessitates a thorough understanding of patient selection criteria and familiarity with available device modes and titration strategies. While literature offers insights into these aspects, practical constraints often limit our options in device selection and mode availability, both in hospital and home settings. Providers typically operate within the confines of specific devices offered by their institution or supplier, thereby influencing treatment decisions. Nevertheless, advocating for access to appropriate devices and modes remains crucial in optimizing patient outcomes.

We are excited about the emergence of telemonitoring, as it addresses a key challenge in the management of patients on non-invasive ventilation transitioning from hospital to home care. In the hospital setting, we have the luxury of being present, continuously titrating the device, and monitoring patient response. However, once patients return home, this level of oversight diminishes significantly. While in-home visits are feasible, they cannot provide round-the-clock surveillance, making telemonitoring an invaluable tool.

Telemonitoring enables us to remotely adjust device settings, enhance patient adherence, troubleshoot issues, and even anticipate exacerbations. Its evolving capabilities hold promise in optimizing non-invasive ventilation outcomes in home settings. Studies have demonstrated the efficacy of non-invasive ventilation in prolonging exercise endurance in COPD patients. However, implementing this during routine activities outside clinical settings poses logistical challenges, as most devices lack portability and usability during normal activities.

Nevertheless, there are exceptions to this limitation, which we will delve into further. Overall, telemonitoring represents a significant advancement in the management of COPD patients on non-invasive ventilation, offering enhanced support and optimization beyond the confines of traditional care settings.

Thoracic Restrictive Disorders

Another group of conditions we frequently consider is what we refer to as thoracic restrictive disorders. This encompasses a broad spectrum of conditions characterized by hypercapnic respiratory failure, where ventilatory defects impede adequate air movement in and out of the chest, resulting in elevated CO2 levels exceeding 45 millimeters of mercury.

A prominent category within this group comprises neuromuscular disorders, including conditions such as ALS, spinal cord injuries, muscular dystrophy, diaphragm paralysis, and spina bifida. Additionally, certain congenital central hypoventilation syndromes may hinder sufficient air exchange. Chest wall deformities, notably kyphoscoliosis, also fall under this classification. Furthermore, ventilatory drive defects, where patients lack the innate urge to breathe adequately, are pertinent considerations.

It is crucial to note that interstitial lung diseases are not typically classified under thoracic restrictive disorders despite causing restrictive pulmonary dysfunction. Consequently, thorough assessment is imperative to rule out obstructive sleep apnea (OSA), which, although less common in these conditions compared to COPD, may still occur. Monitoring CO2 and oxygen levels during wakefulness and sleep is essential post-therapy initiation, with sleep testing reserved for cases suggestive of OSA. Non-invasive ventilation remains a viable therapeutic option for these patients.

Obesity Hypoventilation Syndrome (OHS)

Another disorder to consider is obesity hypoventilation syndrome (OHS), characterized by the combination of obesity (with a BMI greater than 30), daytime hypercapnia exceeding 45 millimeters of mercury for CO2, and a diagnosis of obstructive sleep apnea (OSA). It is crucial to exclude other potential causes of alveolar hypoventilation before confirming this diagnosis.

Given the co-existence of OSA in these patients, continuous positive airway pressure (CPAP) is typically the initial treatment choice. However, CPAP may prove ineffective or poorly tolerated in correcting the ventilation disorder, especially when patients are hypoventilating alongside their OSA. In such cases, non-invasive ventilation becomes necessary to address their respiratory needs effectively.

Careful titration is essential for these patients, particularly regarding pressure selection, to reduce the apnea-hypopnea index to normal levels (less than five). Additionally, treatment must aim to alleviate both hypoventilation and hypoxia. Patients with OHS require comprehensive monitoring and follow-up, including sleep lab titration and clinic visits to assess blood gases and device adherence. Typically, follow-up appointments are scheduled four to six weeks post-initiation of non-invasive ventilation, allowing patients sufficient time to adjust to and utilize the device properly.

Interstitial Lung Disease (ILD)

Interstitial lung disease (ILD) encompasses a diverse array of progressive and debilitating lung conditions characterized by similarities in lung pathology and radiographic findings. However, with hundreds of distinct ILDs identified, the patient population exhibits considerable heterogeneity.

Management of ILD often involves oxygen therapy to maintain adequate oxygen saturation levels, yet achieving this can be challenging due to various factors contributing to limited exercise tolerance in these patients. In instances where oxygen therapy alone proves insufficient, considering adjunctive non-invasive ventilation may be beneficial. Non-invasive ventilation can help improve the ventilation-perfusion (VQ) ratio, reduce respiratory effort, and enhance exercise tolerance, particularly during episodes of exercise-induced desaturation.

While evidence supporting the use of non-invasive ventilation in ILD remains limited compared to other respiratory conditions, preliminary studies have shown promising results. Some studies have demonstrated improved oxygen saturation levels during exercise with the use of non-invasive ventilation, while others have observed enhancements in physical functioning and quality of life following non-invasive ventilation therapy.

Though the evidence base for non-invasive ventilation in ILD is still evolving, it remains a viable option to consider, especially for patients experiencing significant functional impairment. While more research is needed to establish its efficacy definitively in this patient population, non-invasive ventilation stands as a potential intervention to enhance the management and quality of life for individuals with ILD. Now that we have identified the patient groups that may benefit from non-invasive ventilation. Let's discuss the practical aspects of its implementation.

Methods for Non-Invasive Ventilation

• Traditional positive pressure ventilation with various interfaces (NIV)
• Proportional Open Ventilation (POV®)
• Negative pressure ventilation (NPV) or Biphasic Cuirass Ventilation (BCV)
• Tidal Assist Ventilation (TAV®)

Our discussion briefly touches on traditional positive pressure ventilation, which is a commonly utilized method known as non-invasive ventilation. This approach involves delivering positive pressure to the airway through various interfaces, a technique frequently employed in hospitalized patients and increasingly utilized in home care settings.

Next, explore proportional open ventilation, a distinct technique offering notable advantages. Following that, we will review negative pressure ventilation, an older yet still relevant method historically associated with the iron lung, originally developed during the polio epidemics. Negative pressure ventilation, often referred to as Biphasic Cuirass Ventilation (BCV) by the sole provider of this technology, presents unique benefits worth considering. Finally, we will touch briefly on Tidal Assist Ventilation, a newer approach that may gain prominence in the future.

Non-Invasive Ventilation

Traditional NIV

Traditional non-invasive ventilation (NIV), is a widely employed method utilizing interfaces to deliver either volume or pressure ventilation to patients across all age groups, from neonates to adults. These interfaces are meticulously designed to provide a snug fit while allowing for minor leaks to prevent potential pressure ulcers. With hundreds of interface options available, the selection process is critical, considering factors such as patient comfort and tolerance.

One noteworthy interface worth mentioning is mouthpiece ventilation, which is often overlooked in acute care settings but offers substantial benefits to many patients. While some devices feature preset values, others, like AVAPs, offer auto-adjustment capabilities, ensuring consistent tidal volume delivery with each breath.

A primary advantage of NIV is its avoidance of invasive procedures like endotracheal intubation, which come with a host of potential complications. Patients previously tracheostomized due to prolonged invasive mechanical ventilation can potentially transition to NIV, a more tolerable option for many.

However, challenges persist, primarily centered around patient intolerance or discomfort with the interface. Addressing these issues often involves exploring various interface options and rotating between them to alleviate pressure points and irritation. Ensuring access to a diverse range of interfaces is essential, particularly in home care settings, where patient comfort and adherence are paramount.

While traditional NIV offers a plethora of interface options—from full face masks to nasal prongs and minimalist designs—it is crucial to recognize that access to every interface may be limited depending on the clinical setting. Nonetheless, prioritizing interface comfort and patient preference can significantly enhance the effectiveness and acceptance of NIV therapy, mirroring the challenges faced with CPAP therapy. Thus, a comprehensive approach that incorporates patient-centered care and interface variety is essential to optimize outcomes in NIV implementation.

Mouthpiece Ventilation (MPV)

Mouthpiece ventilation (MPV), often overlooked in acute care settings, serves as a vital daytime non-invasive respiratory support method, particularly for patients with neuromuscular disorders. With MPV, patients utilize a mouthpiece or straw to facilitate ventilation. During MPV, patients intentionally initiate a series of disconnections, whether partial or complete, from the ventilator, followed by reconnections. Essentially, with each inhalation, patients have the autonomy to determine the volume of air they wish to intake. By adjusting the seal with their lips on the mouthpiece, patients can modulate their breaths.

A tight, complete seal ensures nearly full tidal volume (approximately 100%), as dictated by the settings of the volume-cycled ventilator. Conversely, a more relaxed or incomplete seal results in either partial tidal volume or, in some instances, no tidal volume intake at all, ranging from 0 to 99%. This flexibility allows patients to tailor their ventilation to their comfort and respiratory needs, promoting a more personalized and effective approach to non-invasive respiratory support.

Devices

A Breas ventilator is equipped with a mouthpiece that simplifies mouthpiece ventilation. It is typically mounted on an adjustable arm for easy positioning directly in front of the patient's mouth. Theoretically, leaks during mouthpiece ventilation will not cause discomfort because they are determined and managed by the patient. However, this holds true specifically for volume-cycled modes of ventilation. In volume-cycled modes, patients have control over the amount of air they inhale, allowing them to adjust the seal with their lips on the mouthpiece to accommodate intentional leaks without discomfort.

Conversely, in pressure-cycled modes of ventilation, leaks can indeed result in discomfort. This discomfort stems from the ventilator's automatic compensation for leaks by delivering additional flow, which can be excessive and difficult for the patient to manage. As a result, patients may experience challenges in speaking and swallowing during MPV, highlighting the importance of utilizing volume-cycled modes to optimize patient comfort and adherence. Mouthpiece ventilation provides a range of devices, and while the following list is not exhaustive, it highlights the importance of identifying the most appropriate option for each patient.

• Vyaire LTV
• ResMed Astral
• Breas Vivo65
• Breas Vivo45
• PhillipsTrilogy EV300
• Ventec VOCSN
• Movair Luisa
• Phillips Trilogy 100

Common options include the Vyaire LTV, ResMed Astral, and various models from Breas, with notable features such as integrated end-tidal CO2 monitoring in Breas devices, enhancing patient care. The Phillips Trilogy and Ventec VOCSN are also prominent choices. The VOCSN, notable for its multifunctionality, integrates ventilation, oxygen concentrator, suction, and nebulizer functions into a single device, streamlining mobility for active patients.

For instance, without the Ventec VOCSN, patients relying on traditional devices like the Phillips Trilogy would need additional equipment for oxygen supply, suctioning, and nebulization, complicating mobility. The Movair Lusia is a newer addition generating considerable excitement, alongside established options like the Phillips Trilogy 100, commonly employed for home use.

While these examples offer insight, collaborating with durable medical suppliers remains crucial to explore available options tailored to individual needs in standard non-invasive ventilation. In addition to the devices mentioned, it is worth noting that advancements in non-invasive ventilation technology continue to evolve, offering enhanced features and capabilities. For instance, some newer models may incorporate innovative algorithms for more precise patient monitoring and therapy delivery. Features such as remote monitoring capabilities, wireless connectivity, and user-friendly interfaces are becoming increasingly common, facilitating seamless integration into patients' daily lives.

Furthermore, considerations such as portability, battery life, and ease of maintenance play pivotal roles in device selection, particularly for patients who lead active lifestyles or require frequent travel. As technology advances, the aim is to provide patients with greater autonomy, comfort, and flexibility in managing their respiratory conditions.

It is important for healthcare providers to stay abreast of the latest developments in non-invasive ventilation technology and collaborate closely with patients and durable medical equipment suppliers to ensure optimal device selection and patient outcomes. By leveraging the benefits of cutting-edge technology, healthcare professionals can enhance the quality of care and improve the overall experience for patients relying on non-invasive ventilation.

Novel Methods of Non-invasive Ventilation

Proportional Open Ventilation (POV)

Let's delve into one of the novel methods of non-invasive ventilation, known as proportional open ventilation (POV). Originally developed by Brief Technologies under the name Non-Invasive Open Ventilation (NIOV), this innovative approach has evolved and is now trademarked by Hillrom as proportional open ventilation or POV. While NILV may still be referenced in the literature as the original terminology, it is essential to recognize the transition to POV.

Proportional open ventilation synchronously delivers positive inspiratory pressure and supplemental oxygen, typically via a nasal pillow interface. It operates by augmenting tidal volume during spontaneous breathing, making it particularly suitable for individuals with limited tolerance for physical activity due to breathlessness. The device offers a myriad of programmable settings tailored to meet the unique needs of each patient. Notably, patients experiencing significant dyspnea during exertion may find proportional open ventilation beneficial.

Baxter Hillrom Life 2000 Ventilator 

The interface of this ventilation method incorporates openings that leverage the Venturi principle to entrain room air, which combines with the preset volume from the device and the patient's own effort. The total delivered tidal volume results from the interplay of these factors. Currently available from Baxter Hillrom under the name Life 2000 Ventilator, this technology represents a promising advancement in non-invasive ventilation, offering enhanced support for patients with respiratory challenges.

The Baxter Hillrom Life 2000 Ventilator device has three patient-selectable prescription settings, denoted by pictograms on the right-hand side of the interface. The top pictogram illustrates someone walking, representing the highest level of support suitable for mobility. The middle pictogram depicts someone sitting, which is ideal for home activities and daily routines. The bottom pictogram is designated for restful states.

These three distinct settings offer patients considerable flexibility in tailoring their support levels to match their varying activities and ventilatory needs. Whether they require continuous support or wish to adjust settings periodically, the interface simplifies the process with the push of a button, adapting seamlessly to their breathing patterns.

This adaptability proves invaluable in both clinical and home settings. In the hospital, clinicians can readily titrate ventilation settings to accommodate patients' evolving needs. Conversely, in-home care settings, periodic adjustments by healthcare providers ensure optimal support, as patients may not have the expertise to modify settings independently.

Approved for both invasive and non-invasive use, this device holds promise not only for post-acute care but also for promoting mobility in acute care settings. Streamlining equipment and reducing bulk facilitates patient mobility with ease. Powered by a rechargeable lithium-ion battery, it weighs only about a pound, making it remarkably lightweight and portable—a stark contrast to traditional ventilator setups. Its compact size, akin to a large home telephone, further enhances its practicality and accessibility for patients.

• Clinician adjustable settings: 
  • PEEP: 0 to 10 cmH2O 
  • Breath Rate: 1 to 40 BPM 
  • Breath Timeout Period: 20 or 60 seconds
  • Breath Timeout Action: 12 BPM or 3 LPM 
  • Delivered Volume: 50 mL to 750 mL 
  • Gas source: Oxygen or Air 
  • I-Time: 0.15 to 3.00 seconds 
  • Trigger Sensitivity

The clinician has the flexibility to fine-tune settings within each activity level—rest, sitting, and walking. These adjustable parameters include PEEP (positive end-expiratory pressure), breath rate, and breath timeout period—the duration the machine waits before detecting a cessation in breathing. In the event of breath absence, the device can be programmed to maintain a continuous flow of oxygen or revert to a predefined breath rate, typically 12 breaths per minute.

Furthermore, the clinician can customize settings such as delivered volume, gas source (air compressor or oxygen tank), and inspiratory time—a critical consideration, especially for patients with COPD. Ensuring the device accurately detects patient breaths is paramount, and sensitivity adjustments allow for precise responsiveness.

A comprehensive array of clinician-adjustable alarms is available, covering low respiratory limits, low and high-pressure thresholds, and the breath timeout period. These alarms serve as essential safeguards, alerting clinicians to deviations from desired parameters, including excessively high or low breath rates. Adjustments can then be made promptly to optimize patient comfort and safety—a standard feature across most ventilators.

• Clinician adjustable alarms:
• Low Respiratory Limit: 0 to 119 BPM 
• High Respiratory Limit: 5 to 120 BPM 
• Low PIP Limit: 0 to 15 cmH2O 
• High PIP Limit: 5 to 40 cmH2O 
• Breath Timeout Period: 20 or 60 seconds 
• High Breath Rate: 5 to 120 BPM 
• Low Breath Rate: 0 to 119 BPM

Then there are also some fixed alarms:

• Low/High Source Pressure 
• Low Battery 
• Low/High Delivery Pressure 
• High PEEP Pressure 
• System fault

The Life 2000 ventilator incorporates an extensive alarm system designed to alert clinicians to various potential issues. These alarms encompass discrepancies in source pressure, battery status, and delivery pressure, as well as high PEEP (positive end-expiratory pressure) levels, among others. This comprehensive alarm functionality distinguishes the Life 2000 as a full-fledged ventilator, ensuring thorough monitoring and prompt identification of critical situations. The interface commonly paired with the Life 2000 ventilator optimizes its functionality and usability, facilitating seamless integration into patient care protocols.

Breathe Pillows Entrainment Interface

The interface used with the Life 2000 ventilator, known as Breathe Pillows, embodies the principles of POV NIOV (proportional open ventilation, non-invasive open ventilation). It comprises cannulas equipped with tubes for delivering both oxygen and positive pressure alongside small air entrainment ports designed to remain open to allow the machine to draw in air as needed to meet the patient's ventilation requirements. Additionally, the cannulas feature sensing ports to detect the patient's breathing patterns. Despite its advanced functionality, the Breathe Pillows interface resembles a standard nasal cannula, albeit with slightly larger ports entering the nose, available in various sizes ranging from extra small to extra large. Moreover, users have the flexibility to connect this ventilator to alternative interfaces if desired.

Breathe Universal Circuit Connector

The Life 2000 ventilator features a universal circuit connector that offers compatibility with various types of interfaces. Whether the patient prefers using a mask typically utilized for CPAP or BiPAP therapy at night or requires a full face mask or tracheostomy tube during the day, this ventilator can be seamlessly connected to accommodate their needs. This versatility extends to patients with tracheostomies who may benefit from additional respiratory support during periods of activity. The ease of switching between different interfaces makes it convenient for healthcare providers to transition patients from the hospital or acute care setting to the home environment. This universal circuit connector enhances flexibility and adaptability in providing non-invasive ventilation tailored to each patient's requirements.

Versatile Configurations

The Life2000 Ventilation System offers three configurations to maximize versatility. The first is the stationary setup, where the patient remains at home, seated in their chair, connected to a compressor. Additionally, up to 50 feet of tubing can be attached to the compressor, allowing the patient to move around the home while still receiving respiratory support.

For patients requiring support during daily activities such as using the bathroom or preparing meals, the system can be worn while being active within the home environment. It can also be worn outside the home by connecting it to an alternate pressure source, typically an oxygen cylinder. The device is compact and attaches to the patient's waist, with a belt clip for easy carrying. A carrying case is also provided for added convenience.

Research indicates that the Life2000 system can enhance activities of daily living (ADL) performance at home by significantly increasing endurance time, improving oxygenation, and reducing dyspnea, fatigue, and discomfort. This practical solution proves beneficial for oxygen-dependent COPD patients seeking to improve their activity and exercise tolerance. 

NIV has demonstrated effectiveness in improving exercise endurance in COPD patients. However, traditional NIV devices are often not designed for portability, making routine use outside of clinical settings challenging. With lightweight devices like POV, providing non-invasive ventilation during exercise becomes much more feasible and convenient for patients, thereby potentially enhancing their exercise tolerance and quality of life.   

Novel Methods of Non-Invasive Ventilation

Negative Pressure Ventilation (NPV)

The next type of ventilation we will discuss is NPV or non-invasive positive pressure ventilation. Mechanical ventilation originally began with negative pressure ventilation in the early 1930s, particularly during the polio epidemics of the mid-20th century when many patients developed respiratory failure. Devices such as iron lungs were used, but they required patients to be enclosed, making care challenging. Despite this, negative pressure ventilation saw considerable success. Nowadays, more comfortable devices have been developed, leading to increased interest in using non-invasive negative pressure ventilation due to its improved convenience and comfort compared to earlier iterations.

Hayek Biphasic Cuirass ventilator (BCV)

The Hayek Biphasic Cuirass ventilator (BCV) is a non-invasive ventilator that has gained popularity for its efficacy and versatility. Unlike traditional positive pressure ventilation devices, the Hayek ventilator does not require a mask, eliminating issues related to mask discomfort or interface complications. It utilizes negative pressure ventilation, which helps with lung recruitment, volume expansion, and gas exchange improvement.

One notable feature of the Hayek ventilator is its ability to deliver both negative and positive pressure to the chest wall. This biphasic approach aids in promoting inspiration and expiration, making it particularly beneficial for patients struggling with elevated CO2 levels. With multifunction capabilities, including controlled ventilation, the Hayek ventilator offers clinicians flexibility in tailoring ventilation support to individual patient needs.

The Hayek Biphasic Cuirass ventilator offers several advanced features to enhance patient comfort and respiratory support. One notable feature is its ability to synchronize ventilation with the patient's spontaneous breathing, improving comfort and synchronicity. Additionally, the ventilator includes a built-in high-frequency chest wall oscillation function, which can aid in mobilizing secretions for patients with secretion clearance issues. It also incorporates a cough assist feature, providing additional support for patients with excessive secretions.

The device consists of a shell that is placed over the patient's chest, with a foam backing for comfort. It comes in various sizes to ensure proper fit and comfort for different patients. The ventilator itself is connected to the shell via a simple hose, through which settings such as negative and positive pressure, as well as respiratory rate, can be adjusted. Despite its advanced capabilities, the device is relatively straightforward to use, making it suitable for a wide range of patients, including pediatrics and even infants. Its ability to mimic natural breathing patterns with negative pressure on inspiration makes it particularly advantageous for patients with various respiratory conditions, including those with congenital heart defects who may require extensive surgeries.

The Hayek BCV offers significant advantages in promoting cardiac output and blood return to the chest, thereby supporting better cardiac function. Its multifunctional capabilities, combined with a single interface, simplify respiratory support for patients, eliminating the need to switch between different devices for chest wall oscillation or ventilation. This integrated approach reduces patient discomfort and the need for sedation, particularly in the acute care setting where sedation may be required due to endotracheal tube discomfort.

The synchronization of the ventilator with the patient's spontaneous breathing reduces the risk of hospital-acquired infections associated with intubated patients. Overall, the use of the Cuirass ventilator has been associated with shorter hospital stays, making it a valuable option to consider for patients who could benefit from non-invasive ventilation in both acute and post-acute care settings.

The use of negative pressure ventilation, such as with the Hayek Biphasic Cuirass ventilator, offers several advantages over positive pressure ventilation. Negative pressure ventilation provides more homogeneous lung inflation, ensuring that all parts of the lung receive adequate ventilation, unlike positive pressure ventilation, which may inflate only the already inflated areas. This approach is safer and more effective, reducing the need for lung recruitment maneuvers and potentially harmful interventions.

Negative pressure ventilation mimics the natural intrathoracic pressure wave of spontaneous respiration, promoting cardiac function by facilitating the return of blood to the chest cavity. In contrast, positive pressure ventilation, particularly with PEEP, may decrease cardiac output by impeding blood return to the chest. The biphasic thoracic ventilation provided by the Cuirass ventilator supports cardiac function similarly to spontaneous breathing, offering a significant advantage in patient care. Additionally, the cost-effectiveness and versatility of the device make it suitable for use in both hospital and home settings.

Nocturnal negative pressure ventilation is a highly effective method for preventing sleep-induced reductions in alveolar ventilation, particularly in patients experiencing elevated CO2 levels during sleep. This approach serves as a practical long-term management strategy for individuals with non-obstructive chronic respiratory failure. Unlike positive pressure techniques, negative pressure ventilation supports both inspiratory and expiratory work of breathing in a natural manner, offering patients the ability to eat, speak, and drink without interference.

Moreover, negative pressure ventilation minimizes the risks and complications associated with other ventilation methods, making it a preferred choice for many patients. It has demonstrated effectiveness across various patient groups, including those with neuromuscular disorders, COPD, cystic fibrosis, and even acute respiratory distress syndrome (ARDS). The versatility and favorable patient outcomes associated with negative pressure ventilation highlights its significance in respiratory care.

Inogen TAV

The Inogen Tidal Assist Ventilator (TAV) offers a compact and non-obtrusive solution for patients requiring respiratory support. The device is equipped with three settings: Tidal Assist, Pulse, and Constant. In the Tidal Assist mode, patients can select from five settings ranging from one to five, with each setting delivering varying volumes of air assistance. This mode is particularly beneficial for patients who require additional respiratory support during activities or periods of exertion.

The Pulse mode functions similarly to traditional pulse dose oxygen concentrators, delivering oxygen in short bursts based on the patient's inhalation. The Constant mode provides a continuous flow of oxygen as needed. Patients can adjust the settings based on their oxygen requirements and activity levels.

The device comes with a regulator and specific adapter to ensure compatibility and proper functioning. It offers flexibility and convenience for patients needing respiratory assistance in various situations, whether at home or on the go. The TAV is specifically designed for patients with COPD, providing assisted non-invasive ventilation in a portable and lightweight unit. Similar to the Life 2000 ventilator, it offers simplicity and ease of use. The device features settings ranging from one to five, where each setting delivers a different volume boost to the patient's breathing, ranging from 50 to 250 milliliters.

The technology is integrated into the nasal interface, utilizing two tiny discs surrounded by pillows to provide higher oxygen flow pressure, up to five times the volume per breath compared to oxygen alone. The device operates on a single AA battery, making it convenient for patients to carry with them, weighing only 3.8 ounces with the battery installed.

Although there is limited published literature and reimbursement challenges, studies have shown promising results. A study conducted at a pulmonary rehab center in California demonstrated that patients using oxygen therapy with the TAV were able to increase their exercise tolerance compared to those using oxygen therapy alone. This indicates the potential for the TAV to improve patient outcomes and increase exercise capacity in COPD and other respiratory conditions.

NIV Comparisons

Indeed, traditional non-invasive positive pressure ventilation (NIPPV) with a mask or other interface has several advantages:

• Well-established: NIPPV has been extensively used and studied, making it a familiar and reliable option for healthcare providers.
• Hospital to home transition: Hospitals are proficient at setting up NIPPV for patients, facilitating a smooth transition to home care.
• Variety of interfaces and devices: There are numerous interface options available, allowing for customization to meet individual patient needs and preferences.
• Useful across multiple disorders: NIPPV has shown efficacy in various respiratory disorders, including COPD and thoracic restrictive disorders, based on extensive clinical experience and research.

On the other hand, proportional open ventilation (POV) offers unique advantages, particularly for activities of daily living (ADLs):

• Portability: POV devices are designed to be portable, allowing patients to engage in ADLs and other activities while receiving ventilation support.
• Adaptability: POV devices have multiple settings that can accommodate changes in activity level, providing flexibility for patients as they move about.
• Comfortable interface: The nasal pillows interface used with POV devices is comfortable and minimally obtrusive, enhancing patient comfort and compliance.

Overall, while traditional NIPPV is well-established and effective, POV offers additional advantages in terms of portability, adaptability, and comfort, particularly for patients engaging in daily activities. The choice between these options should be based on individual patient needs and preferences, as well as clinical considerations. Certainly, while non-invasive ventilation (NIV) offers many benefits, it also comes with some disadvantages:

• Cumbersome with activity: Standard NIV devices can be challenging to use during physical activity. Patients may require assistance, and the equipment can be cumbersome, hindering mobility.
• Difficulty in adjusting to the interface: Some patients find it challenging to adjust to the interface, such as masks or nasal cannulas used in traditional NIV. Discomfort or dislike of the interface may lead to non-compliance with treatment.
• Risk of pressure sores: Proper application of NIV devices is crucial to prevent leaks, which can lead to pressure sores or skin irritation. Achieving a tight seal without causing discomfort can be challenging.
• Minimal leak requirement: NIV devices typically require a minimal leak to maintain effective ventilation. Balancing the need for a seal with the risk of pressure sores can be challenging for healthcare providers.

In contrast, POV devices, such as the Breathe Pillows, offer a comfortable interface and may mitigate some of these disadvantages. The nasal pillow interface used with POV devices is designed for comfort and may be more tolerable for patients. Additionally, the ability to adjust settings and accommodate changing conditions provides flexibility and may improve patient compliance. Overall, while NIV has its challenges, advancements in technology, such as POV devices, aim to address some of these issues and improve patient comfort and compliance with non-invasive ventilation therapy.

We have encountered some pressure sore issues with NPV, where the pressure may build up on the chest due to the cuirass shell's contact with the skin. However, we have implemented effective strategies to mitigate this problem, so it is typically not a major concern. Negative pressure ventilation, or NPV, is not as widely embraced as other methods. Many healthcare professionals have moved away from NPV, as it may not be as comfortable or familiar as positive pressure ventilation. This highlights a disadvantage that warrants further consideration and exploration. NPV also necessitates good upper airway function, as patients must manage secretions and cough effectively. If a patient struggles with these aspects, NPV may not be suitable for them. Additionally, NPV lacks mobility, meaning it cannot be easily used while performing daily activities or moving around. In summary, I hope this overview has provided valuable insights into the various available non-invasive ventilation methods, along with important considerations for patient care. 

Questions and Answers

How are hospitals adapting to the use of newer non-invasive ventilation devices in the post-acute care setting?

Hospitals face limitations in accessing a wide range of positive pressure devices due to budgetary constraints. While some hospitals may have a variety of options, many are restricted to one or two devices. This limitation necessitates careful consideration of available options and familiarity with patient needs. Additionally, hospitals may have access to programs like the hospital-to-home program, which assists in setting up patients for home use of specific devices.

What advice is offered for selecting the appropriate non-invasive ventilation device?

It is crucial to explore all available options and consider patient-specific needs when selecting a device. Understanding the patient population and their requirements is essential. However, certain devices, such as the Life 2000 POV, may require involvement from external companies like Hillrom for setup and support.

Are there specific considerations for non-invasive negative pressure ventilation?

Yes, non-invasive negative pressure ventilation requires specialized equipment and expertise. Companies like Hayek provide assistance in selecting and implementing these devices, offering training and ongoing support. This option presents a unique alternative for patients with specific respiratory needs.

How important is it to recognize that there is no one-size-fits-all approach in selecting non-invasive ventilation devices?

Recognizing the diversity of patient needs is paramount. Each patient may require a tailored approach, and what works for one individual may not be suitable for another. Therefore, understanding the available options and patient-specific requirements is crucial for effective care delivery.

References

Select references are listed here.  A complete reference list is provided in the course handout.

Annunziata, A., Calabrese, C., Simioli, F., Coppola, A., Flora, M., Marotta, A., Di Spirito, V., Didonna, F., Cicalese, M., & Fiorentino, G. (2022). Negative-pressure ventilation in neuromuscular diseases in the acute setting. Journal of Clinical Medicine, 11(9), 2589.

Brochard, L. J. (2023). Mechanical ventilation: Negative to positive and back again. Critical Care Clinics, 39(3), 437–449.

Cooksey, J. A., & Sergew, A. (2020). Noninvasive ventilation in amyotrophic lateral sclerosis. Sleep Medicine Clinics, 15(4), 527–538.

Cuerpo, S., Palomo, M., Hernández-González, F., Francesqui, J., Albacar, N., Hernández, C., Blanco, I., Embid, C., & Sellares, J. (2020). Improving home oxygen therapy in patients with interstitial lung diseases: Application of a noninvasive ventilation device. Therapeutic Advances in Respiratory Disease, 14, 1753466620963027.

Dong, S., Lu, W., & Wang, Y. (2023). Positive- and negative-pressure ventilation characterized by local and global pulmonary mechanics. American Journal of Respiratory and Critical Care Medicine, 207(6), 800.

Dretzke, J., Wang, J., Yao, M., Guan, N., Ling, M., Zhang, E., Mukherjee, D., Hall, J., Jowett, S., Mukherjee, R., Moore, D. J., & Turner, A. M. (2022). Home non-invasive ventilation in COPD: A global systematic review. Chronic Obstructive Pulmonary Diseases, 9(2), 237–251.

Frazier, W., van Eijndhoven, E., Murphy, R., & Jena, A. B. (2021). Noninvasive ventilation at home reduces mortality in COPD with CRF. American Journal of Managed Care, 27(9), e308–e315.

Gong Y, Sankari A. Noninvasive Ventilation. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK578188/