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Non-invasive Ventilatory Support in the Elderly

  • Kasiemobi E. PulliamEmail author
  • Timothy A. Pritts
Surgical Care (F Luchette and R Gonzalez, Section Editors)
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  1. Topical Collection on Surgical Care

Abstract

Purpose of Review

The first description of non-invasive ventilation use began in the 1920s. Since then, its role in patient care has evolved through increased clinical knowledge and scientific advancements. The utilization of non-invasive ventilation has broadened from initial application in acute in-hospital ICU settings to now include the outpatient settings. This review discusses the history of non-invasive ventilation and its role in acute in-hospital chronic obstructive pulmonary disease (COPD) exacerbations, cardiogenic pulmonary edema, and weaning from mechanical ventilation in the elderly. The elderly population represents a significant portion of patients hospitalized for the aforementioned conditions. These groups often have more limitations related to the use of invasive mechanical ventilation (IMV); therefore, it is essential to understand the impact of non-invasive ventilation on hospital outcomes.

Recent Findings

There is strong clinical evidence supporting the use of non-invasive ventilation in patients with respiratory failure secondary to acute COPD exacerbations and cardiogenic pulmonary edema. When compared to standard medical management of these conditions, there is a consistent and significant reduction in the rate of endotracheal intubation and in-hospital mortality.

Summary

The basis of non-invasive ventilation applicability has been determined by significant reduction in mortality and intubation rates. Although survival benefits have been observed, there still remain limitations to the clinical applicability of non-invasive ventilation in certain patient populations and conditions that require further investigation.

Keywords

Non-invasive ventilation Elderly population History and literature review Acute in-hospital setting 

Notes

Compliance with Ethical Standards

Conflict of Interest

Kasiemobi E. Pulliam and Timothy A. Pritts each declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Drinker PA, McKhann CF 3rd. Landmark perspective: the iron lung. First practical means of respiratory support. JAMA. 1986;255(11):1476–80.Google Scholar
  2. 2.
    Motley HL, Cournand A, et al. Intermittent positive pressure breathing; a means of administering artificial respiration in man. J Am Med Assoc. 1948;137(4):370–82.Google Scholar
  3. 3.
    Motley HL, Lang LP, Gordon B. Use of intermittent positive pressure breathing combined with nebulization in pulmonary disease. Am J Med. 1948;5(6):853–6.Google Scholar
  4. 4.
    Pierson DJ. History and epidemiology of noninvasive ventilation in the acute-care setting. Respir Care. 2009;54(1):40–52.Google Scholar
  5. 5.
    Pierson DJ. Noninvasive positive pressure ventilation: history and terminology. Respir Care. 1990;42(4):370–9.Google Scholar
  6. 6.
    Baker JP. Magnitude of usage of intermittent positive pressure breathing. Am Rev Respir Dis. 1974;110(6 Pt 2):170–7.Google Scholar
  7. 7.
    Murray JF. Review of the state of the art in intermittent positive pressure breathing therapy. Am Rev Respir Dis. 1974;110(6 Pt 2):193–9.Google Scholar
  8. 8.
    Pingleton SK. Barotrauma in acute lung injury: is it important? Crit Care Med. 1995;23(2):223–4.Google Scholar
  9. 9.
    Haake R, Schlichttg R, Ulstad DR, Henschen RR. Barotrauma. Pathophysiology, risk factors, and prevention. Chest. 1987;91(4):608–13.Google Scholar
  10. 10.
    Tremblay LN, Slutsky AS. Ventilator-induced injury: from barotrauma to biotrauma. Proc Assoc Am Physicians. 1998;110(6):482–8.Google Scholar
  11. 11.
    Sullivan CE, et al. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981;1(8225):862–5.Google Scholar
  12. 12.
    Kerby GR, Mayer LS, Pingleton SK. Nocturnal positive pressure ventilation via nasal mask. Am Rev Respir Dis. 1987;135(3):738–40.Google Scholar
  13. 13.
    Bersten AD, Holt AW, Vedig AE, Skowronski GA, Baggoley CJ. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med. 1991;325(26):1825–30.Google Scholar
  14. 14.
    Bott J, Carroll MP, Conway JH, Keilty SEJ, Ward EM, Brown AM, et al. Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet. 1993;341(8860):1555–7.Google Scholar
  15. 15.
    Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817–22.Google Scholar
  16. 16.
    Ambrosino N, Vagheggini G. Noninvasive positive pressure ventilation in the acute care setting: where are we? Eur Respir J. 2008;31(4):874–86.Google Scholar
  17. 17.
    Perera PN, Armstrong EP, Sherrill DL, Skrepnek GH. Acute exacerbations of COPD in the United States: inpatient burden and predictors of costs and mortality. COPD. 2012;9(2):131–41.Google Scholar
  18. 18.
    Halpin DM, Miravitlles M, Metzdorf N, Celli B. Impact and prevention of severe exacerbations of COPD: a review of the evidence. Int J Chron Obstruct Pulmon Dis. 2017;12:2891–908.Google Scholar
  19. 19.
    Celli BR, MacNee W, Force AET. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23(6):932–46.Google Scholar
  20. 20.
    Organized jointly by the American Thoracic Society, t.E.R.S.t.E.S.o.I.C.M., F. the Societe de Reanimation de Langue, and D. approved by Ats Board of Directors. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure. Am J Respir Crit Care Med. 2001;163(1):283–91.Google Scholar
  21. 21.
    Conti G, Antonelli M, Navalesi P, Rocco M, Bufi M, Spadetta G, et al. Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med. 2002;28(12):1701–7.Google Scholar
  22. 22.
    Kramer N, Meyer TJ, Meharg J, Cece RD, Hill NS. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med. 1995;151(6):1799–806.Google Scholar
  23. 23.
    Angus RM, Ahmed AA, Fenwick LJ, Peacock AJ. Comparison of the acute effects on gas exchange of nasal ventilation and doxapram in exacerbations of chronic obstructive pulmonary disease. Thorax. 1996;51(10):1048–50.Google Scholar
  24. 24.
    Celikel T, et al. Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. Chest. 1998;114(6):1636–42.Google Scholar
  25. 25.
    Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000;355(9219):1931–5.Google Scholar
  26. 26.
    Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163(2):540–77.Google Scholar
  27. 27.
    • Osadnik CR, et al. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017;7:CD004104 Meta-analysis 17 randomized controlled trials published from 1998–2010. This resource is a thorough analysis of not only the primary outcomes of mortality risk and rate of intubation but also listing potential sources of bias and risk of bias for all the included studies. Google Scholar
  28. 28.
    • Wedzicha J. A. E. C.-C, Miravitlles M, Hurst JR, Calverley PM, Albert RK, Anzueto A, … Krishnan J. A. A. C.-C. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3)  https://doi.org/10.1183/13993003.00791-2016 Clinical recommendations were formulated by experts on the Task Force of COPD based on a systemic review and meta-analysis of 21 randomized controlled trials. This resource includes a statement of the quality of evidence as well as a grade for the recommendation (strong/conditional). For example, recommendations considered to be “strong recommendation” represent interventions where the benefits outweigh the adverse affects.
  29. 29.
    Nicolini A, Santo M, Ferrera L, Ferrari-Bravo M, Barlascini C, Perazzo A. The use of non-invasive ventilation in very old patients with hypercapnic acute respiratory failure because of COPD exacerbation. Int J Clin Pract. 2014;68(12):1523–9.Google Scholar
  30. 30.
    Wier LM, et al. Overview of hospitalizations among patients with COPD, 2008: Statistical Brief #106. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs; 2006. Rockville (MD).Google Scholar
  31. 31.
    Nava S, Grassi M, Fanfulla F, Domenighetti G, Carlucci A, Perren A, et al. Non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure: a randomised controlled trial. Age Ageing. 2011;40(4):444–50.Google Scholar
  32. 32.
    Corral-Gudino L, Jorge-Sánchez RJ, García-Aparicio J, Herrero-Herrero JI, López-Bernús A, Borao-Cengotita-Bengoa M, et al. Use of noninvasive ventilation on internal wards for elderly patients with limitations to respiratory care: a cohort study. Eur J Clin Investig. 2011;41(1):59–69.Google Scholar
  33. 33.
    Mehta AB, Douglas IS, Walkey AJ. Hospital noninvasive ventilation case volume and outcomes of acute exacerbations of chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2016;13(10):1752–9.Google Scholar
  34. 34.
    Luo Z, et al. High-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (HAPPEN): study protocol for a multicenter randomized controlled trial. Trials. 2018;19(1):645.Google Scholar
  35. 35.
    Fisher KA, Mazor KM, Goff S, Stefan MS, Pekow PS, Williams LA, et al. Successful use of noninvasive ventilation in chronic obstructive pulmonary disease. How do high-performing hospitals do it? Ann Am Thorac Soc. 2017;14(11):1674–81.Google Scholar
  36. 36.
    Lopez-Campos JL, Jara-Palomares L, Muñoz X, Bustamante V, Barreiro E. Lights and shadows of non-invasive mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations. Ann Thorac Med. 2015;10(2):87–93.Google Scholar
  37. 37.
    Vaudan S, Ratano D, Beuret P, Hauptmann J, Contal O, Garin N. Impact of a dedicated noninvasive ventilation team on intubation and mortality rates in severe COPD exacerbations. Respir Care. 2015;60(10):1404–8.Google Scholar
  38. 38.
    McDermott, K.W.E., Anne; Sun, Ruirui. Trends in hospital inpatient stays in the United States, 2005-2014. Statistical Brief #225. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs 2017.Google Scholar
  39. 39.
    Girou E, Brun-Buisson C, Taillé S, Lemaire F, Brochard L. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA. 2003;290(22):2985–91.Google Scholar
  40. 40.
    Nieminen MS, Böhm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, et al. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J. 2005;26(4):384–416.Google Scholar
  41. 41.
    Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142–51.Google Scholar
  42. 42.
    Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito JA. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA. 2005;294(24):3124–30.Google Scholar
  43. 43.
    Potts JM. Noninvasive positive pressure ventilation: effect on mortality in acute cardiogenic pulmonary edema: a pragmatic meta-analysis. Pol Arch Med Wewn. 2009;119(6):349–53.Google Scholar
  44. 44.
    Goodacre SW, Gray A, Newby D. Errors in meta-analysis regarding the 3CPO trial. Ann Intern Med. 2010;153(4):277–8 author reply 278.Google Scholar
  45. 45.
    Bello G, De Santis P, Antonelli M. Non-invasive ventilation in cardiogenic pulmonary edema. Ann Transl Med. 2018;6(18):355.Google Scholar
  46. 46.
    Weng CL, Zhao YT, Liu QH, Fu CJ, Sun F, Ma YL, et al. Meta-analysis: noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010;152(9):590–600.Google Scholar
  47. 47.
    Mariani J, Macchia A, Belziti C, DeAbreu M, Gagliardi J, Doval H, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema: a meta-analysis of randomized controlled trials. J Card Fail. 2011;17(10):850–9.Google Scholar
  48. 48.
    Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013;(5): CD005351  https://doi.org/10.1002/14651858.CD005351.pub3. A meta-analysis of 32 randomized controlled trials outlining the primary outcomes of mortality risk, rate of intubation, and the GRADE approach to assess the quality of evidence for each outcome.
  49. 49.
    S.K., E. Use of noninvasive ventilation to facilitate weaning from mechanical ventilation. In: Noninvasive mechanical ventilation and difficult weaning in critical care. Cham: Springer; 2016.Google Scholar
  50. 50.
    Kurmani S, Squire I. Acute heart failure: definition, classification and epidemiology. Curr Heart Fail Rep. 2017;14(5):385–92.Google Scholar
  51. 51.
    L'Her E, et al. Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients. Intensive Care Med. 2004;30(5):882–8.Google Scholar
  52. 52.
    Mehta AB, Syeda SN, Wiener RS, Walkey AJ. Epidemiological trends in invasive mechanical ventilation in the United States: a population-based study. J Crit Care. 2015;30(6):1217–21.Google Scholar
  53. 53.
    Heunks LM, van der Hoeven JG. Clinical review: the ABC of weaning failure—a structured approach. Crit Care. 2010;14(6):245.Google Scholar
  54. 54.
    Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033–56.Google Scholar
  55. 55.
    Epstein SK. Noninvasive ventilation to shorten the duration of mechanical ventilation. Respir Care. 2009;54(2):198–208 discussion 208-11.Google Scholar
  56. 56.
    Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350(24):2452–60.Google Scholar
  57. 57.
    Hilbert G, Gruson D, Portel L, Gbikpi-Benissan G, Cardinaud JP. Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J. 1998;11(6):1349–53.Google Scholar
  58. 58.
    Jiang JS, Kao SJ, Wang SN. Effect of early application of biphasic positive airway pressure on the outcome of extubation in ventilator weaning. Respirology. 1999;4(2):161–5.Google Scholar
  59. 59.
    Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33(11):2465–70.Google Scholar
  60. 60.
    Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173(2):164–70.Google Scholar
  61. 61.
    Nava S, Ambrosino N, Clini E, Prato M, Orlando G, Vitacca M, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998;128(9):721–8.Google Scholar
  62. 62.
    Girault C, et al. Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med. 1999;160(1):86–92.Google Scholar
  63. 63.
    Ferrer M, Esquinas A, Arancibia F, Bauer TT, Gonzalez G, Carrillo A, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;168(1):70–6.Google Scholar
  64. 64.
    Vaschetto R, Turucz E, Dellapiazza F, Guido S, Colombo D, Cammarota G, et al. Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study. Intensive Care Med. 2012;38(10):1599–606.Google Scholar
  65. 65.
    Trevisan CE, Vieira SR, W. Research Group in Mechanical Ventilation. Noninvasive mechanical ventilation may be useful in treating patients who fail weaning from invasive mechanical ventilation: a randomized clinical trial. Crit Care. 2008;12(2):R51.Google Scholar
  66. 66.
    Collaborating Research Group for Noninvasive Mechanical Ventilation of Chinese Respiratory, S. Pulmonary infection control window in treatment of severe respiratory failure of chronic obstructive pulmonary diseases: a prospective, randomized controlled, multi-centred study. Chin Med J (Engl). 2005;118(19):1589–94.Google Scholar
  67. 67.
    Prasad SB, Chaudhry D, Khanna R. Role of noninvasive ventilation in weaning from mechanical ventilation in patients of chronic obstructive pulmonary disease: an Indian experience. Indian J Crit Care Med. 2009;13(4):207–12.Google Scholar
  68. 68.
    Zou SH, Zhou R, Chen P, Luo H, Xiang XD, Lu YD, et al. Application of sequential noninvasive following invasive mechanical ventilation in COPD patients with severe respiratory failure by investigating the appearance of pulmonary-infection-control-window. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2006;31(1):120–4.Google Scholar
  69. 69.
    Chen J, Qiu D, Tao D. Time for extubation and sequential noninvasive mechanical ventilation in COPD patients with exacerbated respiratory failure who received invasive ventilation. Zhonghua Jie He He Hu Xi Za Zhi. 2001;24(2):99–100.Google Scholar
  70. 70.
    Rabie Agmy G, Metwally M. Noninvasive ventilation in the weaning of patients with acute-on-chronic respiratory failure due to COPD. Egyptian J Chest Dis Tuberculosis. 2012;2012:84–91.Google Scholar
  71. 71.
    Tawfeek M, Ali-Elnabtity A. Noninvasive proportional assist ventilation may be useful in weaning patients who failed a spontaneous breathing trial. Egyptian J Anaesthes. 2012;28:89–94.Google Scholar
  72. 72.
    Rabie GM, Mohamed AZ, Mohamed RN. Noninvasive ventilation in the weaning of patients with acute-on-chronic respiratory failure due to COPD. CHEST. 2004;126(4):755S.Google Scholar
  73. 73.
    Wang X, Du X, Zhang W. Observation of the results and discussion on the timing of transition from invasive mechanical ventilation to noninvasive ventilation in COPD patients with concomitant acute respiratory failure. Shandong Med J. 2004;44:4–6.Google Scholar
  74. 74.
    Zheng R, Liu L, Yang Y. Prospective randomized controlled clinical study of sequential noninvasive following invasive mechanical ventilation in patients with acute respiratory failure induced COPD. Chinese J Emerg Med. 2005;14:21–5.Google Scholar
  75. 75.
    Hill N, Lin D, Levy M. Noninvasive positive pressure ventilation (NPPV) to facilitate extubation after acute respiratory failure: a feasibility study. Am J Respir Crit Care Med. 2000;161:A263.Google Scholar
  76. 76.
    Girault C, Bubenheim M, Abroug F, Diehl JL, Elatrous S, Beuret P, et al. Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial. Am J Respir Crit Care Med. 2011;184(6):672–9.Google Scholar
  77. 77.
    Burns KE, et al. Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review. CMAJ. 2014;186(3):E112–22.Google Scholar
  78. 78.
    Hess DR, Branson RD. Know your ventilator to beat the leak. Chest. 2012;142(2):274–5.Google Scholar
  79. 79.
    Chandra D, Stamm JA, Taylor B, Ramos RM, Satterwhite L, Krishnan JA, et al. Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998-2008. Am J Respir Crit Care Med. 2012;185(2):152–9.Google Scholar
  80. 80.
    Antonelli M, Conti G. Noninvasive positive pressure ventilation as treatment for acute respiratory failure in critically ill patients. Crit Care. 2000;4(1):15–22.Google Scholar
  81. 81.
    Stevenson NJ, Walker PP, Costello RW, Calverley PMA. Lung mechanics and dyspnea during exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(12):1510–6.Google Scholar
  82. 82.
    O’Donnell DE, Parker CM. COPD exacerbations · 3: pathophysiology. Thorax. 2006;61(4):354–61.Google Scholar
  83. 83.
    Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, … Raoof S. M. O. T. T. F. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2).  https://doi.org/10.1183/13993003.02426-2016.
  84. 84.
    Sharp JT, Griffith GT, Bunnell IL, Greene DG. Ventilatory mechanics in pulmonary edema in man. J Clin Invest. 1958;37(1):111–7.Google Scholar
  85. 85.
    Bierer GB, Soo Hoo GW. Noninvasive ventilation for acute respiratory failure: a national survey of Veterans Affairs hospitals. Respir Care. 2009;54(10):1313–20.Google Scholar
  86. 86.
    Hess DR, Pang JM, Camargo CA Jr. A survey of the use of noninvasive ventilation in academic emergency departments in the United States. Respir Care. 2009;54(10):1306–12.Google Scholar
  87. 87.
    Maheshwari V, Paioli D, Rothaar R, Hill NS. Utilization of noninvasive ventilation in acute care hospitals: a regional survey. Chest. 2006;129(5):1226–33.Google Scholar
  88. 88.
    Gay PC. Complications of noninvasive ventilation in acute care. Respir Care. 2009;54(2):246–57 discussion 257-8.Google Scholar
  89. 89.
    Bach JR, B.P, Hess DR, Hill NS, McIntyre N, Pearson D, et al. Consensus statement: noninvasive positive pressure ventilation. Respir Care. 1997;42:365–9.Google Scholar
  90. 90.
    Pang D, Keenan SP, Cook DJ, Sibbald WJ. The effect of positive pressure airway support on mortality and the need for intubation in cardiogenic pulmonary edema: a systematic review. Chest. 1998;114(4):1185–92.Google Scholar
  91. 91.
    Chiumello D. Is noninvasive ventilation still underused by physicians? Respir Care. 2009;54(10):1302–3.Google Scholar

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Authors and Affiliations

  1. 1.Department of SurgeryUniversity of CincinnatiCincinnatiUSA

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