Non-invasive Ventilation: Why Does It Fail?

Abstract

Intense interest and investigation have surrounded non-invasive ventilation (NIV) over the past decade. For many patients, especially those suffering an exacerbation of chronic obstructive pulmonary disease (COPD), NIV, rather than intubation and invasive ventilation, is often considered the standard of care. This change in practice flows from studies demonstrating that, when compared to conventional intubation and ventilation, NIV effectively relieves symptoms, improves gas exchange, reduces the work of breathing (WOB), reduces complications, shortens the length of intensive care unit (ICU) stay, and improves survival [1–5]. Studies have shown consistently that intubation is unnecessary for the majority of COPD patients treated with NIV. For example, success rates in a large number of trials have been as follows: Vi-tacca et al. 82% [6]; Pennock et al. 75% [7]; Kramer et al. 69% [2]; Ambrosino et al. 78% [8]; Brochard et al. 74% [1]; Vitacca et al. 74% [9]; and Antonelli et al. 69% [3]. It is questionable, however, if these results can be generalized to wide populations in diverse care settings. Practical experience with NIV may not reach success rates as high as those reported in the literature. In fact, many physicians, nurses, and respiratory therapists have become discouraged with NIV because their patients so often come to intubation despite NIV; often following hours or days of intensive effort and frustration. In this chapter, we consider why many practitioners have not duplicated the success rates of published trials and we discuss measures to maximize the practical effectiveness of NIV.