Neonatal nasal intermittent positive pressure ventilation: a survey of practice in England.

BACKGROUND: Less invasive techniques of respiratory support are increasingly popular. OBJECTIVE: To determine how widespread the use of neonatal nasal intermittent positive airway pressure (NIPPV) has become and describe the range of practice used in NIPPV in England. METHODS: 95 English Neonatal intensive care units were asked to provide information about NIPPV devices, interfaces, indications, guidelines, use of synchronisation, complications, settings and weaning. RESULTS: 91 (96%) units replied. NIPPV was used by 44/91 (48%) units; few complications were seen. 34/44 (77%) used a synchronising device, 35/44 (80%) used NIPPV for "rescuing" babies for whom continuous positive airway pressure failed-59% routinely after extubation and 16% as a first-line treatment. A wide range of pressure and rate settings were used. CONCLUSIONS: In England, NIPPV is commonly used, with considerable variability in the techniques applied. The wide range of clinical approaches highlights the paucity of evidence available. More evidence is needed to establish best practice.

[Comparative study between intermittent (Müller Reanimator) and continuous positive airway pressure in the postoperative period of coronary artery bypass grafting]. / Estudo comparativo entre a pressão positiva intermitente (Reanimador de Müller) e contínua no pós-operatório de cirurgia de revascularização do miocárdio.

OBJECTIVE: To compare the effect of the use of intermittent and continuous positive airway pressure in postoperative patients undergoing coronary artery bypass grafting. METHODS: This study included forty patients divided into two groups: one undergoing continuous positive airway pressure (CPAP Group), and the other undergoing intermittent pressure (Müller Resuscitator Group). The patients were evaluated in relation to the several study variables at the following time points: preoperative, 3rd, 24th, and 48th hours. RESULTS: The patient groups were homogeneous in relation to the several demographic and clinical variables. The values of pO2, pCO2 and sO2 were within normal limits and no significant differences were found between the groups. Regarding respirometry, the groups showed significant differences in the tidal volume and respiratory rate at the 48th postoperative hour. Dyspnea and use of accessory muscle in postoperative assessments were found with a significantly higher frequency in patients undergoing CPAP. Patients undergoing Müller Resuscitator had a normal chest radiograph more frequently than did patients undergoing CPAP. CONCLUSION: Both devices were shown to be able to keep pO2, pCO2, and sO2 values within normal limits. However, when the objective was pulmonary reexpansion with less imposed workload, the Müller Resuscitator was more effective because of its prompter action and consequently lower levels of dyspnea, respiratory rate (RR) and use of accessory muscle were observed.

Estudo comparativo entre a pressão positiva intermitente (Reanimador de Müller) e contínua no pós-operatório de cirurgia de revascularização do miocárdio / Comparative study between intermittent (Müller Reanimator) and continuous positive airway pressure in the postoperative period of coronary artery bypass grafting

OBJETIVO: Comparar o efeito da aplicação da pressão positiva intermitente e contínua em pacientes no pós-operatório de cirurgia de revascularização do miocárdio. MÉTODOS: Neste estudo foram considerados quarenta pacientes, divididos em dois grupos: um submetido a pressão positiva contínua (Grupo CPAP), e outro submetido a pressão intermitente (Grupo Reanimador de Müller). Os pacientes foram avaliados nos momentos: pré-operatório, 3ª, 24ª e 48ª horas, em relação às diversas variáveis do estudo. RESULTADOS: Os grupos de pacientes eram homogêneos em relação a diversas variáveis demográficas e clínicas. Os valores gasométricos de PO2, PCO2 e SO2 estiveram dentro dos parâmetros de normalidade e não foram encontradas diferenças significantes entre os grupos. Na ventilometria os grupos apresentaram diferenças significativas no volume corrente e freqüência respiratória no pós-operatório de 48 horas. A dispnéia e a participação da musculatura acessória, nas avaliações do pós-operatório, foram encontradas com freqüência significativamente maior nos pacientes submetidos ao CPAP. Pacientes submetidos ao Reanimador de Müller apresentaram radiografia de tórax normal com maior freqüência do que pacientes submetidos ao CPAP. CONCLUSÃO: Observou-se que ambos os recursos foram capazes de manter valores de PO2, PCO2 e SO2 dentro da normalidade. Porém, quando se busca a reexpansão pulmonar, com menor carga de trabalho imposta, o Reanimador de Müller foi mais efetivo pela forma mais rápida de ação e, conseqüentemente, apresentou menores índices de dispnéia, freqüência respiratória (FR) e atividade de musculatura acessória.

[Intermittent mandatory ventilation]. / Ventilación mandatoria intermitente.

Intermittent mandatory ventilation (IMV) is a mode of ventilation that allows the patient to make spontaneous breaths during the expiratory phase of mandatory ventilator breaths. There are two types of IMV according to whether respirator breaths are synchronized with the patient's respiratory efforts: Non-synchronized IMV and synchronized IMV (SIMV), and according to whether SIMV is volume- or pressure programmed. The main advantage of SIMV is that the respirator delivers the preset ventilator pressure and rate while allowing the patient to breath spontaneously, thus facilitating progressive weaning from mechanical ventilation. It diminishes the risk of barotrauma, produces less hemodynamic com-promise than control ventilation, reduces atrophy of respiratory muscles and the need for sedation and muscle relaxation and can be associated with pressure support ventilation.

Breathing pattern and additional work of breathing in spontaneously breathing patients with different ventilatory demands during inspiratory pressure support and automatic tube compensation.

OBJECTIVE: We designed a new ventilatory mode to support spontaneously breathing, intubated patients and to improve weaning from mechanical ventilation. This mode, named Automatic Tube Compensation (ATC), compensates for the flow-dependent pressure drop across the endotracheal tube (ETT) and controls tracheal pressure to a constant value. In this study, we compared ATC with conventional patient-triggered inspiratory pressure support (IPS). DESIGN: A prospective, interventional study. SETTING: A medical intensive care unit (ICU) and an ICU for heart and thoracic surgery in a university hospital. PATIENTS: We investigated two groups of intubated, spontaneously breathing patients: ten postoperative patients without lung injury, who had a normal minute ventilation (VE) of 7.6 +/- 1.7 l/min, and six critically ill patients who showed increased ventilatory demand (VE = 16.8 +/- 3.0 l/ min). INTERVENTIONS: We measured the breathing pattern [VE, tidal volume (VT), and respiratory rate (RR)] and additional work of breathing (WOBadd) due to ETT resistance and demand valve resistance. Measurements were performed under IPS of 5, 10, and 15 mbar and under ATC. RESULTS: The response of VT, RR, and WOBadd to different ventilatory modes was different in both patient groups, whereas VE remained unchanged. In postoperative patients, ATC, IPS of 10 mbar, and IPS of 15 mbar were sufficient to compensate for WOBadd. In contrast, WOBadd under IPS was greatly increased in patients with increased ventilatory demand, and only ATC was able to compensate for WOBadd. CONCLUSIONS: The breathing pattern response to IPS and ATC is different in patients with differing ventilatory demand. ATC, in contrast to IPS, is a suitable mode to compensate for WOBadd in patients with increased ventilatory demand. When WOBadd was avoided using ATC, the patients did not need additional pressure support.

The effects of therapist-evaluation of orders and interaction with physicians on the appropriateness of respiratory care.

UNLABELLED: Because our Respiratory Care Department resources were overburdened and many orders for medicated aerosol therapy (MAT) and lung hyperinflation therapy (LHT) seemed inappropriate, we developed ordering guidelines for MAT and LHT. We then studied the effects on numbers of inappropriate treatments when therapist-evaluators discussed questionable orders with physicians. METHODS: For 6 weeks, the physicians were divided into two groups, one interactive with therapists, the other serving as controls. The physicians then switched groups for a second 6-week period. Therapist-evaluators examined all orders for MAT and LHT and suggested therapy changes to interactive-group physicians who wrote questionable orders; they did not discuss inappropriate orders with control-group physicians. The percentages of inappropriate treatments ordered by both physician groups were recorded, and the costs of inappropriate therapy were calculated. After the 12-week study, the program continued, with evaluators interacting with all physicians when treatment was inappropriate. RESULTS: Of treatments ordered by control-group physicians, 48% were inappropriate. Of treatments ordered by physicians in the interactive groups, 35% were inappropriate. Inappropriate treatments cost $15,960 in labor and supplies and required 3.6 full-time technicians. The cost of evaluation was $1,193. By 6 months following the study, therapist-physician interaction had reduced inappropriate treatments to 11% of treatments given. CONCLUSIONS: The use of ordering guidelines and therapist-evaluators who interact with physicians can significantly reduce the number of inappropriate respiratory care treatments and reduce costs.

[A control trial of home I.P.P.B. therapy in patients with chronic obstructive respiratory insufficiency. Protocol and state of the study (author's transl)]. / Présentation d'un essai thérapeutique en cours concernant la ventilation assistée à domicile chez les insuffisants respiratoires chroniques de type obstructif.

Because a previous retrospective study did not allow any conclusion as to the efficacy of home IPPB therapy in patients with chronic airflow obstruction, a control trial has been started. The protocol includes definition of patients, modalities of treatment, criteria for evaluation. Among criteria for a patient to enter the trial is a chronic hypercapnia (with PaCO2 greater than or equal to 48 mmHg) observed over a preliminary period of 4 months. At the end of this period patients are allocated at random into two groups with and without IPPB at home (at least 1 to 2 hours daily through a mouthpiece); medical prescriptions are same in the 2 groups so as surveillance which is planned for 2 years. Evaluation should be based upon 5 predetermined criteria. This trial is in progress.

[Two-year assisted ventilation at home experiment study of 15 patients (author's transl)]. / Expérience de deux années de ventilation assistée à domicile. Surveillance de 15 malades.

Assisted ventilation at home requiring volume relaxators affected 15 patients suffering from a restrictive syndrome (cyphoscoliosis or after effects of tuberculosis). The blood gases of 8 patients who had been looked after for more than one year, at home by the physio-therapist and in hospital by repeated controls, improved (especially the PaO2). The most important fact is the noteworthy decline in the annual time of hospitalisation.

[Technique and supervision of home assisted ventilation (author's transl)]. / Technique et surveillance de la ventilation assistée à domicile (V.A.D.).

Based on data obtained from 260 patients ventilated through a mouth-piece, several notions concerning equipment and supervision requirements have become clear.--In our opinion, the indications should not be reserved for extremely severe patients; in their case cardiac complications are constant in spite of usual treatment. These patients, most often respiratory encephalopathic, are not very receptive to the "directions for use" of home assisted ventilation.--On the contrary, chronic hypoxia-hypercapnia, whatever its origin, accompanied by slight or transitory cardiac signs, has much more chance of being treated successfully.--The adaptation of the patient to the respirator before his release from the hospital must be worked out until a clinical and biological improvement can be obtained, at the risk of probable failure.--Supervision at home should disclose any alteration in the patient's clinical condition. It can only be carried out by the conjoined visits of the practicing doctor, nurse, technician, etc. The contacts between the practicing doctor and the hospital physician should be frequent. The ideal solution is systematic visits to the hospital.

[Results of home assisted ventilation of non-paralytic and tracheostomized chronic respiratory insufficient patients (author's transl)]. / Résultats de la ventilation assistée à domicile (V.A.D.) de l'insuffisant respiratoire chronique (I.R.C.) non paralytique, trachéotomisé.

The following results have been obtained from a study of 118 tracheostomized patients ventilated at home: --Survival on the whole is generally prolonged. --The prognosis of tracheostomized subjects with restrictive syndrome is totally modified in length and quality when the patients are ventilated. --In the case of obstructive syndrome, the length and quality of survival are probably increased. However, it seems that assisted ventilation at home leads only to the disappearance of asphyxiating paroxysms and right cardiac failure. It does not seem to prevent the unrelenting evolution of the disease.

[Long-term results of intermittent ventilatory assistance for 74 severe obstructive chronic respiratory insufficient patients (PaCO2 greater than 50 Torr) ventilated for more than a year (author's transl)]. / Résultats à long terme de l'assistance ventilatoire intermittente chez 74 insuffisants respiratoires chroniques obstructifs graves a PaCO2 greater than 50 Torr appareillés depuis plus d'un an.

From 1967 to 1978, home assisted ventilation (HAD) was applied to 74 severe chronic respiratory insufficient patients (67 COPD-7 restrictive). These patients used volume generators through mouth piece, except 3 of them who had a tracheostomy. The main results of this study are a highly statistically significant decrement (P less than 0,001) of the hospitalization durations and of the frequency of ARF, as well as an improvement of the survival duration in front of a non-tested group, and a significant decrease of haematocrit (less than 0,05) and P.V.R. (P less than 0,01). But blood gases and functional tests are not statistically different. Age (greater than 55 years) and delay after first ARF (greater than 2 years) when starting HAD are considered as pejorative factors.

[Nine-year study of home assisted ventilation in cases of severe respiratory handicap (author's transl)]. / Expérience de 9 années de V.A.D. chez de grands handicapés respiratoires.

When other treatments fail, the prognosis of some chronic respiratory insufficient patients with frequently occurring failures improved when a tracheostomy canula was installed and connected to a respiratory for several hours a day. The even partial correction of blood gas disorders avoids a relapse in right cardiac failure and enables home care of the patient who can resume formerly abandonned activities. Home assisted ventilation greatly modifies the somatic and psychological condition of the patient and requires excellent cooperation by the family and strict technical supervision, at the risk of failure.

[Technic and supervision of home assisted ventilation (H.A.V.) in tracheostomized chronic respiratory insufficient (C.R.I.) patients (author's transl)]. / Technique et surveillance de la ventilation assistée à domicile (V.A.D.) des insuffisants respiratoires chroniques (I.R.C.) trachéotomisés.

With 200 patients during the last 15 years the daily use of apparatus and supervision modalities, as described in the present work, has shown that H.A.V. is entirely possible in tracheostomized C.R.I. patients. Rather strict conditions must be respected (as with hemodialysis at home) if H.A.V. is to be medically and materially successful. The expenses involved can vary greatly according to the medical and material management (choice of study material, economic maintenance, minimal oxygen consumption through proper adjustment...). Finally, the use of assisted ventilation requires a choice amont several adjustment possibilities which are still subject to evolution.

[Intermittent positive pressure breathing (IPPB) with respirators in home nursing]. / Uberdruckinhalation (IPPB) mit Respiratoren in der Heimbehandlung.

29 patients using a home respirator have been studied. Management of the respirator and inhalation were correct in 86%. Bacteriologic contamination in home treatment poses few problems. Blood gases and spirometric lung function tests do not demonstrate amelioration but show stabilization in long term treatment. Costs are high. Nevertheless, this treatment is indicated in certain carefully selected patients. Follow-up checks are essential.