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ORIGINAL CONTRIBUTION |
From the Division of Pulmonary and Critical Care Medicine at Temple University School of Medicine in Philadelphia, Pa.
Address correspondence to Francis C. Cordova, MD, Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, 3401 N Broad St, Philadelphia, PA 19140-5103. E-mail: cordovf{at}tuhs.temple.edu
Background: Noninvasive positive-pressure ventilation (NPPV) is commonly used to improve ventilation and oxygenation in patients with acute respiratory failure (ARF). Mask leak and intolerance due to facial discomfort or claustrophobia often occur with NPPV and are frequently cited reasons for treatment failure.
Methods: Retrospective review of patient records from a tertiary-care referral hospital.
Results: We report the effectiveness of a full face mask in the application of NPPV for 10 nonambulatory patients (mean [SD], 61 [9] years) who had a combined total of 13 episodes of ARF. After these patients were unable to receive NPPV therapy via the more commonly available nasal or oronasal masks, care was provided using full face masks. Eight of 10 patients had hypercapnic respiratory failure; 2 patients, hypoxemic respiratory failure. All patients were placed on ventilation initially using a bi-level positive airway pressure device. Subsequently, patient ventilation was achieved using a Puritan Bennett 7200a ventilator for on-line respiratory monitoring. The mean (SD) duration of treatment with NPPV was 9.7 (2.7) hours per day for 3.0 (1.6) days. Following NPPV via full face mask, the patients' PaCO2 decreased (65 [20] vs 82 [27] mm Hg, P=.09) and pH increased significantly (7.36 [0.07] vs 7.26 [0.07], P<.05) in less than 2 hours. Moreover, the patients demonstrated decreased respiratory rate (18 [7] vs 32 [8] breaths/min, P<.01), heart rate (106 [13] vs 124 [16] beats/min, P=.008), and Acute Physiology and Chronic Health Evaluation II scores (12 [3] vs 17 [4], P<.005) after NPPV via full face mask. These cardiorespiratory alterations occurred as early as 1 hour after NPPV initiation and were maintained throughout treatment. Two patients required endotracheal intubation because of copious purulent secretions.
Conclusion: For individuals with hypercapnic respiratory failure who cannot tolerate NPPV using nasal or oronasal masks, use of full face masks may improve outcomes, allowing physicians to avoid ordering endotracheal intubation and mechanical ventilation.
Some of the factors that limit the use of NPPV are related to problems with patient-mask interfacing. Previously, Criner and colleagues18 compared the efficacy of NPPV via full face mask versus nasal and oronasal masks in patients with chronic respiratory failure. Their study determined that full face masks could more effectively increase minute ventilation measurements and decrease PaCO2 than other mask types. Moreover, that study found that full face masks decreased mouth and mask leaks, enhanced tolerability, and were more comfortable for patients than other mask types. Similarly, other investigators19,20 have reported a decrease in intubation rates and mask-related complications with the use of a new type of full face mask called the "helmet."
The present study describes 10 patients who had a combined total of 13 episodes of ARF. After these nonambulatory patients were unable to receive NPPV therapy via more commonly available nasal or oronasal masks, treatment was delivered using full face masks (Total Face Mask [TFM], Respironics Inc, Monroeville, Pa). Using TFM, we explored the need for endotracheal intubation and examined a variety of respiratory and hemodynamic parameters.
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Methods |
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Acute Physiology and Chronic Health Evaluation (APACHE) II scores were used to measure illness severity in all patients receiving NPPV.21 The following three components were used to determine APACHE II scores:
In order to determine the total APACHE II score, we combined the values for each of the three components noted.
Mask Selection and Ventilation Targets
All patients were initially treated with NPPV via conventional nasal or
oronasal face masks (Respironics Inc, Monroeville, Pa) using a bi-level
positive airway pressure device (BiPAP, Respironics Inc, Monroeville, Pa)
followed by a conventional intensive care unit (ICU) volume ventilator
(Puritan Bennett 7200a, Puritan Bennett, Carlsbad, Calif). A conventional
volume ventilator was used because of the need for on-line respiratory
monitoring. Figure 1
and Figure 2,
respectively, show the nasal and oronasal face masks used in the present
study.
Mechanical ventilator settings were chosen while monitoring patients' respiratory rates, end-inspiratory and end-expiratory airway pressures, and inspiratory and expiratory flows and volumes. The final settings considered optimal were those that improved the patients' gas exchange, and those that visually decreased labored breathing and improved patient comfort. For the purposes of this study, "labored breathing" and "patient discomfort" were defined as failure to decrease the respiratory rate to less than 30 breaths/min or to achieve a tidal volume greater than 6 mL/kg, and failure to diminish sternocleidomastoid muscle activity as assessed both visually and by palpation.
One of the authors (G.J.C.) conducted all patient evaluations (ie, physical examinations and clinical evaluations) and supervised NPPV initiation. Patients who had extensive mouth or mask leaks, poor mask tolerance, or an inability to increase applied ventilation to target levels so as to stabilize their gas exchange and diminish labored breathing within 1 hour of treatment with nasal or oronasal masks were considered for treatment with NPPV via full face mask (Figure 3). All variables reported were obtained while patients received ventilation via TFM. We received institutional review board approval to use the TFM on a compassionate basis.
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Statistical Analysis
An analysis of variance was used to compare ventilatory variables, arterial
blood gas levels, and APACHE II scores on and off NPPV (SigmaStat Software;
Systat Software Inc, Richmond, Calif). The Wilcoxon rank sum test was used for
data that are not normally distributed. A P value of less than .05
was considered statistically significant. Demographic data are reported as
mean (SD).
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Results |
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In the 13 episodes of ARF, 11 episodes were due to hypercapnic respiratory failure with an admission PaCO2 value ranging from 52 to 116 mm Hg (6.9-15.5 kPa). Overall, the mean PaCO2 value on admission was 71 (28) mm Hg (9.5 [4] kPa). All patients were initially treated with NPPV using conventional nasal or oronasal masks and were either intolerant of the mask or failed to show clinical improvement. In the 7 patients for whom arterial blood gas was measured after NPPV initiation with conventional masks, acute respiratory acidosis failed to improve after 1 hour of treatment as reflected by persistent acidemia (NPPV using conventional masks, 7.26 [0.1] vs baseline, 7.29 [0.07], P<.1) and hypercapnia (PaCO2 with NPPV using conventional masks, 75 [34] mm Hg [10 (5) kPa] vs baseline, 59 [27] mm Hg [7.9 (4) kPa], P<.03). All patients were acutely ill as reflected by the moderately high mean APACHE II score of 18 (3).
Following ineffectiveness of conventional masks in this cohort, TFM was applied. The initial inspiratory positive airway pressure was 21 (4) cm H2O with baseline continuous positive airway pressure of 3 (3) cm H2O (Table 2). The average pressure boost (ie, difference between inspiratory and continuous positive airway pressure levels) was 18 (4) cm H2O. All patients were treated with NPPV via the pressure support mode; 6 patients in the pressure support mode with backup 4 to 6 breaths/min of intermittent mandatory ventilation. During NPPV treatment with TFM, all patients received ventilation without difficulty. The average minute ventilation was 12.9 (8.1) L, tidal volume was 585 (100) mL, and respiratory rate was 33 (7) breaths/min.
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When compared with breathing supplemental oxygen alone, PaO2/FIO2 values tended to be higher and PaCO2 values tended to be lower in patients with NPPV via TFM, but these values did not reach statistical significance (Figure 5). On days 2 and 3 of treatment, however, pH values during NPPV (7.32 [0.05] vs 7.40 [0.05]) and while spontaneous breathing (7.32 [0.12] vs 7.37 [0.04]) were significantly greater when compared with ICU admission values (7.29 [0.06], P<.05).
Expired minute ventilation and tidal volume were measured daily in all patients during NPPV treatment (Figure 6). During the first 3 days of NPPV application, mean (SD) minute ventilation was 12.6 (7.1) L and tidal volume was 647 (147) mL, with a range of 400 to 1000 mL. These values remained stable during treatment.
Before NPPV initiation, APACHE II scores were determined. Researchers continued to monitor these scores daily (Figure 7). After treatment initiation, APACHE II scores were significantly lower in patients while on NPPV and during spontaneous breathing. Lower scores were the result of reductions in acute physiologic scores reflecting improvements in gas exchange as well as hemodynamic and respiratory data. That is, patients had higher blood pressure, lower respiratory rates, and a lower incidence of hypercapnia.
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Although several studies have now reported in prospective and controlled fashions the beneficial effects of NPPV therapy in ARF,6-9,11,12,19,25 the reasons that treatment fails in 30% to 40% of patients has not been well documented. Commonly cited reasons for failure of NPPV are inability to meet increased ventilation targets and patient mask-intolerance, including problems associated with the mask's being frequently dislodged (eg, nursing care required to ensure mask placement).14,19,22,26 In a prospective, randomized controlled trial comparing the efficacy of NPPV versus conventional mechanical ventilation in patients with ARF, 10 (31%) of 32 patients treated with NPPV eventually required endotracheal intubation.8 The reasons for NPPV failure in that study were inability to improve oxygenation (4 patients), intolerance of NPPV (2 patients), hemodynamic instability (2 patients), persistent dyspnea (1 patient), and excessive purulent secretions (1 patient). In a survey of 42 ICUs on the type of ventilatory support used in patients with ARF (N=689), NPPV was initially used as first-line treatment in 108 (16%) patients.16 Most of the patients who were treated with NPPV had hypercapnic respiratory failure (50%), with 27% having pulmonary edema, and 14% hypoxemic respiratory failure. In 52 (48%) of these 108 patients, NPPV therapy was terminated early because of a lack of clinical response, patients' inability to handle purulent secretions, patient intolerance of NPPV, and full dependence on ventilatory support.16 Forty-three of these patients ultimately required endotracheal intubation. Multiple regression analysis revealed that the Simplified Acute Physiology Score II and intolerance to NPPV were two independent predictors of the need for mechanical ventilation. Indeed, when patients with ARF are unable to tolerate NPPV therapy because of poor mask interface, the result often is interrupted therapy leading to a decrease in treatment efficacy.
The ventilation targets achieved in our patient population were relatively high with little mask adjustment requirements and no incidents of facial skin breakdown. Moreover, mask leaks noted in 5 patients were minimal and were not a limitation in achieving high ventilation targets. We believe that these three factors (ie, lack of mask adjustment, skin breakdown, and minimal mask leaks) were instrumental in the success of using full face masks over the other two types of masks that failed in the same patient population. Because the full face mask is large and is designed to cover the entire face, it might appear that problems with claustrophobia or dead space would have been significant limitations. Conversely, patients reported fewer incidents of claustrophobia with a full face mask than with conventional nasal or oronasal masks. This reduction may have been due to an unobstructed field of vision during use of the full face mask, as well as the patients' ability to communicate verbally with healthcare providers, which is more difficult with other types of masks. In addition, the reduction in incidents of claustrophobia may also be attributed to a sensation of air flowing over the entire face while using the full face mask, which could potentially decrease dyspnea.27
Despite having a larger dead space volume than with other masks (1500 cc with TFM compared with 105 cc with a nasal mask and 250 cc with an oronasal mask), no patient demonstrated further increases in PaCO2 or more labored breathing while using the TFM. To minimize the potential adverse effects of an increased dead space while using the mask, all patients were treated with a continuous base flow of oxygen and air mixture (according to the patient's FIO2 need) to wash out dead space and/or an ancillary flow of oxygen delivered directly into the mask port. In addition, there are two small bore orifices located on either side of the mask inlet connector acting as small exhalation valves. Finally, all patients were placed on ventilation with a double limb ventilator tubing setup (ie, separate inspiratory and expiratory limbs) that further avoided rebreathing CO2.
The limitations of the present study are its retrospective nature, small sample size, and lack of control subjects. However, the strength of the current study lies in the achieved success of NPPV via full face mask in extremely ill patients—patients in whom NPPV therapy had previously failed with conventional masks, and who had a high likelihood of undergoing intubation as a result of ARF.
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Submitted February 2, 2005; revision received March 13, 2006; accepted June 20, 2006.
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References |
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