Noninvasive positive-pressure ventilation:the little things do make the difference!

The application of noninvasive positive pressure, either as continuous positive airway pressure or noninvasive positive-pressure ventilation (NPPV), has become established as the primary approach for ventilatory support in a number of clinical settings.1 In fact there are at least 15 randomized, controlled clinical trials evaluating the effect of NPPV in the management of acute exacerbations of chronic obstructive pulmonary disease (COPD).2 These data have demonstrated that NPPV during a moderate or severe acute COPD exacerbation decreases the incidence of endotracheal intubation, duration of mechanical ventilation, duration of intensive care unit (ICU) stay, duration of hospitalization, hospital costs, and, most importantly, mortality.2,3 Additional data, although not as compelling as the above, support the use of NPPV in the management of acute cardiogenic pulmonary edema, acute respiratory failure in immunocompromised patients, patients awaiting lung transplantation, and as a bridge between invasive ventilation and spontaneous unsupported breathing.1 Clearly, NPPV is the standard of care for the management of acute respiratory failure in many of these circumstances. However, in many institutions the success rate for NPPV is much lower than that demonstrated in the literature.