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Advisory Board Trends in Noninvasive Respiratory Support: Continuum of Care Noninvasive ventilation provides ventilatory support without the use of invasive respiratory de- Richard Branson, MS, RRT, FAARC Professor of Surgery vices. It can often eliminate the need for intubation and preserve normal respiratory tract func- University of Cincinnati College of Medicine tions. Noninvasive positive pressure ventilation (NPPV) delivers a set pressure for each breath, as Cincinnati, OH opposed to negative pressure ventilation, which exposes the chest wall to subatmospheric pres- Kathleen Deakins, MS, RRT, NPS sure during inspiration. NPPV is usually delivered by a nasal or face mask, thus eliminating the Supervisor Pediatric Respiratory Care Rainbow Babies & Children’s Hospital of need for intubation or tracheostomy. NPPV can be given by a pressure-controlled ventilator, a University Hospitals Cleveland, OH volume ventilator, a bilevel positive airway pressure (BIPAP or bilevel ventilator) device, or a con-

William Galvin, MSEd, RRT, CPFT, AE-C, FAARC tinuous positive airway pressure (CPAP) device. The main clinical rule with noninvasive ventila- Program Director, Respiratory Care Program Gwynedd Mercy College, tion is to use the most cost-effective and simplest method to achieve the desired therapeutic goals. Gwynedd Valley, Pa. The recent introduction of high flow oxygen therapy, NPPV, and CPAP, have provided a contin- Carl Haas, MS, RRT, FAARC uum of care that offers the respiratory therapist simpler, less costly options before proceeding to Educational & Research Coordinator University Hospitals and Health Centers the more costly, invasive procedures. In this edition of Clinical Foundations, we describe these Ann Arbor, MI noninvasive strategies beginning with high flow oxygen (simplest and least costly) and proceed- Richard Kallet, MSc, RRT, FAARC Clinical Projects Manager ing to NPPV and CPAP. University of California Cardiovascular Research Institute San Francisco, CA High Flow Oxygen Delivery Neil MacIntyre, MD, FAARC Medical Director of Respiratory Services Duke University Medical Center By Jonathan Waugh PhD, RRT, RPFT Durham, NC High flow therapy (HFT) delivers warm, humidified gas to the patient through a nasal cannula. Tim Myers, BS, RRT-NPS Pediatric Respiratory Care Body temperature and pressure saturated gas can be beneficial, regardless of whether the patient Rainbow Babies and Children’s Hospital Cleveland, OH is receiving supplemental oxygen, although the mechanism is not yet fully clear. Breathing cool, dry gases can produce deleterious effects in the respiratory tract and when delivered through an Tim Op’t Holt, EdD, RRT, AE-C, FAARC Professor, Department of Respiratory Care and artificial airway, can magnify the negative impact of ventilation. HFT can be used in the emer- Cardiopulmonary Sciences University of Southern Alabama gency room and other settings and is suitable for patients high oxygen requirements. Discussed Mobile, AL in this article are several devices used to deliver HFT. Also discussed are the many current and Helen Sorenson, MA, RRT, FAARC Assistant Professor, Dept. of Respiratory Care potential applications of HFT. University of Texas Health Sciences Center San Antonio, TX Noninvasive Ventilation By Tim Op’t Holt EdD, RRT, AE-C, FAARC and William Pruitt, MBA, RRT, CPFT, AE-C Noninvasive positive pressure ventilation (NPPV) is viable alternative to ventilating in many pa- tients and continuous positive air pressure (CPAP) has several uses, including mobilizing secre- tions, reducing or preventing atelectasis, reducing air trapping in chronic obstructive pulmonary disease (COPD), and others. NPPV has been used as a bridge to successful extubation and in the treatment of new onset respiratory failure following extubation. Duration of ventilation has been shown to decrease in patients who were extubated and ventilated with NPPV, and were fail- ing spontaneous breathing trials. Shortening the duration of ventilation also decreases the need for tracheostomy, the need for tube feeding, the incidence of nosocomial pneumonias, and death. Compared to invasive ventilation, NPPV has also been shown to decrease mortality, the incidence of nosocomial pneumonia, hospital length of stay and total duration of ventilation. Other topics of discussion in this article include the uses of wet or dry CPAP, fixed or variable gas delivery, and tips for dealing with claustrophobia and noncompliance.

L-1111-0601 Trends in Non-invasive Respiratory Support: flow rates up to 40 L/min at BTPS and be used with infants to adults.13 Salter Labs Continuum of Care (Arvin, California) introduced a nasal cannula and non-heated bubble humidi- fer in 2004 that could deliver flow rates up High Flow Oxygen to 15 L/min with a little more than 70% relative humidity (RH).13 This flow range Delivery is higher than the traditional nasal can- nula but not sufficient to meet a patient’s By Jonathan B. Waugh RRT, RPFT, PhD full minute ventilation requirement (the resulting significant dilution with room air helps explain why ambient tempera- igh flow therapy is the deliv- ture is used). In 2005, Smiths Medical ery of high inspired gas flows Heated humidification ASD (Weston, Mass.) introduced the (ideally greater than the pa- AquinOx®, a heated aerosol (15-35 tient’s peak inspiratory de- L/min at 95-100% RH) that uses a filter Hmand) which may or may not have an can proximal to the patient designed to cap- increased oxygen concentration. For a ture particulate water and allow only mo- gas flow to fully supply a patient’s rest- lecular humidity to pass through to pedi- ing minute ventilation, the gas should prevent intraoperative atric or adult patients. be warm and humidified (ideally at The most recent high flow nasal can- body temperature and pressure saturat- hypothermia or hasten nula (HFNC) devices come from Hud- ed [BTPS]). The importance of warming son RCI /Teleflex Medical (Durham, NC), and humidifying inspired gas has been Fisher & Paykel Healthcare (Laguna Hills, known for several decades.1-6 Breathing rewarming and to re- Calif.), and Southmedic (Barrie, On- cool, dry gases can produce deleterious tario). The Hudson RCI Comfort Flo™ effects such as mucosal damage, reduced duce Humidification System features a single ciliary motility, decreased mucus produc- limb, smooth bore, double heated wire tion, bronchospasm, and nasal discom- circuit and a specialized humidification fort and bleeding.7 Delivering cool, dry or eliminate episodes of column capable of BTPS humidification gases via an artificial airway can magni- at flows ranging from 1-40 L/min. Four fy the negative impact of ventilation (e.g. sizes of cannula, from premature infant retained secretions, mucus plugging, atel- spirator MT-1000 which could produce to adult, are packaged separately. The sys- ectasis, increased work of breathing, hy- up to 20 L/min at BTPS, intended to en- tem is disposable, thus minimizing the poxemia, and hypothermia).8 Converse- hance cystic fibrosis secretion clearance. risk of cross-contamination and bacteri- ly, some studies have shown a protective Two years later, a new model designed al growth. The system is intended for use or even therapeutic effect from inhaling to treat race horses for exercise-induced with Aquapak® prefilled water products warm, humidified gas (WHG).9 Heated pulmonary hemhorrage was found to be and is compatible with all of the Con- humidification can prevent intraopera- an effective both before and after treat- chaTherm® heated wire capable heaters. tive hypothermia or hasten rewarming10 ment. Transpirator Technologies Inc. (Hudson RCI product literature). and has been shown to reduce or elimi- marketed a horse model which is cur- F&P Healthcare combines a heated nate episodes of nocturnal asthma11 and rently used by many stakes winners and humidifier (MR850), breathing circuit exercise-induced asthma.12 These benefits tracks in the USA and Canada. Although (RT329), and infant nasal cannula that can be observed without using supple- the company developed a model for hu- will deliver about 2 L/min BTPS before mental oxygen. man use, it was never brought to market. triggering a 40 cm H2O system pressure Therapeutic administration of WHG In 1997, Vapotherm (Stevensville, Mary- relief valve. Five new F&P low resistance to spontaneously breathing patients is land) licensed rights to develop a shoe cannulas designed for neonatal and pedi- not a new concept, but only in the past box-sized device (Model 2000i) for hu- atric use are now available with reported decade have nasal cannula been used. In man use using new membrane technol- maximum flow rates ranging from 6-8 1987, the Oxygen Enrichment Company ogy, similar to the membrane filter used L/min BTPS. An adult high flow pack- introduced the dishwasher-sized Tran- in hemodialysis. This device can achieve age capable of 50 L/min is scheduled

2 for release in Fall 2006.61 Southmedic is the effect of tracheal gas insufflation and taking a new direction in HFT with the thereby provide ventilatory assistance. In Oxymask™. The mostly open mask shell The clinical rule of us- summary, we have documented evidence is designed to direct a plume of gas (24- that high flows via nasal cannula can pro- 90% O , depending on a selected flow of duce improvement but the mechanism of 2 ing the most simple and 1-40 L/min) at ambient temperature to action has yet to be elucidated. the nose and mouth, blanketing them in To obtain the potential benefits of a way that acts as a reservoir. cost-effective therapy to high gas flows by nasal cannula, the gas must be properly conditioned to make How Does High Flow Therapy satisfactorily treat the it tolerable to the patient. Optimum hu- Benefit the Patient? midity is achieved when the inspired gas Respiratory textbooks for the past is at body core temperature and at 100% twenty years have typically noted that patient has led many RH.5 Mucosal dysfunction can often be the flow rate for a nasal cannula should seen with gas that is thermally inappro- not exceed 6-8 L/min. Some mention priate with humidity outside the optimal that higher flows at ambient temperature ygen (or in the form of decreasing the level.6 Every breath not at BTPS presents a from a bubble humidifier can cause nasal FDO2 requirement). Several mechanisms water volume and energy (thermal) chal- discomfort, due to the expectation that of action have been discussed as pos- lenge to the airway mucosa which is typi- the nasopharyngeal reservoir would be sible explanations. Some authors have cally handled well by the upper airways. completely saturated. Therefore, the de- suggested that high flows of BTPS gas When the challenge exceeds the homeo- livered oxygen concentration was thought can impart significant but not excessive static mechanism, then airway dysfunc- to plateau at flow rates greater than 6-8 moisture to water-deficient airways, pro- tion begins and may progress to altera- L/min. Oddly enough, earlier studies of ducing a stabilizing and perhaps protec- tions in the ventilation-perfusion ratio oxygen appliances demonstrated that tive effect. This may also enhance ciliary and a decrease in compliance. Drying oxygen concentrations continued to in- movement and mucous clearance. (It is of the airways can produce an osmotic crease at flow rates above 8 L/min. Kory well-known that airways contain pres- challenge to mucosal cell function21 and et al14 and Poulton et al15 documented sure and temperature receptors and it is cause nasal congestion by altering muco- flow rates up to 10 L/min and report- conceivable that these may be stimulat- sal blood flux22, but attempting to com- ed that the fraction of delivered oxygen ed by high BTPS gas flow). A few stud- pensate with aerosolized or instilled wa-

(FDO2) continued to increase up to the ies indicate that high nasal cannula flow ter may be hazardous due to the potential highest flow tested. In 1976, Gibson et al creates a small degree of positive airway of these methods to deliver excess water observed that oxygen concentrations in pressure which would explain at least in to the airways. Molecular humidity is the the trachea continued to increase at flows part why oxygen requirements decrease safest form of humidification for HFT as high as 15 L/min.16 More recently, Wet- and signs of decreased breathing effort (especially for young patients) because 20 tstein reported that an FDO2 as high as is often seen. Others argue that HFT the water content is limited to what can 0.75 could be achieved at a flow rate of 15 by nasal cannula can flush the anatomic be carried in the vapor phase. L/min, depending on breathing pattern.17 deadspace of the upper airways similar to Malinowski et al reported fractional oxy- What Are the Current and Potential gen concentrations up to 0.84 at a flow Applications of HFT? rate of 25 L/min.18 Using an anatomical- Many clinicians experienced in the ly correct head extension airway model, use of HFT by nasal cannula use it in Tiep found that tracheal oxygen concen- place of a nonrebreather mask (NRM). trations increased over the tested range of Walsh reported that CHF patients in the 10-30 L/min.19 These experiments indi- emergency room had higher oxygen sat- cate that oxygen delivery for a nasal can- urations with a 20 L/min nasal cannula nula does not plateau at 6-8 L/min. compared with NRM.23 Spontaneously Published studies and case reports of breathing patients with high oxygen re- patients treated with HFT by nasal can- quirements (e.g. interstitial pulmonary nula (HFT-NC) demonstrate that there fibrosis, congestive heart failure, pulmo- can be a beneficial effect from BTPS high nary edema, chronic obstructive pulmo- flows, independent of supplemental ox- ComfortFlo (Hudson RCI, Teleflex Medical) nary disease [COPD]) would be suitable

3 candidates for HFT. The clinical rule of gas measurement on HFT-NC revealed a using the most simple and cost-effec- pH of 7.34, a PaCO2 of 44, a PaO2 of 67, a tive therapy to satisfactorily treat the pa- base deficit of –2 with a HCO3 of 22, and tient has led many to use HFT as a way to a SaO2 of 92%. The patient also received avoid mechanical ventilation. In clinical a transfusion of packed red blood cells reports by Taft (n=61) and Hill (n=29), (45 cc) over a two-hour period. The pre- patients had pre-HFT mean oxygen sat- and post-ductal SpO2 remained at 98%, urations of 88% and respiratory rates of enabling weaning of FIO2 to 0.40 over a 25 bpm or greater and all were able to 2-hour period (see Figures 2 & 3). avoid mechanical ventilation.24,25 Rojas The blood gas measurement on HFT- et al (n=377) reported a 51% decrease in NC settings of 6 L/min and 40% O2 had a the use of mechanical ventilation, with a pH of 7.32, PaCO of 48, PaO of 96, base Figure 2. Chest film of patient in supine position soon 2 2 97.3% decrease in nasal continuous posi- after starting HFT-NC therapy. deficit of –2 with a HCO3 of 25, and a tive airway pressure (CPAP).26 Some HFT tachypneic with f = 60–90 bpm. Pre-duc- SaO2 of 97%. Antibiotics were started on nasal cannula devices have the ability to tal SpO2 was 100% on 1 L/min oxygen via the patient when the referring hospital deliver heliox and nitric oxide.27-29 Clini- traditional nasal cannula. The initial um- divulged an untreated maternal beta he- cians are using HFT-NC to enhance ex- bilical line blood gas measurement (pH molytic Streptococcus infection 24 hours ercise tolerance for asthmatic and COPD 7.27, PaCO2 = 47, PaO2 = 35, base defi- after transport. The ease of application of 30-34 patients. Successful traumatic and cit = –6, HCO3 = 18, and SaO2 = 63%) the HFT-NC system, the reduced risk of post-operative rewarming has been done revealed mixed acidosis. The chest radio- skin/nasal trauma-breakdown, and the with HFT-NC.35,36 Sreenan et al found graph revealed eight ribs expanded and ability to alter pulmonary function were HFT-NC as effective as nasal CPAP for was otherwise unremarkable (see Figure strong points for using this modality for treating apnea of prematurity and Mar- 1). this case of respiratory distress due to pa- tinez-Gomez reported increased success Pre- and post-ductal SpO2 measure- renchymal lung disease as evidenced by with infant extubations.37, 38 Lung trans- ments revealed a gradient of 13%. Nasal poor CO2 clearance and maternal history. plant candidates needing to exercise pri- cannula flow was increased to 2 L/min or to surgery have used HFT-NC tolerate without any change in the gradient. A Summary pre-conditioning.39 5% albumin infusion (10cc/kg) was giv- At present, we have documented evi- en over 15 minutes without a significant dence that high flows via nasal cannula Case Study change in status. The patient was placed can produce patient improvement but Consider the following infant case on HFT-NC (Vapotherm 2000i) for re- the mechanism of action has yet to be study (adapted from a contribution by spiratory distress and oxygenation dif- elucidated. Further research is needed to Douglas Petsinger, BS, RRT, Children’s ficulties. Coarctation of the aorta was determine if there is a particular flow for Healthcare of Atlanta, Atlanta, Georgia). ruled out by echocardiogram. Initial HFT- each of the infant, child, and adult flow

The patient was a 3.0 kg, 36-week old in- NC settings were 100% O2 and a flow of ranges that would be a best starting point. fant with the diagnosis of coronary artery 6 L/min (based upon CPAP settings and The utility of HFT-NC should be investi- fistula and patent ductus arteriosis. The the concurrent hemodynamics). The pre- gated for more patient populations such patient arrived in normal sinus rhythm, and post-ductal gradient resolved over a cystic fibrosis. mild respiratory distress, and moderately 15-minute period and the initial blood Jonathan B. Waugh, PhD, RRT, RPFT, is As- sociate Professor and Director of Clinical Education, to present. Respiratory Thera- py Program, Dept. of Critical and Diagnos- tic Care, University of Alabama at Birming- ham, Birmingham, Alabama. He is also Clinical Consultant at the COPD Clinic, Uni- versity of Alabama at Birmingham Kirklin Clinic. He holds several professional af- filiations, including being a reviewer for CHEST, the journal of the American Col- lege of Chest Physicians. He is the author or coauthor of many abstracts and articles and has presented at many medical meet- Figure 1. Chest film of patient in supine position prior Figure 3. Chest film of patient in prone position the fol- ings related to respiratory care. to starting HFT-NC therapy. lowing morning after starting HFT-NC therapy.

4 Trends in Non-invasive Respiratory Support: ventilator-related complications (i.e. nos- ocomial pneumonia). Esteban et al found Continuum of Care that noninvasive ventilation did not de- crease mortality in patients who had to be reintubated and speculated on reasons Part I: Noninvasive why NPPV was ineffective in preventing the need for reintubation.42 These in- Ventilation cluded the health care team’s experience with NPPV, the timing of implementa- By Tim Op’t Holt, EdD, RRT, AE-C, FAARC tion, and the demographics of the study oninvasive positive pressure likely to be successful. This seems to be population (only 10% were COPD). The ventilation (NPPV) has been particularly true for patients recovering delay in reintubation may have been the seen as a viable alternative to from an exacerbation of COPD. reason for this increase in death and may ventilating any patient who Burns et al came to similar conclu- have only prolonged the inevitable clini- does not show any contraindication to its sions after reviewing five trials among cal deterioration, characterized by cardi- N 41 use. The focus of this review will be the 171 patients with predominantly COPD. ac ischemia, increased respiratory mus- use of NPPV immediately after extuba- Compared to invasive ventilation, NPPV cle fatigue, aspiration pneumonitis, and tion as a means of shortening intubation decreased mortality, the incidence of nos- complications of emergency reintubation. time, its continued success in ventilating ocomial pneumonia, hospital length of One might conclude from these studies patients with exacerbation of COPD, and stay and total duration of ventilation (all that NPPV may be effective in preventing the marginal success in ventilating pa- P<0.05). The duration of ventilation re- postextubation respiratory failure, but it tients with hypoxemic respiratory failure. lated to weaning was unchanged with the must be implemented shortly after ex- NPPV has been used as a bridge to use of NPPV. Like Ferrer, these authors tubation. Delaying reintubation until 48 successful extubation (i.e. extubation be- attribute the decrease in mortality to a hours after initial extubation causes sig- fore it would have normally been per- reduction of nosocomial infection, this nificant morbidity and mortality. formed) and in the treatment of new being the result of shorter endotracheal This conclusion is supported by a onset respiratory failure following extu- intubation time or less need for trache- study by Nava and colleagues in which bation. ostomy. Despite these outcomes, the au- preventive application of NPPV (within Ferrer et. al. observed that the du- thors were cautious to recommend NPPV 48 hours) after a successful spontaneous ration of ventilation, among other vari- for weaning, based on the small number breathing trial and extubation reduced ables, was decreased in patients who were of patients in some studies and hetero- the need for reintubation.43 The etiology extubated and ventilated with NPPV, and geneity in pooling the results of these of extubation failure and the time to re- yet were failing spontaneous breathing studies. They note that while the out- intubation are both strong predictors of trials.40 These authors also demonstrat- comes are promising, “the net benefits, outcome. The need for reintubation in ed a decrease in the incidence of noso- risks, and consequences associated with this 48-hour period is based on clinical comial pneumonia, increased survival, a adopting the NPPV weaning strategy signs of failure such as tachypnea, new- decreased incidence of serious compli- have not been fully elucidated.” They rec- onset accessory muscle use, and abdomi- cations, decreased need for tracheosto- ommended that if NPPV weaning is to nal paradox. my, and no need for sedation. These out- be adopted, it should be in patients with In a similar study, Ferrer and col- comes were attributed to a more normal COPD in a controlled intensive care en- leagues attributed several factors to ex- breathing pattern (not rapid and shal- vironment. plain the success of NPPV in avoiding low), and the ability of NPPV to improve Another issue that has been studied is postextubation respiratory failure. These hypoxemia and hypercapnia. Shortening the effectiveness of NPPV postextubation include the high percentage of chroni- the duration of ventilation also decreased after new-onset respiratory failure. The cally hypercapnic COPD patients in the the need for tracheostomy, the need for documented need for reintubation after study (51%), early application on NPPV, tube-feeding, the incidence of nosoco- new-onset respiratory failure is 13-19%. use of a ventilator specifically for NPPV, mial pneumonias, and death. It seems In this event, should patients be reintu- and staff experience with NPPV.44 Hyper- that from this study, one could conclude bated or placed on NPPV? While reintu- capnia during weaning attempts should that once a patient is stabilized on inva- bation protects the airway, it is associated alert the staff to start measures such as sive ventilation and if they had no exclu- with a significantly higher mortality rate NPPV immediately following extubation. sion criteria for NPPV, that intubation is because of intubation-related risks and NPPV is commonly used in patients

5 with an exacerbation of COPD. The evi- face mask. A new product has been re- dence for this will not be reviewed here, cently released that utilizes a nasal pillow because a trial of NPPV is now the stan- or prong and resembles an oversized oxy- dard of care for patients with COPD gen cannula (Nasal Aire II Critical Care, exacerbation. Other questions remain Hudson RCI/Teleflex Medical). There are about the use of NPPV in stable COPD, no published studies on this new product in a mild exacerbation, the effects of a va- as of yet. riety of patient interfaces, and the appro- In a controlled prospective multi- priate time to extubate the COPD patient center study of 90 patients with an infec- prior to initiation of NPPV. tious exacerbation of unspecified severi- A two-year Italian multicenter trial ty (unknown pH and PaCO2), Wang and of NPPV investigated the potential bene- associates examined the issue of when to fits of adding NPPV to long term oxygen extubate the patient with exacerbation of Hybrid Dual-Airway Interface (Hudson RCI/Teleflex therapy (LTOT) in patients with stable Medical) COPD in order to implement NPPV and COPD and chronic hypoxemia.45 Re- able, permit more mouth leakage and are take advantage of its known outcomes.62 sults demonstrated an improvement in less reliable at maintaining tidal volumes. They hypothesized that if a pulmonary daytime PaCO2, dyspnea, and health re- Kwok et al determined that patients with infection control (PIC) window could lated quality of life in the NPPV + LTOT acute respiratory failure treated with be identified, early extubation followed group, compared to LTOT alone. The au- NPPV are more intolerant of nasal, rath- by NPPV could be successful. The PIC thors concluded that while there were er than oronasal masks, primarily due window was identified as the time when improvements in ventilation, dyspnea, to mouth air leaks.47 Rather than con- the following criteria were met: signifi- and health-related quality of life, further demn the nasal mask, the authors con- cantly decreased radiographic infiltrates, study was needed to determine if LTOT + cluded that the masks performed simi- reduced quantity of sputum, decreased NPPV was effective in reducing the fre- larly in other respects. It may be common body temperature, normal leukocyte quency and severity of exacerbation. practice to begin NPPV with an orona- count, and a mandatory ventilator rate In COPD exacerbation, NPPV has sal mask. Once the patient is comfortable of 10-12 breaths/minute with PSV of 10- been shown to reduce the need for intu- and stable, a trial of the nasal mask may 12 cm H2O. When the PIC occurred, pa- bation, and to decrease total duration of be warranted if the patient can control tients were randomized to remain intu- ventilation, hospital length of stay, mor- any mouth air leak. A new dual-airway bated with a standard weaning protocol, tality, work of breathing, and pneumo- interface that consists of an oral cushion or be extubated to NPPV. The strategy nia. Most of the research has been direct- that covers the mouth and two nasal pil- was successful. The NPPV group had a ed to patients with severe exacerbation lows that fit into the patients’ nostrils will shorter duration of ventilation by about

(pH<7.3, PaCO2 > 50 mm Hg). Others be available in 2007. At this time there are 5 days, a lower incidence of nosocomial have sought to determine if NPPV is as no published studies. pneumonia, fewer ICU days, and a lower effective in patients with a mild exacer- More recently, a full head helmet has hospital mortality. It appears that if a PIC bation (pH >7.3).46 In the NPPV group, been developed and tested for use during can be identified and the patient success- the Borg dyspnea index was decreased NPPV. This clear plastic helmet adheres fully extubated, the other complications (P=0.004). However, NPPV was not well at the neck and has straps under the axil- of invasive mechanical ventilation may tolerated in this group of patients. Over lae. The helmet is connected to the ven- be avoided. 50% of patients did not wear the mask tilator via a standard 2-tube circuit.48 Although NPPV is well established as directed. While there was a decrease in The helmet was better tolerated and al- in hypercapnic respiratory failure, its use dyspnea, other benefits were not demon- lowed longer NPPV times with minimal in hypoxemic respiratory failure is not as strated. Therefore, the authors could not air leaks, so it may be a viable alternative clearly established. In congestive heart recommend NPPV for this cohort. to the oronasal mask. Increased PaCO2 failure (CHF), most patients are treated One of the most common reasons for in the helmet group was thought to be with diuretics, oxygen and nitrates, with failure of NPPV is patient intolerance of due to CO2 rebreathing and less reduc- some patients also requiring CPAP. The the mask. While oronasal masks permit tion in inspiratory effort (i.e. the patient question of the usefulness of NPPV in mouth breathing and reduce mouth air works harder with the helmet on when CHF patients remained in the late 1990s, leaks, they interfere with speech, eating, the treatment is failing). The authors and several studies revealed a decrease and expectoration and may cause claus- recommended the use of the helmet for in intubation rate when NPPV was used trophobia. Nasal masks, while comfort- COPD patients who do not tolerate the as cited in the study by Levitt.49 Results

6 demonstrated no difference in respirato- ry rate, SpO , dyspnea score, or hospital 2 Part II: stay. Continuous Ferrer randomized patients to re- ceive 50% oxygen by entrainment mask Positive Airway Pressure or NPPV.50 Intubation rate for the group Bill Pruitt, MBA, RRT, CPFT, AE-C was significantly less (P<0.01) when NPPV was used, a difference which per- sisted in the pneumonia subgroup, but not for patients with acute respiratory ontinuous positive airway to the causes for poor compliance, most distress syndrome (ARDS), trauma, or pressure (CPAP) has been of the effort has focused on issues related CHF. This observation led the author to found to be effective in treat- to humidification, use of more sophisti- question the advice of subsequent stud- ing sleep disorders such as ob- cated machines that alter delivery of the ies of NPPV in patients with ARDS due structive sleep apnea and hypopnea, and positive pressure, and patient education. to the severity of hypoxemia and impair- C has been extensively utilized in these In this article, we look at recent findings ment of pulmonary mechanics. In addi- sleep disturbances. However, CPAP has on these three topics and discuss several tion to the decreased intubation rate, pa- also been used to help patients mobilize issues related to CPAP interfaces tients in the NPPV group had a shorter secretions, reduce or prevent atelecta- hospital stay among intensive care unit sis, reduce air trapping in COPD, reduce Wet or Dry CPAP? (ICU) survivors and a lower ICU mortal- severe asthma attacks and cardiogen- CPAP devices use air flow to create a ity. ic pulmonary edema, and treat hypox- positive pressure in the oropharynx and In a review of 31 randomized clini- emia. Long-term use, particularly in pa- laryngopharynx. The flow may be con- cal trials of NPPV in acute hypoxemic re- tients with sleep disorders, has revealed stant or varying based on the design of spiratory failure, results varied depend- that patient noncompliance is a problem. the machine, and most CPAP systems ing on etiology of hypoxemia.51 Half of Compliance can be affected by many is- have an intentional outlet to vent the ex- the trials showed a lower rate of intuba- sues, including self-image and appear- cess flow. Thus, there is a tendency to dry tion with NPPV. Of seven trials reporting ance, feelings of claustrophobia, discom- the oronasal mucosa which causes dis- length of ICU stay, two suggested benefit fort with the interface (pressure from comfort and noncompliance. In a ran- from NPPV. The pooled results favored the nasal mask, nasal pillows, oronasal domized, controlled, parallel, double- NPPV. They concluded that patients with mask), discomfort due to the headgear blinded study of 70 patients with newly acute hypoxemic respiratory failure are and straps around the head, irritation diagnosed obstructive sleep apnea syn- less likely to require endotracheal intu- due to leaks around the interface, con- drome, Duong et al compared the use of bation when NPPV is added to standard junctivitis, nasal congestion, nose bleeds, heat humidification (n=34) versus place- treatment. There may be a potential to mouth breathing, oronasal drying, and bo (n=36) during the first night of na- improve patient outcome, however, small skin irritation.52 Several of the problems sal CPAP (nCPAP) titration.54 Following sample sizes and heterogeneity of study vary with patient body position and with night-time nCPAP titration, the patients samples prevented a more definite con- the level of required treatment pressure, completed a questionnaire to assess their clusion. They noted that the literature either of which can cause leaks or alter quality of sleep, toleration of the nCPAP, does not support routine NPPV for pa- pressure points on the face or head. Ac- likelihood to use nCPAP in the future, tients presenting with acute hypoxemic cording to the literature, trials with var- and level of nasal side-effects (i.e. stuffi- respiratory failure, but strong consider- ious masks and headgear are the most ness, discharge, etc.) Nasal airway resis- ation should be given to its use in patient common approach to finding the right tance was measured with a published, groups with a known high mortality rate, system. standardized procedure in accordance if they are normally required to undergo In a study conducted in France, re- with the International Committee on invasive mechanical ventilation (immno- searchers looked at CPAP compliance Objective Assessment of the Nasal Air- supressed patients or post-thoracotomy over a 9-year period.53 Of the 137 consec- ways.55 The authors concluded that com- patients). utive patients enrolled in the study, (after pared to placebo, heated humidification In summary, the successful applica- accounting for 30 patients who died and in the initiation of nCPAP did not pro- tion of NPPV in patients with hypoxemic 5 lost to follow-up), 30 (29%) patients vide significant benefit in reducing nasal failure is less certain than in those with stopped using CPAP, most of them dur- airway resistance, symptoms, toleration COPD. ing the first five years. In research related of the therapy, nor did it affect the likeli-

7 hood of future use. was a problem. However, they also found In another study covering a longer that there was a tendency for claustropho- period of time, researchers in a Veterans Patients with the poor- bia scores to decrease over time, suggest- Affairs hospital examined the effect of ing that frequent use and familiarity with heated humidification on patient com- est the sensation of wearing a CPAP inter- pliance and quality of life.56 A total of face can improve compliance in patients 98 patients with obstructive sleep apnea who initially experienced claustrophobia. (OSA) were started on nCPAP and ran- adherence to CPAP Patients undergoing magnetic resonance domly assigned to heated humidification imaging (MRI) also experience claustro- (n=49) or standard care (n=49). Data was therapy phobia and various methods have been gathered regarding nCPAP compliance, used to reduce it, including cognitive be- quality of life, subjective sleepiness, nasal havioral therapy, combination therapy symptoms and side effects after 1, 3, and and each uses its own, unique algorithm utilizing distraction and guided threat 12 months of therapy. The authors found to set the flow. Because they allow one to reappraisal, and desensitization. They no significant difference in compliance, vary the flow, the assumption is that au- recommend these strategies as potential- sleepiness, or quality of life. Initially at 1 tomatic adjustments (APAP) would be ly useful interventions to improve CPAP month there was a significant difference more comfortable and should increase compliance in claustrophobic patients. between groups in the incidence of dry compliance. A 2004 Cochrane review of There is some evidence to support mouth and nose. However, at 3 and 12 interventions for improving compliance patient education for reducing sleep months, there was no significant differ- with CPAP in patients with OSA exam- problems associated with CPAP and in ence in these side effects. In a 2003 cross- ined 14 studies comparing APAP to fixed improving compliance. In a Swiss study over study comparing 3 weeks of humidi- CPAP.58 The authors evaluated param- by Golay et al (n=35; 22 male, 13 female), fied nCPAP with non-humidified nCPAP, eters such as patient compliance (hours a one-day educational program was there was no difference between treat- per night of CPAP usage) percentage of given to patients diagnosed with OSA ment arms in terms of subjective treat- days when CPAP is used, patient prefer- who had been using CPAP for at least 6 ment satisfaction or alertness. The au- ence, patient withdrawal from treatment, months prior to enrollment.60 Spouses thors concluded that although the results daytime sleepiness, arousals, treatment were included in the program. The topics support the use of heated humidification pressures, apnea/hypopnea index, quality covered in the program included, “What as a strategy to reduce side-effects related of life, and adverse effects/tolerability. Af- does CPAP do?”, “How to use CPAP”, to CPAP, there is insufficient evidence to ter analyzing the results, they concluded “The benefits of CPAP”, “Daily life with support its routine use.57 that the evidence did not justify the use CPAP and its disadvantages”, “What I can For those cases that may need or of APAP in unselected patients. There do to address my particular situation?” A want humidification, companies are of- was only marginal benefit for patients round table discussion with the patient fering CPAP units to newly diagnosed needing treatment pressures above 10 cm and spouse on “Intimacy and CPAP” was patients that include a built-in humidifi- also included. The night following the H2O, or patients who had been identified er as an integral part of the device (for ex- as not complying with fixed CPAP. program, the patients were examined to ample, see the Resmed S8 or Respironics establish baseline sleep data. They were REM star M series CPAP units.) For those Knowledge/Understanding: Keys to examined again at 3 months and the who already have a CPAP unit and need success? sleep scores were compared with baseline. to add humidification, a stand-alone can As noted, noncompliance has been Preliminary results reflected a significant be added to the system (for example, see a problem with CPAP. Aside from the decrease in the Epworth Sleepiness Scale the Hudson/RCI/Teleflex Medical, Con- problems related to the device and in- (11 +1 before, 8 + 0.8 after; p<0.05) and chatherm® 2000 or the Fisher & Paykel terface, the patient’s acceptance of CPAP 24% of the patients increased their usage HC150 humidification units.) treatment also contributes to the compli- of CPAP by more than one hour. ance issue. Chasens et al evaluated claus- Fixed or variable? trophobia as a cause for noncompliance Interfaces – the bridge between Constant or fixed CPAP units de- and found that patients with the poorest CPAP machine and patient liver a constant flow of air whereas auto- adherence to CPAP therapy had signifi- There are many manufacturers of adjusting CPAP units titrate the flow cantly higher claustrophobia scores.59 Of CPAP devices and almost all have their throughout the night to optimize the the 153 patients who participated in the own interface or several interfaces. (See pressure. Various devices are available study, 30% reported that claustrophobia Table 1) The interfaces most often used

8 for long-term CPAP include the nasal Table 1. CPAP masks and interface devices so many choices and the cost becomes mask, nasal pillows, or the oronasal mask. Mfg/Dist. Mask/Interface prohibitive to keep a large number of de- A new design in interface technology has AEIOMed Headrest signs on hand. Beyond these obstacles, combined an oral mask with nasal pillows DeVilbiss Serenity some manufacturers recommend us- to deliver the air flow/pressure to both Hans Rudolph VIP 7500,VIP 76 ing only their mask with their CPAP de- upper airway openings. Full-face mask Fisher & Paykel Aclaim, HC405, HC406, vice exclusively. Finally, as new designs/ HC431, HC481, oRACLE or whole head applications (sometimes Puritan Bennett Adam, Breeze, Dreamseal devices are introduced to the medical called a CPAP helmet) have been explored Resmed Activa, Mirage / market, most SDCs cannot easily retire in more acute settings with varying de- Ultra-Mirage the older equipment and change to new- grees of success. Each interface is held in Swift Vista er releases. place by headgear and straps around the ResMed Corp UltraMirage Once the parameters for treatment Respironics Comfortclassic, head. Some devices call for two or three Comfortcurve, are established, the patient receives a pre- straps, others use one. The straps are ad- Comfortfull, scription for CPAP and is referred to a justable by using hook and loop connec- Comfortgel, Comfortselect, home health or durable medical equip- tions. (In the helmet application, the de- Pro le Lite, Simplicity, Total ment (DME) company to receive their vice is sealed around the neck with a soft Face CPAP system. If the prescription specifies Somnotech Nasal Mask cushion and held in place with adjustable a particular interface, the company will Hudson RCI/Teleex Hybrid, Nasal-Pap straps around the underarms.) Freestyle, Nasal-Aire II, supply it. If not specified, the company Nasal Aire II Petite, Respica will often use the same approach as seen Problems contributing to Tiarra Snapp in the SDC; the right size device will be noncompliance Viasys Healthcare Lyra tried in the home setting and if there are Nasal and oronasal mask designs can Derived from the American Sleep Apnea Association Apnea Support Forum compliance problems, the company may http://www.apneasupport.org/about2841.html (accessed 9/2/06) and Product cause a pressure point on the bridge of Index (2006) RT Journal for Resp Care Practitioners 19(4):12. have one or two other optional interfaces the nose. Interfaces may have a brace that to try. The same limitations apply in the rests against the forehead, also causing a comes out of the mouth due to the flow home as seen with the SDC regarding the pressure point. Some of the nasal pillow delivery. variety of interfaces available (too many systems and the oral mask/nasal pillow Patients are evaluated in a sleep dis- choices, prohibitive cost, manufacturer- combination design avoid the problems orders center (SDC) to see if there is a specified interfaces, release of new de- related to pressure points on the nose or sleep disorder present and if the problem signs/devices). Moreover, some patients forehead, but may cause pressure points may be treated by CPAP. The SDC will of- may not inform the DME company of on the nares. Headgear may cause some ten use one type of interface of the ap- any problems after the initial visit and set- minor discomfort as the head lies on the propriate size to fit the patient’s face and up, and may just stop using the device. If pillow but this can usually be relieved by perform a “CPAP study” to establish the neither the SDC nor the DME schedules repositioning the head. Some patients right settings (CPAP or bi-level pressure, a follow-up visit with these patients, they dislike using CPAP due to problems with supplemental oxygen, etc.) Should the may never use their device. This is an un- swallowing while receiving positive pres- patient have problems with the interface, fortunate situation that may be avoided sure. As they swallow, the positive pres- another may be tried – however, most provided the proper interface is used and sure is trapped in the Eustachian tubes SDCs do not have a wide range of dif- more emphasis is placed on follow-up and pressurizes the eardrum. This creates ferent interfaces designs since there are with CPAP patients. Still, the selection the same sensation as that experienced of the patient interface and headgear is during an airline flight in a pressurized often arbitrary – depending on the SDC cabin but the pressure cannot be relieved and DME. However, the appropriate se- unless the interface is removed and the lection is usually quite subjective and in- pressure is released. If the patient opens dividualized depending on the patient’s his mouth while wearing a nasal mask cooperation, comfort, and patience. or nasal pillows, the flow of gas from the CPAP has been shown to be effec- CPAP device constantly rushes out of the tive in treating a variety of problems and mouth. A chin strap may be used to stop has been a great help to many thousands this from happening. Finally, it is most of patients. However, a significant num- difficult to speak while receiving CPAP ber of patients become noncompliant therapy, again due to the rush of air that Nasal-Aire ll (Hudson RCI, Teleflex Medical) and miss the benefits of this intervention.

9 Problems that contribute to noncompli- 12. Amirav I, Panz V, Joffe BI, Dowdswell R, Plit M, 29. Newhart J. Delivery of nitric oxide via vapotherm. Seftel HC. Effects of inspired air conditions on cat- Respir Care 49(11), 1398. 2004. ance are sometimes difficult to correct echolamine response to exercise in asthma. Pediatr 30. Frick J, Sabato K, Flori H. Vapotherm: A simple de- due to the pressures, flow, interfaces, and Pulmonol 1994;18:99-103. vice becomes a simple solution in the PICU. Respir head straps needed to properly adminis- 13. Waugh JB, Granger WM. An evaluation of 2 new Care 49(11), 1392. 2004. ter CPAP. Trials with various configura- devices for nasal high-flow gas therapy. Respir 31. Fencl NA, Hedgman AS, Godinez RI. Nitric oxide tions of masks, nasal pillows, and head- Care 2004;49:902-906. delivery with high flow nasal cannula: A case study. gear are sometimes necessary to find the 14. Kory RC, Bergmann JC, Sweet RD, Smith JR. Com- Respir Care 49(11), 1399. 2004. parative evaluation of oxygen therapy techniques. 32. Nugent T, Criner GJ, Chatila W. Effect of vapo- right combination, provided the clinician JAMA 1962;179:767-772. therm, a high-flow humidified O2 delivery device, can entice the patient continue using the 15. Poulton TJ, Comer PB, Gibson RL. Face tent vs. on breathing in COPD patterns during excercise. CPAP system while the various configu- face mask for oxygen therapy. Anesthesiology American Journal of Respiratory and Critical Care rations are being tried, and depending on 1978;49:224-225. Medicine 165(8), A592. 2002. being able to choose from various devices. 16. Gibson RL, Comer PB, Beckham RW, McGraw CP. 33. Ciccolella DE, Rao R, McCool D, Criner GJ. Effect As we have seen from these studies, nei- Actual tracheal oxygen concentrations with com- of high-flow, vapor-phased, humidified nasal can- monly used oxygen equipment. Anesthesiology nula (HF-HNC) oxygen on ventilatory mechan- ther humidification nor APAP have made 1976;44:71-73. ics, blood gases and comfort in severe hypercap- a substantial impact on compliance. Pro- 17. Wettstein RB, Peters JI, Shelledy DS. Pharyngeal nic COPD patients (COPD) and normal subjects viding education and understanding, and oxygen concentration in normal subjects wear- at rest. Am J Respir Crit Care Med 163(5), A501. 2001. dealing with the discomfort of claustro- ing high flow nasal cannula. Respiratory Care 2004;49:1444. 34. Chatila W, Nugent T, Vance G, Gaughan J, Criner phobia may be the most effective tools 18. Malinowski T, Lamberti J. Oxygen concentrations GJ. The effects of high-flow vs low-flow oxygen on for increasing compliance once the best via nasal cannula at high flowrates. Respiratory exercise in advanced obstructive airways disease. fitting, best feeling interface has been se- Care 47(9), 1039. 2002. Chest 2004;126:1108-1115. lected. References 19. Tiep B, Barnett M. High flow nasal vs high flow 35. Hewitt MJ, Duke JH, Brasseaux B, Wilson J, Miles 1. Ingelstedt S. Studies on the conditioning of air mask oxygen delivery: Tracheal gas concentrations R, Khalil I. A case study: Utilizing the vapotherm in the respiratory tract. Acta Otolaryngol Suppl through a head extension airway model. Respira- 2000i high flow nasal cannula system to rewarm a 1956;131:1-80. tory Care 47(9), 1079. 2002. nonintubated hypothermic trauma patient. Respir Care 49(11), 1368. 2004. 2. Andersen I, Lundqvist GR, Jensen PL, Proctor DF. 20. Bamford O, Lain D. Effect of high nasal gas flow Human response to 78-hour exposure to dry air. on upper airway pressure. Respiratory Care 49(11), 36. Frank SM, Hesel TW, El-Rahmany HK, Tran KM, Arch Environ Health 1974; 29:319-324. 1443. 2004. Bamford OS. Warmed humidified inspired oxygen accelerates postoperative rewarming. J Clin Anesth 3. Andersen IB, Lundqvist GR, Proctor DF. Human 21. Tabka Z, Ben Jebria A, Vergeret J, Guenard H. Ef- 2000;12(4):283-7. nasal mucosal function under four controlled hu- fect of dry warm air on respiratory water loss in midities. Am Rev Respir Dis 1972;106:438-449. children with exercise-induced asthma. Chest 37. Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H. High-flow nasal cannulae in the management 4. Josenhans WT, Melville GN, Ulmer WT. Effects of 1988;94:81-86. of apnea of prematurity: a comparison with con- humidity in inspired air on airway resistance and 22. Hayes MJ, McGregor FB, Roberts DN, Schrot- ventional nasal continuous positive airway pres- functional residual capacity in patients with respi- er RC, Pride NB. Continuous nasal positive air- sure. Pediatrics 2001;107:1081-1083. ratory diseases. Respiration 1969;26:435-442. way pressure with a mouth leak: effect on nasal 38. Martinez-Gomez R, Lefkowitz B, Hall W. Case re- 5. Rankin N. What is optimum humidity? Respir mucosal blood flux and nasal geometry. Thorax port: Successful extubation of a former premature Care Clin N Am 1998;4:321-328. 1995;50:1179-1182. infant using vapotherm high-flow therapy after 23. Walsh J. Winning by a nose. Advance for Respira- 6. Williams R, Rankin N, Smith T, Galler D, Seakins P. multiple attempts using conventional methods. tory Care Practitioners 15(9), 24-25. 2006. Relationship between the humidity and tempera- Respiratory Care 49(11), 1375. 2004. ture of inspired gas and the function of the airway 24. Taft A, Battles R, Bamford O, Cortez F, Nguyen A, 39. Biggar D, Hoerr BS, Clinkscale D, Trulock E, Pat- mucosa. Crit Care Med 1996;24:1920-1929. Hill J. Prospective evaluation of the vapotherm terson GA. Pulmonary rehabilitation in patients 2000i delivering high flow oxygen therapy (HFT) 7. Fink J. Humidity and bland aerosol therapy. In: with severe end-stage lung disease requiring high via nasal cannula in adult respiratory insufficiency. Wilkins RL, Stoller JK, Scanlan CL, editors. Egan’s flow oxygen with exercise prior to lung transplan- Respir Care 50(11), 1509. 2005. Fundamentals of Respiratory Care. St. Louis: Mos- tation. Respir Care 50(11), 1472. 2005. by, 2003: 737-760. 25. Sarkisian-Donovan J, Hill JJ, Neary MJ, Murphy 40. Ferrer M, Esquinas A, Arancibia F, Bauer TT, Gon- DMF. High flow gas therapy via nasal cannula for 8. Branson RD. Humidification and aerosol therapy zalez G, Carrilo A, Rodriguez-Roisin R, Torres A. respiratory insufficiency. Respiratory Care 49(11), during mechancial ventilation. In: MacIntyre NR, Noninvasive ventilation during persistent weaning 1443. 2004. Branson RD, editors. Mechanical Ventilation. Phil- failure: a randomized controlled trial. Am J Respir adelphia: W.B. Saunders Co., 2001: 103-129. 26. Rojas J. The use of vapotherm in an NICU. Ef- Crit Care Med 2003;168:70-6. fects on respiratory support and cost. Respir Care 9. Sheppard D, Eschenbacher WL, Boushey HA, Beth- 41. Burns KEA, Adhikari NKJ, Meade MO. Nonin- 50(11), 1492. 2005. el RA. Magnitude of the interaction between the vasive positive pressure ventilation as a weaning

bronchomotor effects of sulfur dioxide and those 27. Polston ST, Kim IK. Heliox (70/30 He/O2) via the strategy for intubated adults with respiratory fail- of dry (cold) air. Am Rev Respir Dis 1984;130:52- vapotherm 2000i. Respir Care 49(11), 1392. 2004. ure. The Cochrane Database of Systematic Reviews 55. 28. Meyer K. Helium/oxygen (HEOX) in the emer- 2003(4):CD004127. 10. Weinberg AD. Hypothermia. Ann Emerg Med gency room: Comparison of open system via high 42. Esteban A, Frutos-Vivar F, Ferguson D, Arabi Y, 1993;22:370-377. flow cannula vs. closed system. Respir Care 47(9), Apezteguia C, Gonzalez M, et.al. Noninvasive posi- 11. Chen WY, Chai H. Airway cooling and nocturnal 1047. 2002. tive pressure ventilation for respiratory failure after asthma. Chest 1982;81s:675-680. extubation. NEJM 2004;350:2452-2460.

10 43. Nava S, Gregoretti C, Fanfulla F, Squadrone E, Gras- 57. Neill AM, Wai HS, Bannan SP, Beasley CR, Weath- si M, Carlucci A, et. al. Noninvasive ventilation to erall M, Campbell AJ, Humidified nasal continu- Essential Practices is a serial education pro- prevent respiratory failure after extubation in high- ous positive airway pressure in obstructive sleep gram distributed free-of-charge to health risk patients. Crit Care Med 2006;33(11):2465- apnoea. Eur Resp J 2003;22:258-262. professionals. Essential Practices is published 2470. . 58. Haniffa M, Lasserson TJ, Smith I. Interventions by Saxe Healthcare Communications. The 44. Ferrer M, Valencia M, Nicolas JM, Bernadich to improve compliance with continuous posi- goal of Essential Practices is to present clini- O, Badia JR, Torres A. Early noninvasive ventila- tive airway pressure for obstructive sleep apnoea. cally- and evidenced-based practices to assist tion averts extubation failure in patients at risk: Cochrane Database Syst Rev 2004;(4):CD003531. the clinician in making an informed decision a randomized trial. Am J Respir Crit Care Med 59. Chasens ER, Pack AI, Maislin G, Dinges DF, Weav- on what is best for his/her patient. Opinions 2006;173:164-170. er TE. Claustrophobia and adherence to CPAP expressed in Essential Practices are those of 45. Clini E, Sturani C, Rossi A, Viaggi S, Corrado A, treatment. West J Nurs Res 2005;27:307-21. the authors and not necessarily of the editori- Donner CF, et. al. The Italian multicentre study on 60. Golay A, Girard A, Grandin S, Metrailler JC, Vic- al staff of Saxe Healthcare Communications. noninvasive ventilation in chronic obstructive pul- torion M, Lebas P, Ybarra J, Rochat T. A new edu- The publisher disclaims any responsibility monary disease patients. Eur Respir J 2002;20:529- cational program for patients suffering from sleep or liability for such material. We welcome 538. apnea syndrome. Patient Educ Couns 2006;60:220- opinions and subscription requests from our 46. Keenan S, Powers CE, McCormack DG. Noninva- 227. readers. sive positive pressure ventilation in patients with milder chronic obstructive pulmonary disease ex- Timothy B. Op’t Holt, EdD, RRT, AE-C, Please direct your correspondence to: acerbations: A randomized controlled trial. Respir FAARC, is Director of “Breath of Life” COPD Care 2005;50:610-616. and the Asthma Education and Therapy Saxe Healthcare Communications 47. Kwok H, McCormack J, Cece R, Houtchens J, Hill Program at Victory Health Partners Clinic P.O. Box 1282 N. Controlled trial of oronasal versus nasal mask in Mobile, Alabama, and Consultant to the Burlington, VT 05402 ventilation in the treatment of acute respiratory Ohio Department of Human Services. [email protected] Fax: 802.872.7558 failure. Crit Care Med 2003;31:468-473. At the University of South Alabama, he © Saxe Communications 2006 48. Antonelli M, Pennisi M, Pelosi P, Gregoretti C, is Professor, Department of Respiratory Squadrone V, Rocco M. et al Noninvasive positive Care and Cardiopulmonary Sciences, and pressure ventilation using a helmet in patients with Facilitator, Problem-Based Learning Pro- acute exacerbation of chronic obstructive pulmo- gram, at Ohio State University’s College of nary disease. Anesthesiology 2004;100:16-24. Medicine. 49. Levitt MA. A prospective, randomized trial of BiPAP in severe acute congestive heart failure. J A registered respiratory therapist since Emergency Med 2001;21:363-369. 1977 and an asthma educator, he is Hon- 50. Ferrer M, Esquinas A, Leon M, Gonzalez G, Alar- orary Professor, Department of Intensive con A, Torres A. Noninvasive ventilation in severe Care, China-Japan Friendship Hospital in hypoxemic respiratory failure: A randomized clini- Beijing and a fellow of the American As- cal trial. Am J Respir Crit Care Med 2003;168:1438- sociation for Respiratory Care. 1444. 51. Keenan SP, Sinuff T, Cook DJ, Hill NS. Does non- He is the author or co-author of 8 books invasive positive pressure ventilation improve out- and 30 studies in journals such as AARC come in hypoxemic respiratory failure? A system- Times, Respiratory Care Journal, and the atic review. Crit Care Med 2004;34:2516-2523. American Journal of Respiratory and Criti- cal Care Medicine as well as presented over 52. Heuer A, and Scanlan C. Respiratory care in alter- 35 papers at international conferences. native settings. In Wilkins RL, Stoller JK, Scanlan CL, eds. Egan’s Fundamentals of Respiratory Care, William Pruitt, MBA, RRT, CPFT, AE-C 8th ed. St. Louis, Mosby, 2003:1275. is a senior instructor in respiratory care at 53. Bizieux-Thaminy A, Gagnadoux F, Binquet C, Mes- the University of South Alabama, Depart- lier N, Person C, Racineux, JL. Long term use of ment of Cardiorespiratory Care. He is a nCPAP therapy in sleep apnoea patients. Rev Mal member of the American Association for Respir 2005;22:951-957. [French] Respiratory Care (AARC), and is chairman 54. Duong M, Jayaram L, Camfferman D, Catcheside of the Program and Long Range Planning P, Mykytyn I, McEvoy RD. Use of heated humidi- committee for the Alabama Society for Re- fication during nasal CPAP titration in obstructive spiratory Care (ASRC). He is member of the sleep apnoea syndrome. Eur Resp J 2005;26:679- Dean’s Advisory Council, College of Allied 685. Health, USA, and co-editor of the Nation- al Asthma Educator Certification Board 55. Clement P. Committee report on standardization e-newsletter. He has made several pre- of rhinomanometry. Rhinology 1984;22:151–155. sentations and published many articles in 56. Mador MJ, Krauza M, Pervez A, Pierce D, Braun M. respiratory care journals and magazines. Effect of heated humidification on compliance and quality of life in patients with sleep apnea using nasal continuous positive airway pressure. Chest 2005;128:2151-2158.

11 Questions 1. Which of the following statements are true, based on A. I, III only A. Too many possible devices on the market the literature cited about NPPV during weaning in COPD? B. II, III only B. The cost of the existing interfaces prohibits having a variety I. NPPV should be implemented following stabilization of the COPD C. I, II only of choices patient on CMV, provided there are no contraindications for NPPV. D. III, IV only C. Retiring older devices to bring on new interface designs is challenging II. NPPV is likely to decrease the incidence of nosocomial infection. 6. Which of the following is NOT included in the indications D. All of the above III. NPPV may be delayed for 48 hours after new-onset ventilatory failure for CPAP? to allow time for conventional therapy. A. Reduce atelectasis 11. The maximum adult flow settings for currently available IV. NPPV is more effective in severe exacerbation than in mild exacerbtion B. Treat hypopnea high flow nasal cannula devices range from ______A. I, II, III only C. Treat non-cardiogenic pulmonary edema L/min. B. II, III, IV only D. Reduce air trapping in COPD A. 6 to 8 C. I, III, IV only 7. In the research by Duong et al, what parameter was B. 10 to 35 D. I, II, IV only measured by using a published standardized procedure? C. 15 to 40 D. 20 to 60 2. What was concluded about the addition of NPPV to long A. Quality of sleep term oxygen therapy (LTOT)? B. Nasal airway resistance 12. Which of the following statements are true about high A. NPPV in addition to LTOT decreases the severity of C. Toleration of nCPAP flow nasal cannula devices? exacerbation. D. PAP heated humidifier output for water vapor A. All devices marketed as “high flow nasal cannula” deliver B. NPPV in addition to LTOT decreases the frequency of 8. In the Veterans Affairs hospital study, Madar found a BTPS gas. exacerbation significant difference at one month of use between the B. All devices marketed as “high flow nasal cannula” can be C. NPPV in addition to LTOT improved gas exchange CPAP group receiving an intervention and the CPAP con- used with infants. D. NPPV in addition to LTOT improved gas exchange and trol group in which of the following? C. All devices marketed as “high flow nasal cannula” use a Health-Related Quality of Life variation of an aerosol nebulizer to humidify gas delivered A. Compliance 3. One of the most common reasons for failure of NPPV is: to the patient. B. Quality of life D. All devices marketed as “high flow nasal cannula” generally A. mask intolerance C. Subjective measure of sleepiness produce a higher FDO2 as the flow rate increases. B. failure to decrease the PaCO2 D. Incidence of dry mouth and nose C. failure to increase the PaO 13. Published research on the effects of warm, humidified gas 2 9. In the Cochrane review examining improvement of com- indicates which of the following? D. continued dyspnea pliance with CPAP, which of the following patient groups 4. The pulmonary infection control window is chacterized by showed a marginal benefit for using auto-adjusting I. High flows of oxygen and BTPS gas produce positive effects indepen- all of the following EXCEPT a decrease in: CPAP? dent of each other II. BTPS gas at a FIO of 0.21 can produce beneficial effects in A. sputum production A. Patients who required supplemental oxygen greater than 2 B. dyspnea 3 L/m some patients III. High flow via nasal cannula typically generates a small amount of C. body temperature B. Patients who needed treatment pressures above 10 cm H2O D. infiltrates on the chest radiograph C. Patients with an apnea/hypopnea index greater than positive airway pressure 5. In a review of 31 randomized clinical trials of NPPV in 12 per hour IV. Insufficient humidification leading to drying of the airways can acute hypoxemic respiratory failure, Keenan found that: D. Patients with a Body Mass Index greater than 35. cause nasal congestion A. I, II I. Standard treatment + NPPV decreased the need for intubation 10. Which of the following are limitations for DME companies in trying to establish the correct interface for a CPAP pa- B. I, III II. Study design suffered from small sample size and heterogeneity tient? C. I, II, III III. NPPV should be routine for this cohort D. I, II, III, IV IV. The head helmet is the most effective interface

This program has been approved for 2.0 Participant’s Evaluation Answers contact hours of continuing education (CRCE) The goal of this program is to educate healthcare professionals on the management of the difficult airway in prehospital and hospital by the American Association for Respiratory settings. A B C D A B C D Care (AARC). AARC is accredited as an approv- 1. What is the highest degree you have earned? Circle one. 1 8 er of continuing education in respiratory care. 1. Diploma 2. Associate 3. Bachelors  A B C D A B C D To earn credit, do the following: 4. Masters 5. Doctorate 2 9 2. Indicate to what degree were you able to meet the 1. Read the educational offering (both articles). objectives of this program: A B C D A B C D 3 10 2. Complete the post-test for the educational Objectives offering online at: Upon completion of the course, the reader was able to: A B C D A B C D http://www.saxetesting.com/crce/ 1. List the various types of high flow nasal cannula devices cur- 4 11 rently available. The questions are the same as above A B C D A B C D 3. Complete the learner evaluation. Strongly Agree Strongly Disagree 1 2 3 4 5 6 5 12 4. To earn 2.0 contact hours of continuing 2. Describe the benefits of high flows of BTPS delivered via nasal A B C D A B C D education, you must achieve a score of 75% cannula. 6 13 or more. If you do not pass the test, you may Strongly Agree Strongly Disagree 1 2 3 4 5 6 take it again one more time. You will not be 3. Identify potential applications of high flow nasal cannula A B C D charged to take the test a second time. therapy. 7 5. Upon completion, you may print out your Strongly Agree Strongly Disagree 1 2 3 4 5 6 certificate immediately. If you are an AARC 4. Describe the variables that been improved in patients with This article is no longer member, your results are automatically COPD as a result of the use of early NPPV during the weaning forwarded to the AARC. process. sponsored. You may still take 6. Accreditation expires Apr.1, 2017. Please Strongly Agree Strongly Disagree this test and receive accredi- 1 2 3 4 5 6 consult http://www.saxecommunications. 5. Describe the ASA difficult airway algorithm. taion, however there is a nomi- com/crce/index.html for current annual Strongly Agree Strongly Disagree renewal dates. 1 2 3 4 5 6 nal fee ($10.00) to cover the 7. This article is no longer sponsored. You 6. List the indications for continuous positive airway pressure. cost of accreditation and scor- may still take this test and receive Strongly Agree Strongly Disagree 1 2 3 4 5 6 ing. accreditation, however there is a Please indicateyour agreement with the following statement. nominal fee ($10.00) to cover the cost of “The content of this course was presented without bias of any accreditation and scoring. You may take product or drug.” All tests must be taken online at this test 2 times at no additional charge. Strongly Agree Strongly Disagree http://www.saxetesting.com/crce/ 1 2 3 4 5 6