Chest
Volume 100, Issue 2, August 1991, Pages 445-454
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Clinical Investigations in Critical Care
Noninvasive Face Mask Mechanical Ventilation in Patients with Acute Hypercapnic Respiratory Failure

https://doi.org/10.1378/chest.100.2.445Get rights and content

Mechanically assisted intermittent positive-pressure ventilation effectively provides ventilatory support in patients with respiratory failure but it requires placing an artificial airway. We have previously reported our successful experience delivering mechanical ventilation via a face mask (FMMV) rather than with an endotracheal tube in a pilot study of patients with acute respiratory failure. The present investigation evaluated an additional 18 patients with hypercapnic respiratory failure to determine the efficacy of FMMV in a more homogeneous group and to determine factors predicting its success. FMMV was successful in avoiding intubation in 13 of the 18 patients. A significant initial improvement in Pco2 (>16 percent decrease) and in pH (from <7.30 to >7.30) predicted success. The five patients who failed on FMMV required endotracheal intubation because of inability to improve gas exchange (three patients), apnea due to sedatives (one patient), and management of secretions (one patient). FMMV was generally well accepted with only two patients withdrawn because of intolerance of the mask. The mean duration of FMMV was 25 h. Complications were seen in only two patients (11 percent): aspiration (one patient) and mild skin necrosis (one patient). Seven patients entered the study by meeting entrance criteria after an unsuccessful extubation attempt and therefore received both forms of mechanical ventilation. All but one patient avoided reintubation, and the face mask proved to be as effective as the endotracheal tube as a conduit for delivering the mechanical tidal volume and improving gas exchange. Our findings indicate that FMMV is a viable option for short-term (one to four days) ventilatory support of patients with hypercapnic respiratory failure and insufficiency.

(Chest 1991; 100:445-54)

Section snippets

METHODS and MATERIALS

The study was conducted at the University of Tennessee Health Science Center in Memphis from February 1989 to March 1990. The protocol was approved by the institutional review boards of both the University of Tennessee and the VA Medical Center, Memphis.

Diagnostic criteria for hypercapnic respiratory failure included all of the following: (1) severe dyspnea at rest; (2) respiratory rate (RR) >25 breaths per minute; (3) use of accessory muscles of respiration (AMR) or paradoxical abdominal

Hypercapnic Respiratory Failure Group

Eleven patients (patients 1 to 11), eight men and three women, met all criteria for hypercapnic respiratory failure. Their mean age was 61 years (range, 29 to 75 years). Seven patients had severe COPD (mean FEV1, 900 ml) exacerbated by bronchospasm in five, pneumonia in one, and laryngospasm and bronchospasm after extubation in one. One patient had end-stage renal disease with congestive heart failure and pulmonary fibrosis. One had fibrothorax and two had status asthmaticus (Table 1). Two

DISCUSSION

Inspiratory muscle fatigue is thought to be the final common pathway that causes ventilatory failure in patients with COPD.8 Fatigue occurs when the balance between mechanical impedance and muscle power is tipped in favor of impedance against which the respiratory muscles must work.9 The additional workload is caused most frequently by an increase in airway resistance (bronchospasm, secretions) and less commonly by a reduction in compliance (congestive heart failure, pneumonia). Patients

CONCLUSIONS

Whereas most patients improved with FMMV, the response to treatment and duration of MV could not be predicted by the severity of the underlying lung disease (FEV1) or by the ABG values (Pco2, pH) obtained before initiating ventilation. An improvement in Pco2 and in pH after the first hour of FMMV accurately identified those patients who could be successfully ventilated by this means and who would require short-term ventilatory support (mean, 26 h of FMMV vs 323 h of MV with ETI). The face mask

ACKNOWLEDGMENTS

The investigators wish to thank Dr Dominique Robert (Hôpital de la Croix Rousse, Lyon, France) for having initially generated interest and enthusiasm about this alternative mode of ventilatory support, Dr Elizabeth Tolley for statistical analysis, all of the respiratory therapists who have collaborated on this study, Vicky Franke for secretarial assistance, Dr John P. Griffin for helpful suggestions, and Dr D. Armbruster for editorial review.

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    Manuscript received August 29; revision accepted December 14.

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