From Bi-pap to C-pap and everything in between

So, what is non-invasive ventilation all about? Well you have come to the right place to find out.


Ventilation for Acute Respiratory Failure in COPD Patients  Has Good Initial Outcome

The Vest

Your  Sleep Study

Incidence of Nocturnal Desaturation While Breathing Oxygen in COPD Patients

Predictors of Outcome for Patients With COPD Requiring Invasive Mechanical Ventilation

Underestimation of Nocturnal Hypoxemia Due to Monitoring Conditions in Patients With COPD

     First of all you must forget the commonly held belief many doctors and patients have. That is that to
     use a ventilator successfully you must use it invasively with a tracheotomy. This page will show you
     how a ventilator can be used non invasively.

     Secondly and most importantly in order to avoid being forced into invasive ventilation you must not
     wait until you absolutely need to use a ventilator . You must plan ahead. Don't wait to long to seek
     help if you are developing breathing difficulties. If you wait until you are in an emergency such as heart
     failure or respiratory failure most likely you will be trached.

     For me respiratory difficulties developed gradually. At first I only needed breathing assistance
     overnight. Then I began using the ventilator several hours during the daytime also, until eventually I got
     to the point where I am now. Currently I am only able to breath 5 to 15 minutes at the most
     on my own before I need assistance. When I began having difficulty breathing I didn't want to be using
     a ventilator with a trach. Fortunately the first respiratory doctor I went to see didn't believe in invasive
     ventilation for people with my condition. She specialized in non-invasive ventilation. She set me up
     with my first ventilator equipment. Additionally I began to breath in a unique way over a period of
     time. Because I developed breathing difficulty slowly I began to compensate for a low breath capacity
     by in essence gulping air at the end of every breath. Using neck muscles and ones' lounge you can
     increase your vital capacity to a point where you can sustain your breathing adequately enough to
     breath on your own for longer periods of time.  My story is here

How to Perform Your Own Search on the Health Sciences Library's Ovid Search System

Non Invasive Ventilation (BiPAP)

Nighty Night Mikie!!!! Sweet Dreams thanks to bi-pap

Native Texan <>

Subject: Re: [COPD] BIPAP comment
Tony gave a good description of the BIPAP machine.  I would want to add that originally they fitted me with a CPAP (constant air
pressure, no allowance for exhaling) and I could not adapt to it because I could not fight the pressure of the incoming air to exhale
properly, thus making me feel as if I were being suffocated!  Once I explained this to my pulmonary doctor, he ordered a BIPAP for me
(BIPAPs are more expensive but allows you to breathe OUT as well as helping the inward movement). I really become "one" with
it UNLESS I have sinus troubles then the setting doesn't work.  For instance last night my sinuses were really stuffy, I ended up
taking the BIPAP off and just wearing O2 from the concentrator.  I hear so many people say they never have a problem with it and
that's not true for all of us. It's certainly worth the effort when it's in sync with you, and that's most of the time. I use the BIPAP
because I have severe sleep apnea, stopping breathing (respiratory disturbance index of 58 events per hour).  My PCP ignored my
requests for sleep testing for years, and YES I think it affected my short term and long term memory....think it's due to lack of O2,
as my sat levels were low too.  I don't use O2 at night with the BIPAP because the air movement gives me a boost enough that I
don't need it.
The BIPAP's primary purpose for my needs is to keep the airways open, not associated with the emphysema.  The sleep apnea
continually closed my throat due to collapsing, which caused the sleep trauma.  During these "events" my O2 went to the high 80s,
but when the machine was hooked up to me the O2 went up to an acceptable level (or so I am told), and there has been one in
home test to show that I didn't need O2 with BIPAP. IF the BIPAP had not worked out, then yes I would be on O2 at night. but
the ideal situation was for the BIPAP to work and thereby only need that at night.  I do think that I should wake up more rested
than I do, but that's just my opinion.  Masks are a BIG deal with these CPAPs/BIPAPs!  I bought a Gold Seal thinking that I might
improve over the Mirage...that was a mistake!  Insurance is funny about paying for the better masks to I went to a website that sold
them for a reasonable price and bought another Mirage (still have not put it into service as the old one keeps going).   You might
want to visit this website for good prices on masks and other equipment:
This may get your on the parts page where you can find item #16502 Mirage.  Complete System $131.  (I don't get a commission,
just recommending) Mike in Dallas  (Native Texan)

Lee with his full face mask  LFIELD <LField@TRIAD.RR.COM>
This is a full faced mask and is most usefull if you are a mouth breather or sleep with your mouth open.
Full faced mask provide an excellent seal.
Lee Field

I am 76 years old WWII veteran. I have moderate COPD and severe Sleep Apnea. I have a  Sullivan Bi-Pap with a Sullivan
heated Humidifier. My experience can only be described as  Bi-Pap Hell. It all began after two excursions to a Sleep Lab
(Named after a favorite black dog of some forgotten, thank heavens, Doctor)

 I had a heck of a time. They first gave me a Respironics "Gold Seal" mask that just covered my nose. It had two wide blue
straps that fit over your head. I am a "mouth breather", which I did not know or ever heard about so the mask had to be
implemented with a strap that went under my chin and over my head, in order to keep my big mouth shut.
This was so uncomfortable that I was losing more sleep than gaining any good the mask and Bi-Pap was supposed to help
..After going on the "web: and finding such places as and, I went to my pulmonary doctor without an
appointment and abley raised cain.

I told him that I could not wear such a contraption and that he should have known better. He called the Medical Supply
people and told them that if they did not help me that he would no longer recommend them. It worked. I went to the Med
Supply and they gave me a ResMed "Mirage Full Face Medium Mask System". This consisted of the mask and a flimsy
sort of black strapping that was somewhat similar to the blue straps of the Gold Seal. but much thinner and not as
comfortable. It covered my mouth and nose so that solved the problem of being a mouth breather,
although you do get very dry if you continue breathing thru your mouth. I put up with this for quite a while, waking up at
night, adjusting it and then trying to go back to sleep. This black harness was just not good for me although the Mirage Full
Face Mask was a
winner. So I cut up the black harness and tried doing away with the meshing and the piece over the top of the head. Still not
as comfortable as it should be and still a pain in the ears. I then had the bright idea of using the wide blue straps of the Gold
Seal nose mask with the Mirage. I again cut the webbing, making two
separate pieces. They did not fit thru the holes in the mask as they should, but were forcible. Wow! What a difference. The
Spironic straps with the Mirage was much more comfortable, but of course not completely. I am an active sleeper. I start out
on my right side, sometime during the nigh I am on my back, and I always end up on my left side.

One day while watching the History channel I noticed that the Fighter Pilots were wearing their oxygen masks with one
strap down around the back of their necks. I immediately got my mask and removed the upper strap tightened the lower
strap pulled it down around the back of my neck and sure enough it worked.

I have purchased a new Mirage Face mask, but size Small. I can use one strap on this bringing it down behind my neck. It
has the advantage of fitting under my bottom lip and helping to keep my mouth shut.
The downside is that it is lower on my nose so I bought some Dr. Scholl's "Moleskin Plus Padding" (Foot Dept. any Rx) and
cut up little patches to keep my nose from hurting.

I believe that you must play around with the thing and get it to feel comfortable. I Have had the Bi-Pap for 10 months and am
very comfortable with it, I even put it on for short naps or when I am overly SOB. The main thing is to get tough with your
Supplier and make it their job for you to be comfortable.

Tony in Dallas Hi Tony here in Dallas. I was prescribed a BIPAP/ST unit for CO2 retention on Dec 23, 1999 and have been wearing it every night
since. It has lowered my Co2 level considerably from 82 in Dec to 66 as of June 1st.
A BIPAP/ST stands for BiLevel Positive Airway Pressure. The ST designates the BIPAP also has a backup respiratory rate
incorporated. This means the unit supplies me with forced breaths. FYI: My BIPAP settings are: - TPAP=20 - EPAP=5 -F1O2=
1.5lpm - S/T=14 bpm. Doctors will determine the settings for the BiLevel settings. There are two settings. One for assisting you to
breath in and one for assisting the breath out. This helps flush out the CO2 in your lungs.  It is something you have to get used to. I
did. But after just one or two nights, I slept like a baby.  One other thing that is very important. The mask that is used for BIPAP
machines is most of the time a generic put out by more than one company. Mine was custom made to fit my particular facial features
and works very well. One thing you don't want is the air leaking around the top of the mask into your eyes. That is very uncomfortable
and you can get a cold in your eyes from it.  I had my mask made when they did my sleep study at an outpatient facility lab.  It was
originally like silly putty and about the same color andthey molded it around my nose area and when it hardened it fit perfectly and
did not leak above or below my nose and I have a mustache.  It is not hard and is easy to clean. I was told to clean it with cold water because warm water increases the chance for bacteria go grow. They said also to clean it with a vinegar and water solution. Soak in
a solution of one cup vinegar and 3 cups water. The mask is called a LYON NASAL MASK.  I believe the CPAP is mainly for
sleep apnea.  It is just a set amount of pressure and does not have but one setting to keep the airway open.  It is sort of a hassle but in my case more of a blessing. keep on keepin' on
FYI A CPAP unit has only one setting for a continious positive airway pressure.  It does not make you breathe as its only job is to keep the airway open. A Standard CPAP unit maintains the same pressure while you inhale and exhale.  The constant flow of air keeps the airway open to allow for normal breathing and uninterrupted sleep.  Some patients require a bi-level unit which I use called a BIPAP unit and
has two seperate settings. One higher pressure for inhalation and one lower pressure for exhalation. These BIPAP units can also be set
to give the patient a certain number of breaths per minute as mine does. If I do not take a breath in a certain period of time my machine
will kick in the higher pressure and make me take a breath 14 times per minute. This additional option is desiganated by the indicator /ST
as in BIPAP/ST
My settings are
TPAP=20 cuH20 for inhalation
EPAP=5 cuH2) for exhalation
S/T 14 bpm
and F1O2= 2.5 lpm,,,this is the additonal oxygen I require with my machine. I have to wear a BIPAP not due not only due to sleep apnea but because I am a CO2 retainer and the machine keeps the Co2 flushed out of my lungs.  I also feel very refreshed when I wake up as I think the demand setting for breaths per minute help my lungs to relax and not work as hard.I have lowered the Oxygen flow to 2.0 lpm as
I was retaining more Co2 with the higher oxygen flow setting. This was done with docs approval after two consective ABG's showing high Co2 levels. Normal is 35 to 35 and I am at 66.  I was at 77 at one time, thus the lowering of o2 flow.  This is something you have to get accustomed to as when the forced breath cycle hits, you have to be prepared to take a breath. Let me put it this way,,,you WIlLL take a breath.  It only took me one night to get comfortable with the machine and the settings. You  just have to relax and not try and fight the machine.  Hope this puts some light on the difference between CPAP and BIPAP machines. keep on keepin' on
Tony in Dallas

Jackie LaBreck <>

BiPAP is a machine that has two way 'breathing'.  It pushes air into your lungs when you inhale but also lets up on the pressure when you
exhale.  From what I understand, that is the difference between CPAP and BiPAP.  CPAP has continuous pressure.  Oxygen is attached to
the mask that you wear so that you still get the same liter flow that you are use to. (If your prescription calls for oxygen) I use BiPAP on a
daily basis for sleeping.  Whether it is at night or just napping.  Since starting the BiPAP, I have found that I don't get migraines nearly as
much as I use to and I don't wake up short of breath unless I sleep in the wrong position.  When starting on BiPAP, you do have to get use
to wearing the mask.  The respiratory therapist told me that the best way to get use to it is to put it on for a while and if you start feeling
claustrophobic or can't stand it, take it off for a while, then put it back on.  Basically, getting your body use to it.  I had no problems getting
use to it since, when I was put on it, I was in respiratory distress at the time and was admitted to ICU.  Have never had a problem since
and was only in ICU for 3 days, which wasn't even suppose to be that long but they 'just wanted to make sure' that I was still OK.  I think
BiPAP is wonderful.  Although the best mask 'holders' I have found are called Softcaps, I believe by Respironics. Other ones that I have
used slide up and down on your head and don't hold the mask correctly.  What you will see in the pictures is the softcap.  Mine also has a
'quick release clip' so that you don't have to keep resetting the velcro adjustment every time that you put it on.  I have only really tried two
types of masks so far and they are pretty much the same so I don't have any real recommendations about what type
of mask to actually wear.
Jackie LaBreck/freelady
35 yo cystic fibrosis patient
pre-tx working on getting listed
Essentially, we all have lost and are progressively losing varying amounts of our lungs and it's function.  What that means is that we don't move as much
air in and out of our lungs.  That in turn means we don't bring in as much oxygen and don't move out as much carbon dioxide.  And that means we can and usually do become short of breath.
The alternatives -------
One is to insert a tube through our neck directly into our lungs which is attached to an air compressor which then pumps air directly into our lungs.
It is set to essentially take over the job of breathing for us. That is called a "Trach."
Another option is a cPaP.  This is an air compressor attached to mask covering either the nose and/or the mouth.  It's function is to prevent too
much air being exhaled that causes the small airways to completely close. The cPaP maintains a continuous small pressure to prevent them from closing.
Another option starts with the cPaP, but also adds another function -- that being to replace the air flow lost from the loss of our functioning lung tissue.  That increases the oxygen inhaled and the carbon dioxide exhaled.  That is a BiPaP which also utilizes an air compressor to increase the amount of air inhaled through the nose into the lungs.
The BiPaP can be set to regulate the volume of air inhaled with each breath as well as the number of breaths per minute.  It can also be set to either
force the airflow, or just act to support your natural breathing pattern.  The new models provide a great deal of flexibility that weren't available just a few short years ago.
Generally speaking, a reduction in lung capacity means not only less oxygen, but also more carbon dioxide.  And generally speaking, a higher level of
carbon dioxide more frequently triggers a "shortage of breath" than a lower level of oxygen.  So, the objective then becomes removal of the carbon
dioxide, which is the purpose of the BiPaP.
I've copied the literature I received from VA when I took a BiPaP home.  It simply increases the air flow through your lungs and,
thereby, reducing and/or controlling CO2 levels.  I've used one for close to 2 years now.  I use it when I sleep and I wouldn't be
without it.
It provides almost instant relief from SOB.  I can be heaving just trying to take a breath.  I put that mask on and I stop heaving
instantly.  If you like to breath easy, get the BiPaP or CPaP.
In my opinion, the non-invasive ventilation is under-promoted, mis-understood and vastly under used.  There is nothing else, that
I am aware of, that can bring relief to labored breathing as quickly as the BiPaP, or a variation of PaP (Positive Air Pressure).
It almost feels like a miracle sent from heaven to me.
Dave in Omaha
DGMcNeill@AOL.COM I think the CPAP is mainly prescribed for sleep apnea because patients simply quit breathing and the machine helps to
prevent this by constantly forcing the air into the lungs and keeping the airways open.
The BiPap for is for CO2 retainers.  It forces air into the lungs when we breathe in (the CPAP is continuous)...pushing the CO2
out and lowering the high CO2 levels.
I used a BiPAP for high CO2 levels a couple years ago.  Couldn't stand to wear it more than about 4 hours at during
the day I'd wear it while watching t.v. for a couple hours...and that seemed to work.  The trick to using the machine is to find the
right mask so your comfortable.......
  "amy " My mother uses the BI-pap an has for about a month an half  its a great machine she uses about 7 hours a night not because of sleep
apnea she doesn't have that the respiratory therapist said it gives her lungs a chance to rest an her muscles a chance to strengthen,
also puts it on a couple hours a day or if napping an the when she takes it off  she has an easier time breathing an also feels better it
takes about 3 -5 nights to get use to sleeping with the contraption on your head she said but not uncomfortable just some getting use
too, but she wouldn't take a million dollars for her BI-pap machine,

I used Bi-pap temporarily for a high Co2 retention problem that I had related to Cystic Fibrosis.  I had only used this for a short
time and then the call came in. I know that you can get used to the feeling after a while with the mask on your face.  The good
side of the mask is that you feel much better in the morning and you are breathing better.  For me it pushed out the Co2. It
brought it down considerably. I would do it with ease because it will save your life.
Sleep better,
Risa Gans 1.       I use mine to maintain my co2 levels......My doctor prescribed after a ER visit.... I was retaining co2, and they hoped to
avoid putting me on the ventilator.  They used a bi-pap and monitored me over night...  and they were successful in stablizing me.
My doctor ordered me one for home and I have used it ever since.  I just love my bi-pap.... couldn't live without it.  I feel soooo
good when I awake... so refreshed.  If I don't feel right, many times I will take a nap with it.
2.   I will tell you everything that I know about a bipap from what my pulmonologist has told me.  Your doctor prescribes it.  As
I understand the bipap is 2 level...inspiration and exhalations.  You connect your o2 tubing to the bipap..  In a bipap this forces the
airways open and also forces o2 into the lungs. You get a higher percentage of o2, not sure the exact figure, but I believe its 2 or
3 %  more.    This helps to get rid of co2.  There are 2 level settings, which your doctor orders set when it arrives.  Thats about all
I can tell you.
Air pressure in a cpap opens the airways so one can breathe easier.
3.  I didn't have any real problems adjusting to this, because by that time....I was anxious for anything that would make me better
When co2 is high.... you lose your ability to think clearly, and as it can imagine...... you continue to lose brain
functions, not to mention, your other organs, and I wanted to keep my thought processess I did what I had tooo.....
The mask fits snugly... on your face, shaped like the top part of a nebulizer mask, covering the nose, but sitting on your upper lip.
Its a half mask and does not cover your mouth.  and first you feel like you are suffocating....especially with the forced air
pressure.  Once you get over the adjustment of having this mask on...and how good you feel....I think you will love the results...
There are many different types of masks.  They usually give you the standard mask..   I prefer the headgear with my
helps me to situate it on my head.  It has four straps...that you can adjust to your preference.  and just this last May....  I asked
my supplier about other masks, and the one I  chose..... has the rim of the mask made of  a soft pliable ???.....almost like playdough...
it feels sooo good to the face...... I am very, very happy with this one. It feels like nothing there, and no more crease on the nose. I recommend this one.  I will try to find the name if anyone is interested.  It is very important to find a mask that is comfortable.  If it
doesn't sit right, you will lose the benefit of the bi-pap.
Sophia in Pa  SoFreeA@AOL.COM

My father uses a bi-pap at night for (at least in principle) 8 hours, & also during an afternoon nap of about 3 hours.  He says he
sleeps better during the nap.  He uses a mask that covers his mouth as well as his nose because he tends to breathe through the
mouth when asleep.  His pulmonary problems result from having had TB (& associated surgery) in 1942-46.
The bi-pap seems to have succeeded *most* of the time, so far, in keeping him from having to be on a "real" ventilator.
Best wishes,
Dan Smith

I ask anyone to correct me if I am wrong about anything I say. The only thing I know for sure is that when I can use my
bi-pap it is wonderful!
     I first started on a c-pap. It is a continuous flow of air and your O2 mixed being "blown" in. It usually takes a bit of getting
used to, but if yu can take it, you will be glad you did. The bi-pap not only blows air and your  O2 in, but ,also, helps blow air
out. I never took the time to find out how  or  anything (I believe I will now), but I do know it gives your  lungs, and you a
needed break.
     I can't use mine when I have a nose cold  or anything that would stuff up my nose,because you must sleep with your mouth
closed when using these machines. That even sounds terrible to some people, but if you can at all learn to do it please try. You
----or maybe I should just stick to my own experiences---anyway, it makes me feel so refreshed in the morning and I hardly
ever "nod off" during the day when using  one or the other.
     Really, if you can at all stand it, the little things that you  may get used to anyway, will seem more than worth it.
     May good breathing be with you everywhere you go.
Janice/in  janholly@WEBTV.NET

Once I used a Healthdyne Quantum. This is a fancy Bipap machine. It really is more of a noninvasive ventilator to be exact. It can be
set to breathe for you if you miss a breathe. In other words, it can be set to operate on a timed cycle instead of on demand.  But a
bipap can be set for two pressures. One being the pressure that it has to reach on inhalation. That means it has to reach a certain
back pressure before in stops input. That is set to fill out your lungs completely. Then one can set the so to speak "back pressure"
also. That is the pressure that is maintained when the machine drops the former pressure when you exhale. It does this so you can
exhale easily and not fight that former pressure. This holding of back pressure enables the bronchioles to remain open and also helps
maintain the soft palate to remain closed. It acts almost like pursed lipped breathing. The soft palate in the rear of the mouth is held
shut by this pressure so that no air is forced out of the mouth. You can open that palate by mindfully doing so then the air rushes out
of your mouth instead. What a strange sensation that is!
These machines are only as good as they are set up for. I had considerable problems getting comfortable with mine as it was not set
up well. I learned about it and ended up changing the set points myself until it fit my needs.  And my needs where much higher than
they originally set it up for. That caused me to fight it all the time. Another problem I had with it was when I was sleeping, my
respiratory rate fell off considerably. In doing so, I would not trip the higher intake pressure on the machine. I would fight that and
get low stats till I would finally gasp and trip it again. And many times you don't wake up fully when doing this. Then you wake up
tired. When I caught that happening, I found that the back pressure setting needed to be set higher to keep it tripping at those times.
After I corrected that, it was fine.  Another problem with them is the mask. They have to seal over the nose so that this pressure can
be maintained without leakage. This leads to a few problems. One being keeping it on and in position during sleep. The head gear
is interesting when you get it. Ha, ha! Then there is a problem with chaffing of the nose bridge from it. If that happens it is very sore
and one will need to stop using it till it heals. I found that if one changes the way the mask straps are used, this can be eliminated a
great deal. I would just put the top strap tension enough so that it just held the mask there. Not tight. Then the bottom straps I would
make to pull straight back over the ears instead of at an angle. This enabled me to only need to make it just tight enough to seal and
no tighter. With the straight pull and less pressure, the nose did not suffer the chaffing. I used a gel mask and I think that is what they
all use now. If not, that is what you want with it.  The machine does help a great deal. It keeps the lungs filled out to get the maximum
surface area in use at all times. Many times you can cut your 02 back and still maintain your stats well with it. I could easily. It also
keeps the velocity up in the air ways and so keeps the fluids and mucus clear at night.  It is a pain to get operating right but can be well
worth the effort in many cases. But it needs careful set up to get the comfort and best from it.

Gene Downey

I have had a BiPap since first put on Ox in '98 but even after three different masks I still have not been able to use it overnight.  I even
went so far as to take the three or four straps loose and just had one strap around my head (thinking it would be similar to our paper
face mask or surgical masks) and would not give me that feeling of being confined or claustrophobic.  But no dice.
I just took it out of the closet the day before Olivija's post came in and am in the process of having my supplier come by to make sure
its clean and in working condition so I can try once again to use it.  My SATS have been in the 86 - 88 range for a couple of weeks,
and that after getting my PCP to up my Ox from 1.5 to 2LPM.  I finally purchased a Nonin Oximiter (pulse ox) (
and my  doc said if my ox stayed a constant 89 or below he would up my Ox to 2.  Even with the 2 I am only getting a reading
of 87-88.
"Its the mask, Olivija.  The mask. Beat that and you've got it made."
I ended up taking the BIPAP off and just wearing O2 from the concentrator.  I don't use O2 at night with the BIPAP because the
air movement gives me a boost enough that I don't need it.
Native Texan made the two comments above that seem like a contradiction of some sort.  Are you saying that you just use the
BiPap for the 'pumping' aspect, without having oxygen coming through?
Why?  Even if you say it "gives you a boost enough that you don't need it", it would seem to me you would be ahead by using the ox.
I've felt that if I could just tolerate the mask long enough to take a short nap during the day, or just hold it on for awhile, it would be a tremendous help to me.
Dick Fugatt   rfugatt@NWGA.COM

Hi.  This is Sandra from RI.  I have been on Bi-pap for a little over a year.  I had elevated CO2 levels and was having some of the
problems you mentioned.  Problrms concentrating, memory loss, etc.
I had some difficulties in the beginning because my O2 sat's were still dropping during sleep.  It has been resolved with the addition
of Flovent.  I sleep well now.  I feel much more " clear " headed and the memory problem has gone.  (I still have some senior moments though!!  I use the nasal mask and have the humidification.  I have adjusted pretty well to it, my CO2 levels have dropped to the 60's (haven't had blood gases in a while).  The best thing is that I get a good nights sleep.
I hope this helps

Respironics, Respironics Masks, Respironics Sleep Disorder masks, GoldSeal,
TheSleep Center
The absolutely incredible Respiratory CareSource Pages
Worsening respiratory failure
TheBiPAP Ventilatory Suuport System is designed with advanced technology for use in any location where NIV is administered.
DG DISPATCH - ERS: Non-Invasive Ventilation Linked To Lower Risk Of Infection
The Sleep Apnea InformationClearinghouse
Pulmonary & Critical Care MedicineEvery Breath You Take
Mallinckrodt Puritan-Bennett Product CatalogueBreeze™ SleepGear™
Here are some helpful hints for making your nasal pillows more comfortable Fitting Nasal Pillows
The Custom Made Headgear for Nasal Pillows
Citations: Noninvasive Ventilation
Respiratory Care Education RespironicsBiPAP S/T-D
Noninvasive Ventilatory Support: Who Benefits?   More patients than you might think. Here's how to use it.
RN/MCPHU Home Study Program CE CENTERVentilation Without Intubation
Effects of CPAP-applicationvia nasal mask and mouth-piece on gas exchange and respiratory mechanics after cardiac surgery
Nocturnal Nasal Intermittent Positive Pressure Ventilation (NIPPV) Therapy for chronic respiratory failure: long term effects
Non-invasive assisted ventilation (NIPPV/NIAV) in the management of acute hypercapnic failure secondary to COPD
The results of a pilot study demonstrate that a "mini tracheostomy" for treatment of severe obstructive sleep apnea may be far
   more acceptable to patients than standard tracheostomy or the use of continuous positive airway pressure (CPAP).

Critical Care Ask The Expert Optimal Modes of Ventilation for Weaning
from Medscape Critical Care


Is it better to use the assisted/control or synchronous intermittent mandatory ventilation (SIMV) with pressure support mode of ventilation in patients who fail weaning?

Ahmed Fathy, MD


from Christine Campbell Reardon, MD, 04/30/2002

There has been much written as to the best way to wean patients from mechanical ventilation. Two large trials have shown that 24% to 29% of patients fail in their first attempt at weaning.[1,2] The "difficult-to-wean" patients fail generally because their underlying illness has not resolved sufficiently to permit liberation from mechanical ventilation. The other major barriers to weaning include malnutrition, excessive secretions, presence of autoPEEP, impaired muscle function secondary to hypokalemia, hypophosphatemia, or hypomagnesemia, or respiratory muscle fatigue.

Dysynchrony between the patient and the ventilator can also increase the work of breathing for the patient and can lead to muscle fatigue and weaning failure. Optimizing patient-ventilator synchrony minimizes the individual's work of breathing and allows the patient to receive as much support from the ventilator as possible. It should be noted that respiratory muscles do not completely rest even when a patient is on mechanical ventilation. The inspiratory muscles continue to contract during assisted breaths in IMV, AC, and PS modes. The flow rate, trigger sensitivity, and method of triggering should be assessed as to the adequacy of meeting the patient's ventilatory demand. If the flow setting is too low or the trigger setting not sensitive enough, there will be an increase in the patient's overall work of breathing by making the triggering of inspiration more difficult. Using a flow-triggering mode of ventilation will reduce inspiratory effort 30% to 40% more than pressure triggering during mechanical ventilation.[3,4]

Several trials have compared the efficacy of weaning methods.[1,2] One trial found that the length of weaning was shorter with PS than with IMV or spontaneous breathing trial (SBT).[1] In contrast, another trial demonstrated that a spontaneous breathing trial performed once daily resulted in extubation 3 times more quickly than IMV and 2 times as quickly as PS.[2] The studies differ significantly in the criteria used to determine the suitability for extubation. In the first study, the patients weaned by IMV had to tolerate a rate of 4 for 24 hours prior to extubation. In the second study, once patients tolerated IMV of 5 for 2 hours, they were extubated. Similarly for SBTs, in the first study, the physicians could request 3 SBTs for 2 hours each prior to authorizing extubation attempt. In the second trial, if patients tolerated SBT for 2 hours, they were extubated.

General recommendations for the difficult-to-wean patient include having patience until the underlying disease process resolves sufficiently; optimizing nutritional and metabolic parameters; maximizing patient-ventilator synchrony to reduce the work of breathing; and providing adequate muscle rest. Once the patient is deemed ready for weaning, daily SBT will likely be the most efficacious method of weaning. The goal of the SBT should be 2 hours without clinical distress.







Last edited 5-8-2002