Noninvasive Positive-Pressure Ventilation.

Prince Andrew married Sarah Ferguson on July 23 1986. That day also saw the first use in the United Kingdom of non-invasive positive pressure ventilation by nasal mask. Aged about fifty years, the patient had suffered pulmonary tuberculosis as a youngster and, in the days before antituberculous chemotherapy, had been treated with bilateral pneumothoraces, phrenic crush and finally an apical thoracoplasty. As a result, he had a severe restrictive ventilatory defect but, because in his early years he had ignored the advice of his physicians and smoked for a while, he also suffered a degree of airflow obstruction and emphysema. By the early 1980s he had chronic Type II respiratory failure with massive fluid retention despite very high doses of diuretics. Cyanosed, sleepy and water-logged, he was referred to the Brompton Hospital for a trial of negative pressure ventilation using a tank ventilator. The effect was remarkable, with something like a 12 litre diuresis in the first 24 – 48 hours. A slimmer, pinker and much more talkative patient emerged and thereafter was maintained for a year or two in reasonable health and always good spirits by using a ‘portable’ iron lung at home during sleep. He also returned to work as a jeweller. But the value of negative pressure ventilation at night was compromised by a tendency to upper airway obstruction while asleep: gradually he drifted back into “cor pulmonale”. A further short respite was secured by adding oxygen while he used the iron lung but, even with ventilatory assistance for much of each day, it was eventually clear he was losing ground.