NIPPV: Where Are We Now?

Acute respiratory failure (ARF)-hypoxic or hypercapnic-is a critical condition often necessitating intensive care and mechanical ventilation (invasive or non-invasive) (1). Noninvasive Positive Pressure Ventilation (NIPPV) is increasingly used for specific forms of ARF because of its considerable advantages over invasive mechanical ventilation (IMV) for these conditions. Patients receiving NIPPV must be able to protect their own airway, enabling them to cough and clear secretions spontaneously, thus reducing the risk of hospital-acquired respiratory infections. IMV, on the other hand, bypasses the airway defense system, permitting the entry of irritants and pathogens into the lower airways, and necessitating the insertion of suction catheters that are uncomfortable and traumatic to the lower airways for clearance of secretions. Furthermore, NIPPV requires less sedation than IMV so that patients remain more interactive, retaining the ability to speak, express emotions and eat by mouth, thus reducing the feelings of isolation, powerlessness and anxiety that have been described with IMV (2,3). Not only are complications such as hospital-acquired respiratory infections less common with NIPPV, but so are nosocomial infections generally such as sinusitis and catheter-related blood stream and urinary tract infections, because patients are less likely to have these invasive interventions (3). Moreover, costs associated with IMV including the hospital staff required, nurse working time, need for ICU admission and length of hospital stay are usually reduced by NIPPV (4,5). NIPPV also has a wide applicability within hospitals; for instance, locations that can accommodate this modality are more accessible and diverse than with IMV (Pulmonary wards, high-dependency units, post-surgical recovery, emergency rooms and even at home). NIPPV may be used to prevent disease exacerbation and the need for intubation in patients (1). Based on the available literature, use of NIPPV is easier, more affordable, more comfortable and safer for select patients. NIPPV is not a new intervention. Descriptions of bellows-powered face masks date back to the early 1800s when Chaussier described such a device for use during resuscitation (6). Subsequently, tension pneumothoraces were described in dogs ventilated using bellows during experimental resuscitation leading authorities to discourage the use of such devices. This ushered in the era of negative pressure ventilators and other devices that avoided the application of positive pressure ventilation to the airway that served as resuscitation tools and ventilator assist devices for more than the next century. A few descriptions of the use of noninvasive positive pressure to treat pulmonary edema, pneumonia and asthma appeared …