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1146 MINERVAANESTESIOLOGICA October2012

E X P E R O P I N I O N

Non-invasiveventilation(NIV)isaormodeliveringventilatorysupportwithouttheuseoendotrachealortracheostomytube.Sever-alprospectiverandomizedcontrolledtrialshaveshownthatNIVreducestheneedorintubationandin-hospitalmortalityopatientswithacute

exacerbationochronicobstructivepulmonarydiseaseandacutecardiogenicpulmonaryedema,in such away that NIVis nowadays thefrst-linetreatmentorhypercapnicacuterespiratoryailure (ARF).1, 2 NIV proved its eectivenessalso ater surgery, as support during fberopticbronchoscopy,orthepreventionorespiratoryailureaterextubation,andinselectedpatientswithARF.3-7

Apartromclinical trials,therehasbeenalsoaprogressivelyincreaseduseoNIVinclinical

practice.8-10 Notably, in patients treated with

NIVoutsidetrials,clinicaloutcomesareroughlythesameasinclinicalstudies,meaningthatthistechniqueiswellmasteredbycaregivers.10

egrowinginterestonNIVhasledtore-search interest in developing technical compo-nents o NIV,11-18 particularly the interaces

which could aect the outcome, as shown byNavalesiet al.19einteraceisanessentialcom-ponentsinceitdierentiatesNIVrominvasivemechanicalventilation.GreatattentionhasbeenpaidtotheimprovementoNIVrelatedsidee-ects,20withspecialregardorpatientcomort,user-riendliness,andsaety.Nevertheless,itstillails in about one third o patients.10 Even icausesotreatmentailurearenotentirelyclear,patient selection, and the role o the interaceseemtobekeyissues.21-23

Ater an overview o dierent interaces or

Recentadvancesininteracesornon-invasiveventilation:rombenchstudiestopracticalissues

G.F.SFERRAZZAPAPA1,2,F.DIMARCO2,E.AKOUMIANAKI1,3,L.BROCHARD 1,4

1IntensiveCareDepartment,UniversityHospital,Geneva,Switzerland; 2ClinicadiMalattiedellApparatoRespiratorio,Ospedale San Paolo, Universit degli Studi di Milano, Milano, Italia; 3Department o Intensive Care Medicine,UniversityHospitaloHeraklion,Heraklion,Crete,Greece; 4UniversityoGeneva,Geneva,Switzerland

A B S T R A C T

einteraceis thedefning elemento non-invasive ventilation(NIV). Nowadaysdierenttypeso interaces,whichdierintermsoshape,mechanicalpropertiesandcomort,areavailable,andtheirchoiceandfttingisakeyelementoNIVsuccess.Inthelastdecade,largermaskscoveringtheentireaceandspecifcallydesignedhelmetshavebeendevelopedordeliveringNIV,theoreticallyimprovingcomortandpatienttolerance.Recentstudieshaveshownthat,despitemarkedheterogeneityinmaskinternalvolumeandcompliance,thedynamicdeadspaceand,aboveall,theclinicalecacyodierentmasksisonaverageverysimilar.us,withtheexceptionothenasalmaskandthemouthpiece,avarietyointeracesorNIVcanbeusedintheacutecaresetting.However,preventionandmonitoringointeracesrelatedside-eectsandevaluationopatienttolerancearecrucialtoavoidNIVailure.Tooptimizeeectivenessandcosts,aninteracestrategyorNIVinacuterespiratoryailurecouldbeconvenientin

clinicalpractice.(Minerva Anestesiol 2012;78:1146-53)Key words: Positive-pressurerespiration-Masks-Respiratoryinsuciency.

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RECENTADVANCESININTERFACESFORNONINVASIVEVENTILATION SFERRAZZAPAPA

Vol.78-No.10 MINERVAANESTESIOLOGICA 1147

NIV,thispaperwillbrieyreviewthemostre-centselectedcontributionsprovidingnewfnd-ingsoninteracesorNIV,ocusingmainlyon

theacutecaresetting.

General features of interfaces for NIV

Nowadaysa variety o interaces isavailable(Figures1-3).Afrstdistinction,ocrucialim-portance,concernsleakymasksorsingle-circuitventilatorsversusmaskswithoutintentionalleaksordouble-circuitororasinglecircuitequippedwith an expiratory valve. Beside commerciallyavailable masks, custom-abricated also exist.elatterisdirectlymoldedonpatientace,buttheabricationneedsadditionaltimeoupto30minutesoraskilledoperator,complicatingtheuseintheacutecaresetting.22,24

Even i masks ormed by a unique piece omaterialstillexist,interacesaregenerallymade

otwoormorepartshookedorgluedtogether:aramemadeosti trasparentmaterialandacushionosotmaterialtosealtherameagainstpatientace.2,22Improvementshavebeenreal-izedbyusingdierentcushionswithnewmate-rials(suchashydrogel),andinthefxingsystemwithparticularattention to skinand eyescare.eincreaseinthenumberotheattachmentpoints permitsa more uniorm distribution o

pressure,resultinginamajortoleranceandinreducedleaks.LargerramescoveringtheentireaceandspecifcallydesignedhelmetshavebeenproposedorNIV.3eroleothesenewdevic-eshasbeenthesubjectodedicatedbenchandphysiologicalstudies.11-13,15,18

Te oronasal mask

All interaces or NIV deliver positive pres-sureeitherthroughthemouth,thenoseorboth.

eoronasalmask(Figure1)isthemostwidelyusedintheICU,sincepatientswithARFotenhavea high respiratorydrive and are generallymouth-breathersprobablytoovercomenasalre-sistance.8,10,23esemasksaredisposableandare available indierent sizesandshapes toftbetteratpatientace.

Te full-face mask

e ull-ace, or total ace mask covers the

entireaceincludingtheeyes(Figure1).25is

Figure3.ehelmet.

Figure1.eoronasal(onthelet)andtheull-acemask(ontheright).

Figure2.Nasalandoralinteraces.

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SFERRAZZAPAPA RECENTADVANCESININTERFACESFORNONINVASIVEVENTILATION


directly inserted into the nostril.2 e nasalinteraces have the obvious limitation o non-intentionalleaksipatientbreathethroughthe

mouth, which is requent or patients exhibit-ingahighventilatorydemand.Furthermore,itcannotbeusedincaseonasalobstructionorcongestion.Ontheotherhand,thiskindoin-teracepermitspatientstoeat,talk,cough,andcauseslessclaustrophobia.ereore,itismostlyusedorchronicNIV,whileinacutesettingtheimprovementingastensionappearstobeslowercomparedtoacemasks.euseoanasalmaskintheICUisclearlynotrecommendedsinceitleadstomaskailure inmore than70%othepatients.26

Oral interfaces

Oralinteraces,suchasthemouthpiece,areplacedbetweenpatientlipsdeliveringpressuredirectly into the mouth, thus nasal clips aresometimes usedtoavoidnasal leaks. Dierentshapesandsizeso thisinteraceexistandit isused particularly or neuromuscular disorders

interacehasalargeinnervolumeanditisfxedwithasotsealaroundtheace.roughitslargeperimeteritavoidspressureoverthenasalbridge,

whichis requentlyexposedtopressuresoresastheskinisthinanddirectlyuponthebone.Totalacemaskisdesignedasonesizewhichshouldftmostpatients,makingtheoreticallyeasiermaskfttinginacutepatients.Arecentstudyoundnodierenceonthisissueincomparisonwithoro-nasalmask, having boththe samelevel oper-ceivedcomort,andsimilarapplicationtime.15However,thelimitationothisstudyisitsshort-term nature, whereas dierences in tolerancemay be clinically relevant over longer periods.Noteworthy,thistypeomaskisgenerallymoreexpensive than oronasalmasks, and itis singleuse,orthisreasonitisotensuggestedasasec-ondlineintervention(Figure4).22

Nasal interfaces

ere are two existing types o nasal inter-aces:nasalmasks,designedtocovereithertheullnoseorthenaresonly,andnasalpillows

Figure4.Aninteracestrategyornon-invasiveventilationintheacutecaresetting.Nonleakymaskswithintensivecareunitventilator. #Ipatientnonadaptedveriyalsosettings,leaksandasynchronies.NIV:non-invasiveventilation.

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leaks. Recent bench studies reproducing leaksocusedonthistopic.Louis et al.comparedtheleaklevelsoseveralmasksontheperormance

o our single circuit NIV ventilators with anexhalationportinthemask,alsoreerredtoasintentionalleaks.37eleaklevelaectedsub-stantially ventilator perormance and patient-ventilator synchronization. e mask with thelargestleakwasassociatedwithauto-triggeringand/oradecreasedinspiratory-triggersensitivity.Attheopposite,theinteraceswiththesmallestleak were associated with important rebreath-ing. A physiological study on our volunteersconfrmedthemainresultsothestudy. 37erisksolowlevelsointentionalleaksduetolowpositive end-expiratory pressure (PEEP) levelshavebeenstudied.38Borelet al.showedthee-ectsomaskleaksonecacyoNIVwithanactivelungsimulator.39Withthesettingstested(respiratoryrate15cycles/min,inspiratoryandexpiratory pressure o 14 and 4 cmH2O, anddierentcomplianceandresistancelevels)theyconfrmedthatintentionalleakshigherthan40L/minhadanimpactonthecapacitytoreachthesetinspiratorypressureandthusindeliver-ing the target tidal volume. A compromise intermsoleaksintensityhastobeounddepend-ingontheriskorebreathingversustheneedordeliveringhighpressures.

evarioustypesointeracesarecharacter-izedbymarkedheterogeneityinmaskinternalvolume,complianceandmechanicalproperties.Ageneralconcernoverthenewinteraceshavingalargeinternalvolumeistheriskorebreathing.Fodil et al.specifcallystudiedthisriskbyus-ingnumericalsimulations(usingcomputationaluiddynamic)inourtypesoNIVinteraces,

two oronasal masks, a total ace mask and ahelmet.12, 14Inthis in vitro study, theauthorsshowed a largedierence between theinternalvolumeomask(whichisabout10Lorthehelmet) and the dynamic eective dead space,whichcanbemuchsmallerduetothestreamingeectogases.12eseresults,inlinewiththephysiologicalfndingsdescribedbelow,11,13sug-gestedthatnewmasksshouldbetestedintermsounctionaldeadspace40andthatinternalvol-umeitselshouldnotbea priorialimitingactor

ormaskselection.

requiring long-term ventilation. Since there isnocontactwiththenasalbridge,somecentersproposethealternateuseooralandnasalin-

teracesorpatientswhoneednearlycontinu-ousventilatoryassistance.2,27IntheICU,itishoweverassociatedwithsignifcantlymoreleaksandasynchronyandrequiresaverycooperativepatient.13

Te helmet

ehelmet,originallyusedtodeliverthede-siredoxygenractionduringhyperbaricoxygentherapy,wasfrstproposedordeliverycontinu-ouspositiveairwaypressure(CPAP),andsubse-quentlyorNIV.3,28Itholdstheentireheadothepatientbymeansoatransparenthoodfxedsotlyaroundtheneckortheshoulders(Figure3).ehelmet,availableindierentsizes,iscon-nectedtotheventilatorwithtwotubes,ortheinspiratoryandexpiratorycircuits.NoteworthytherearededicatedhelmetsorCPAP,providedwith a pipe-connectoror thePEEPvalve (e.g.spring-loaded,or water-seal), which needonlya high ow air-oxygen source. Since ithas nocontactwiththeace,thehelmetallowspatienttocough,seeandtalk,withsupposedlyabet-tercomortandtoleranceothepatient,evenispecifcproblemsmay ariseasthe possibleoc-currenceoaxillarydecubitus.3,28Severalstud-ies, mainly with short-term outcomes, oundconictingresultsontheseissues.3,29-33ehel-metshouldbeusedonlywithhighowtoavoidimportantrebreathinganditexposespatientstoahighlevelonoise,reasonwhymostothemarenowprovidedwithearplugs.

ForNIVthisinteraceshouldbeusedbyan

experienced team due to the lack o volumemonitoring,andtheriskoasphyxia.7,22,28,34,35

Bench studies

Proper unctioning o the interace, leaksmanagement and eectiveness o NIV are di-rectly linked. Air leaks can reduce deliveredvolumes,representadiscomortorthepatientsandaectpatient-ventilatorsynchronization.9,36Ingeneral,leaksshouldbeminimizedbutNIV,

bydefnition,hastoworkinthepresenceogas

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latorcontributetogenerateapressuregradient,thusoptimalpatient-ventilatorsynchronizationisextremelyimportant.Vignaux et al. oundin

60patientswithARFventilatedwithanorona-salmaskahighprevalenceosevereasynchronies(43%opatientswithaglobalasynchronyin-dex>10%).36Inthisobservationalstudy,ine-ectiveeortsandtheseverityodelayedcycleswere linked with the amount o leaks. Moreo-ver,amultivariateanalysisshowedthatpatientcomortscalewashigheritheasynchronyindexwas less than 10%. However, whetherall kindoasynchronieshavethesameclinicalimpactisunclear, andthere was no correlation betweenasynchroniesandclinicaloutcome.

Largermasksaredesignedtoimprovecomortandeasy-to-use.In60patientswithARF,Oz-sancaket al.testedthehypothesisothetheoreti-calsuperiorityothetotalace vs.theoronasalmaskonpatientcomortandrapidityoapplica-tionbycaregivers.15Inarandomizedcontrolledtrial,theyoundthatbothinteraceswereper-ceivedassimilarlycomortablebypatientsandrequiredroughlythesametimeormaskftting(median3.5vs.5min,P>0.05.).Contrarytothestudyhypothesis,thetotalacemaskresultedinastrongtrendtowardsamoreearlydiscontinua-tionduetointeraceintolerance(39%vs.16%).

ebeginningoNIVplaysapivotalroleinthesuccessotreatment.In90patientswithhy-percapnicARF,Giraultet al. studiedtheroleotheinitialmaskchoice(nasalvs.oronasalmask)onclinicaleectivenessandtoleranceoNIV. 26Althoughanimprovementinrespiratoryparam-eterswassimilar inthetwo groups, leakswiththenasalmaskresultedinaconsiderablyhigherrateotreatmentailure,andtheneedtochange

interacewhencomparedtooronasalmask.e mouthpiece has been proposed to de-

liverNIV,butitsuseintheacutecaresettingis dicult because o the mandatory need orcooperation andthe impossibility o breathingthrough the nose in patients with high venti-latory needs.27, 42, 43 Moreover, a recent studyshowed a signifcant increase in asynchronies,non-intentionalleaksandpoorcomortwiththeoralinterace,suggestingthatthisdeviceisprob-ablymoresuitableorchronicpatients.13

InthepreviouslydescribedstudybyVargaset

Physiological and clinical studies

Fraticelliet al.studiedtheeectoourinter-acesamouthpiece,aacialmask,andtwo

oronasalinterace(withsmallandlargeinternalvolume)onminuteventilation,gasexchangeandworkobreathingopatientswithARF. 13Despite heterogeneity in the internal volumeothedevices,theauthorsoundnodierenceinshort-termphysiologicalparameterintermso indexes o respiratory eort (pressure-timeproduct,PTP),arterialbloodgasesandbreath-ingpattern.eonlyexceptionwasthemouth-piecebeinglesstolerated.Anotherrecentstudysupportedthehypothesisthatdierenttypeso

masksarelargelyinterchangeable.11In34acutepatientswithacutehypercapnicrespiratoryail-ure,Cuvelieret al. comparedtheclinicalecacyo ull-ace vs. oronasal mask. ey ound nodierenceintheeectivenessoNIVdeliveredwith these two masks (the main outcome waspH 24 hours ater NIV start) despite markeddierencesintheinnervolumeothemasks.

A specifcallyconceivedhelmethasbeende-scribedorNIV.3isinteraceischaracterizedbyalargeinternalvolumereectinganancient

ideaopressurisationinsideabubble.41Duetohighcompliance,thehelmetcanbelessecientin reducing inspiratory eort, and promotingpatient-ventilatorsynchronythan theoro-nasalmask,asindicatedbyhighertriggeringandcy-cling-otimedelaysbythelargernumberoin-eectiveeorts.34isproblemcanbesolvedorminimizedbyusingspecifcsettings,i.e.,higherpressures.Vargas et al. comparedpressure-sup-portventilationdeliveredwithaacemaskandtwohelmets,onewiththesameventilatoryset-

tingsothemaskandtheotherwith50%higherpressuresupportandPEEP.estudywasper-ormed in eleven patients requiring NIV aterextubationorhighriskorespiratorydistress.18When using the same settings, the helmet re-sulted in higher PTP, which reects a less e-ectivenessinunloadingtheinspiratorymuscle;however,usinghighersettingsthisdierencewasabolished.

Synchrony,toleranceandcomortinNIV:theroleotheinterace

DuringNIV,boththepatientandtheventi-

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onstrateaclearsuperioritytooronasalmaskinterms o clinical eectiveness and tolerability.e helmet has unavorable mechanical prop-erties(highcompliance);moreoveritdoesnotallowaproperevaluationoventilatorpressureandowwaveormsthatareimportantactorsorNIVsuccessinpatientssueringromacuteexacerbationochronicobstructivepulmonarydisease.49ehelmetcanbeusedasafrstlineinteraceinexperiencedhandsandorsomein-dicationslikepulmonaryedema.

efrstminutesoNIVapplicationarecru-cialoritssuccess.Ageneralsuggestionistoholdthemaskgentlyonthepatientsaceandprogres-sivelyincreaseventilatorpressure,withtheheadothebedelevated.Skin,eyesandmaskhygieneshould be evaluatedperiodically, withpressurepoints inspection (mainly the nose bridge ormasksandaxillaryregionorthehelmet).IncaseoNIVailure due to the interace a dierentmodelooronasalmaskoraull-acemaskcanbeused,withthechoicebeingmadeinlightointeracesavailabilityandteamexperience(Fig-ure 4).To preventnose bridge oraxillary skin

pressuresores,themostcommonapproachistheapplicationohydrocolloids.

TodatethereisnotanidealNIVinteraceorallpatientsinallcircumstances,thusmanyin-teracesshouldbeavailableatthebedside.Atertheinitialchoiceaperiodicalnewevaluationopatientcomortandpatient-ventilatorsynchro-nization is needed. When clinical stability isreached,apracticalapproachtoreducetheriskoskinlesionscanbetorotatevarioustypesointeraces, which arecharacterized by dierent

shapesandpressurepointsontheace.

al.,patient-ventilatorsynchronizationwasbetterwiththeacemaskthanwiththehelmetduetolonger delay in triggering andcycling-o with

the second (P

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5. JaberS,DelayJM,ChanquesG,SebbaneM,JacquetE,SoucheB et al.Outcomesopatientswithacuterespira-toryailureaterabdominalsurgerytreatedwithnoninva-sivepositivepressureventilation.Chest2005;128:2688-95.

6. Maitre B, Jaber S,Maggiore SM, Bergot E,RichardJC,BakthiariH et al.Continuouspositiveairwaypressuredur-ingfberopticbronchoscopyinhypoxemicpatients.Arand-omizeddouble-blindstudyusinganewdevice.AmJRespirCritCareMed2000;162:1063-7.

7. NavaS,HillN.Non-invasiveventilationinacuterespira-toryailure.Lancet2009;374:250-9.

8. CrimiC,NotoA,PrinciP,EsquinasA,NavaS. AEuro-peansurveyononinvasiveventilationpractices.EurRespir

J2010;36:362-9. 9. DemouleA,GirouE,RichardJC,TailleS,BrochardL.In-

creaseduseo noninvasiveventilationin Frenchintensivecareunits.IntensiveCareMed2006;32:1747-55.

10. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F,ApezteguiaC, BrochardL et al.Evolutionomechanicalventilationinresponsetoclinicalresearch.AmJRespirCrit

CareMed2008;177:170-7.11. Cuvelier A,Pujol W, Pramil S,MolanoLC,ViacrozeC,Muir JF. Cephalic versus oronasal mask or noninvasiveventilationinacutehypercapnicrespiratoryailure .Inten-siveCareMed2009;35:519-26.

12. FodilR,LelloucheF,ManceboJ, Sbirlea-ApiouG,IsabeyD,BrochardL et al.Comparisono patient-ventilatorin-teracesbasedontheircomputerizedeectivedeadspace.IntensiveCareMed2011;37:257-62.

13. Fraticelli AT, Lellouche F, LHer E,Taille S, Mancebo J,BrochardL.Physiologicaleectsodierentinteracesdur-ing noninvasive ventilation or acute respiratory ailure.CritCareMed2009;37:939-45.

14. Olivieri C, Costa R, Conti G, Navalesi P. Bench stud-ies evaluating devices or non-invasive ventilation: criti-cal analysis and uture perspectives. Intensive Care Med

2012;38:160-7.15. Ozsancak A, Sidhom SS, Liesching TN, Howard W,Hill NS. Evaluation o the total ace mask or noninva-sive ventilation to treat acute respiratory ailure. Chest2011;139:1034-41.

16. SchettinoGP, ChatmongkolchartS, Hess DR,KacmarekRM. Position o exhalation port and mask design aectCO2rebreathingduringnoninvasivepositivepressureven-tilation.CritCareMed2003;31:2178-82.

17. SchettinoGP,TucciMR,SousaR,ValenteBarbasCS,Pas-sosAmatoMB,CarvalhoCR.Maskmechanicsandleakdynamicsduringnoninvasivepressuresupportventilation:abenchstudy.IntensiveCareMed2001;27:1887-91.

18. VargasF,illeA,LyazidiA,CampoFR,BrochardL.Hel-metwithspecifcsettingsversus acemaskornoninvasiveventilation.CritCareMed2009;37:1921-8.

19. Navalesi P, Fanulla F, Frigerio P, Gregoretti C, Nava S.Physiologicevaluationo noninvasivemechanicalventila-tiondeliveredwiththreetypesomasksinpatientswithchronic hypercapnic respiratory ailure. Crit Care Med2000;28:1785-90.

20. Gregoretti C, Conalonieri M, Navalesi P, SquadroneV,FrigerioP,BeltrameF et al.Evaluationopatientskinbreakdownandcomortwithanewacemaskornon-in-vasiveventilation:amulti-centerstudy.IntensiveCareMed2002;28:278-84.

21. AmbrosinoN,FoglioK,RubiniF,CliniE,NavaS,VitaccaM. Non-invasive mechanical ventilation in acuterespira-toryailuredueto chronicobstructivepulmonarydisease:correlatesorsuccess.orax1995;50:755-7.

22. NavaS,NavalesiP,GregorettiC.Interacesandhumidif-cationornoninvasivemechanicalventilation.RespirCare2009;54:71-84.

23. SooHooGW,SantiagoS,WilliamsAJ.Nasalmechanical

Conclusions

einteraceisoparamountimportanceoradherencetoNIVtherapyandconsequentlyor

NIVsuccess.echoiceothisdeviceshouldbedonewithspecialcaretomeetpatientsdemandandneeds,consideringthetreatmenttimingandsettings,andbypreerringmaskswhichdeliverpositivepressure through boththemouth andthenoseinpatientswithhighventilatorydrive.50

Benchand physiological studies onnewin-teraces suggests that the internal volume andthe dynamic eectivedead space omasksarenotsocloselyrelated.us,withewexceptions(suchasthenasalmaskandthemouthpiece),in-

teracesarelargelyinterchangeableintheacutecare setting.To improve patient comort, andminimizeleaks,itisadvisabletohavemultipletypesandsizesointeracesandtoapplyawelldefnedprotocoladjustedtothecaregiverexper-tise.Moreover, special ocus should beput ontheimprovementopatient-ventilatorsynchro-ny,patientcomortandtolerance.

Key messages

Recent studies proved that most in-teracesorNIVareinterchangeableintheacutecaresettingwiththeexceptionothenasalmaskandthemouthpiece.

Elementsokeyimportanceinprovid-ingNIVarealsopatient-ventilatorsynchro-ny,patientcomortandtolerance.

Awidechoiceointeracestypesandsizesisadvisable,integratedinawelldefnedprotocoltailoredonthecaregiverexpertise.

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Correspondingauthor:L.Brochard,IntensiveCareUnit,HpitauxUniversitairesdeGenve,RueGabrielle-Perret-Gentil4,1211Genve14,Switzerland.E-mail:[email protected]

ReceivedonFebruary14,2012-AcceptedorpublicationonJune22,2012.

isarticleisreelyavailableatwww.minervamedica.it

r02y2012n10a1146

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