Advances in non‐invasive positive airway pressure technology

Abstract

Non‐invasive ventilation (NIV) has become the standard of care for patients with a range of respiratory and sleep breathing disorders. Technological advances have enabled the development of several newer modes of automatically adapting NIV suitable for patients with more complex breathing abnormalities that may be difficult to manage effectively with more traditional positive airway pressure therapy. These modes allow for more stable ventilation when fluctuating ventilation requirements occur such as in positional upper airway obstruction or state‐related variations in respiratory mechanics and drive. Adaptive servoventilation (ASV) is designed for patients with periodic breathing and central apnoeas in whom carbon dioxide levels are normal to low, with the goal of therapy to dampen and stabilize ventilation. In contrast, volume‐assured pressure support is used in diagnostic groups characterized by hypoventilation, where targeting an effective level of ventilation irrespective of sleep stage or body position is required. These newer modes have the potential to simplify and optimize ventilation, although at present there is no evidence that they are clinically superior to standard home ventilation techniques. The complexity and differences in algorithms and features of various device brands, along with a limited evidence base documenting longer term outcomes, complicate decisions around which patient phenotypes are best suited to these newer modes. In‐built sensor and data storage capabilities of newer home ventilation devices provide the opportunity for earlier recognition of issues with ventilation and to guide corrective action. Further work is needed to determine how this impacts longer term clinical outcomes.

Long-Term Noninvasive Ventilation in the Geneva Lake Area

“…3 Over the past 15 years, home ventilators have undergone major technical evolutions; however, sometimes they are of undetermined clinical relevance. [6][7][8] Volume-assured pressure support, autotitrating expiratory positive airway pressure (EPAP), inspiratory positive airway pressure (IPAP), pressure support, backup rates, and built-in algorithms profiled for certain pathologies are now standard options on many ventilators. [9][10][11][12][13][14][15] More importantly, built-in software provides important information for monitoring efficacy of NIV (ie, estimation of leaks, tidal volume, residual respiratory events, percentage of cycles triggered and cycled by the ventilator, compliance).…”

Efficacy and adherence of noninvasive ventilation treatment in children with Down syndrome

“…40 Despite this, it is widely known that large degrees of leakage will significantly affect NIV performance, as well as comfort. 41 Large air leaks can significantly reduce the level of delivered intra-alveolar pressure, indeed the response of the PAP machine can be reduced by up to 56% in the presence of a leak of 30 L/min. Smaller air leaks can be compensated for by the ventilator.…”

“…To date, there have been no studies investigating NIV leakage in a pediatric population; furthermore, the level of clinical “tolerability” of leaks is not well established in home NIV 40 . Despite this, it is widely known that large degrees of leakage will significantly affect NIV performance, as well as comfort 41 . Large air leaks can significantly reduce the level of delivered intra‐alveolar pressure, indeed the response of the PAP machine can be reduced by up to 56% in the presence of a leak of 30 L/min.…”

Efficacy and adherence of non-invasive ventilation treatment in children with Down syndrome

“…To date, there have been no studies investigating NIV leakage in a paediatric population; furthermore the level of clinical "tolerabilty" of leaks is not well established in home NIV 33 . Despite this, it is widely known that leakage will significantly effect NIV performance 34 . In this study we identified that there was significantly greater leak in the DS cohort relative to their non-DS counterparts and this is particularly evident in those aged >5yrs.…”