Open-Mouthpiece Ventilation Versus Nasal Mask Ventilation in Subjects With COPD Exacerbation and Mild to Moderate Acidosis: A Randomized Trial

Abstract

BACKGROUND: Open mouthpiece ventilation is efficacious in patients with neuromuscular disease. We used this ventilation technique in patients with exacerbations of COPD with mild to moderate acidosis. METHODS: The study was performed in 2 respiratory monitoring care units. Fifty subjects with exacerbations of COPD, breathing frequency > 25, P aCO 2 > 45, and pH between 7.25 and 7.30, as well as Kelly scale < 2 were enrolled. Subjects were randomly assigned to receive noninvasive ventilation (NIV) via nasal mask or mouthpiece ventilation. The primary outcome was improvement in arterial blood gases. Arterial blood gases and breathing frequency were recorded 2 h after the start of the enrollment and then after 12, 24, and 48 h. The duration of NIV, hospital stay, and acceptability of the interface (mouthpiece or nasal mask) using a Likert scale were assessed. RESULTS: No subjects had deterioration of gas exchange. The 2 groups had similar trends in arterial blood gases and breathing frequency. No differences in duration of NIV or hospital stay were noted. However, a significant difference in acceptability was found: subjects preferred mouthpiece ventilation (P < .01). CONCLUSIONS: Open mouthpiece ventilation is a useful technique and may prevent further deterioration of gas exchange in COPD patients with mild to moderate acidosis (similar to traditional NIV delivered by a nasal mask). www.chictr.org registration ChiCTR-TRC-12002672.

Ventilator Settings to Avoid Nuisance Alarms During Mouthpiece Ventilation

“…6 More recently, mouthpiece ventilation use has been shown to treat moderate respiratory acidosis in exacerbation of COPD, showing a reduction in the endotracheal intubation rate in comparison with standard medical therapy 7 , and a non-inferiority to nasal mask in preventing further deterioration of gas exchanges. 10 However, mouthpiece ventilation application is based on the experience of only a few centers, 11 and alarm activation is a frequent drawback. 8 Strategies for avoiding alarm activation may be clinically important.…”

Mouthpiece Ventilation: Just a Home-Care Support?

“…In fact, as mentioned above, although we reported that NIV experience enabled treatment of more severely ill patients, NIV could not reduce the minimum rate of failure, which is intrinsic to the chronic disease and the cause of COPD exacerbation. 27 Despite these limitations, the study by Nicolini et al 22 gives us an important clinical message: mouthpiece ventilation may be considered as another tool in our armamentarium and as an alternative to other interfaces. However, due to its specific features and drawbacks (leaks, etc), it must be managed by an expert hand and in a wellmonitored environment even in moderate COPD exacerbation.…”

“…In this population of subjects, mouthpiece ventilation use has progressively become a valid alternative to tracheostomy, providing benefits in terms of prevention of respiratory infections, reduction of complications associated with tracheostomy procedure and maintenance, 19 reduction in swallowing problems, 20 and improvement in cough, voice, and quality of life. 16,21 In this issue of RESPIRATORY CARE, Dr Nicolini and colleagues 22 report an interesting study in which they compared mouthpiece versus nasal mask ventilation to treat COPD exacerbation with mild to moderate acidosis. Subjects were randomly assigned to receive NIV via a nasal mask or mouthpiece.…”

“…In fact, the correct setting is required to avoid frequent alarms. 28 Some limitations must be considered in the study by Nicolini et al 22 First, it is a very short-term study. As a matter of fact, it would be of great interest to confirm these results with a longer follow-up.…”

“…However, once again, the study considered a nasal mask as the reference mask. In the study by Nicolini et al, 22 more severely ill subjects were enrolled (pH 7.30 -7.25) without worsening the outcomes. This probably occurred because there was only one recruiting center, which had acquired experience with mouthpiece ventilation in recent years.…”