Respiratory care
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For more than 40 years, noninvasive ventilation has been the first-line preferred therapy for acute-on-chronic conditions, such as COPD and cardiogenic pulmonary edema. The use of noninvasive ventilation in the treatment of hypoxemic respiratory failure, however, has been met with mixed results associated with higher risks of intubation (failure of therapy) and with higher risks of mortality. The purpose of this review was to describe the current evidence and important considerations when patients with hypoxemic respiratory failure are managed with noninvasive ventilation.
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CPAP is a spontaneous mode of ventilation that maintains a constant airway pressure during the inspiratory and expiratory phases. This therapeutic modality is used across the continuum of care from pre-hospital treatment to intensive and acute care units to the home care environment to treat a host of acute and chronic clinical conditions. A variety of devices are currently available for the delivery of CPAP, including oxygen-conserving valved systems, continuous-flow generators, portable demand-flow devices, and mechanical ventilators. ⋯ If undetected, this can contribute to adverse patient outcomes. Considerations for device selection depend on the setting (eg, pre-hospital, acute care, critical care, home care), length of therapy (ie, short vs long-term), patient safety (eg, alarms, monitoring devices), and comfort. Understanding the science and clinical application of CPAP delivery systems can assist clinicians in a variety of care settings with selecting the type of device that best matches the clinical setting, and thus with optimizing therapeutic effectiveness by maximizing patient comfort, safety and stability of pressure, and FIO2 delivery.
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Noninvasive ventilation is well established as the ventilatory modality of first choice to treat acute or acute-on-chronic hypercapnic respiratory failure in patients with COPD by improving dyspnea and gas exchange, avoiding the need for intubation, and reducing morbidity and mortality rates. Noninvasive ventilation also offers benefit for patients with COPD and with accompanying pneumonia or with hypercapnic respiratory failure in postextubation, postoperative, and do not intubate settings. ⋯ A newer form of noninvasive ventilatory assistance, high-flow nasal cannula, has emerged in recent years as a technique to not only oxygenate effectively but also to improve ventilatory efficiency and reduce the work of breathing in patients with severe COPD. Results of recent studies indicate that high-flow nasal cannula therapy can benefit some patients with acute hypercapnic respiratory failure, either instead of or in combination with noninvasive ventilation, but more study is needed.
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Noninvasive respiratory support has been a proven intervention for patients with acute respiratory failure. CPAP, noninvasive ventilation, and high-flow nasal cannula have been effectively used to support the respiratory needs of this patient population. ⋯ This paper reviews these factors, along with other issues that may impact tolerance of these devices. By addressing these factors and tailoring the intervention to the needs of the individual patient, the clinician can improve the likelihood of successful management of the respiratory condition in the patient with acute respiratory failure who receives noninvasive respiratory support.