Chest
Volume 133, Issue 5, May 2008, Pages 1275-1286
Journal home page for Chest

Postgraduate Education Corner: Contemporary Reviews in Sleep Medicine
Nocturnal Noninvasive Ventilation

https://doi.org/10.1378/chest.07-1527Get rights and content

Nocturnal noninvasive ventilation (NNV), the provision of ventilatory assistance via a noninvasive interface mainly during sleep, has assumed an important role in the management of chronic hypoventilatory syndromes. This review focuses on recent developments related to the use of NNV to treat various forms of chronic respiratory failure or insufficiency. In the past, NNV has been used mainly to treat respiratory insufficiency in patients with neuromuscular disease (NMD) or chest wall deformity; it should be instituted when these patients have orthopnea or daytime symptoms associated with nocturnal hypoventilation. An emerging application is to treat obesity-hypoventilation syndrome, particularly in continuous positive airway pressure (CPAP) failures. Additionally, it has a role in managing some patients with obstructive sleep apnea who are hypoventilating or find the lower expiratory pressure with bilevel positive pressure ventilators more tolerable than with CPAP alone. NNV to treat severe, stable COPD remains controversial, although a subgroup of patients with hypercapnea and sleep-disordered breathing (SDB) seems most likely to respond favorably. NNV to treat central SDB in patients with congestive heart failure continues to be investigated. Recent findings from a Canadian CPAP trial were disappointing, but preliminary results on a novel adaptive NNV mode are promising.

Section snippets

NNV: Mechanism of Action

Disorders responsive to NNV are characterized by gradually progressive hypoventilation, usually starting with sleep-related hypoventilation. Patients are capable of spontaneous breathing without ventilatory support, but have symptoms such as daytime hypersomnolence, fatigue, and morning headaches that reflect nocturnal hypoventilation and its adverse effects on sleep. Such patients sometimes present with acute exacerbations precipitated by respiratory infections. After an acute hospitalization,

General Approach to the Patient Requiring NNV

Patients at risk for nocturnal hypoventilation are those with underlying NMD, severe kyphoscoliosis or COPD, and obesity hypoventilation. They should be followed up for symptoms of hypoventilation and poor sleep quality, and pulmonary function should be monitored. Elevation of serum bicarbonate may be helpful as an indicator of CO2 retention, but arterial blood gas levels should be determined for confirmation if CO2 retention is suspected. Patients with chronic CO2 retention should always have

Obstructive SDB

CPAP is the most widely applied therapy for OSA, stenting the upper airway and preventing the intermittent collapse that characterizes the syndrome.2 Other possible salutary effects include reflex dilation of upper airway muscles, increased tracheal stretch due to increased lung volume, and reduced upper airway edema.1617 CPAP is effective for the vast majority of OSA cases and, compared to other forms of PAP such as bilevel PAP or autotitrating PAP (APAP), requires less technology (and perhaps

References (99)

  • LegerP et al.

    Nasal intermittent positive pressure ventilation: long term follow-up in patients with severe chronic respiratory insufficiency

    Chest

    (1994)
  • LaubM et al.

    Survival of patients on home mechanical ventilation: a nationwide prospective study

    Respir Med

    (2007)
  • FarreroE et al.

    Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement

    Chest

    (2005)
  • BourkeSC et al.

    Effects of non-invasive ventilation on survival and quality of life in patients with amyotrophic lateral sclerosis: a randomized controlled trial

    Lancet Neurol

    (2006)
  • BachJR

    A comparison of long-term ventilatory support alternatives from the perspective of the patient and care giver

    Chest

    (1993)
  • BachJR et al.

    The ventilator-assisted individual: cost analysis of institutionalization vs rehabilitation and in-home management

    Chest

    (1992)
  • RaphaelJC et al.

    Randomized trial of preventive nasal ventilation in Duchenne muscular dystrophy

    Lancet

    (1994)
  • SimondsAK

    Recent advances in respiratory care for neuromuscular disease

    Chest

    (2006)
  • CrinerGJ et al.

    Efficacy and compliance with noninvasive positive pressure ventilation in patients with chronic respiratory failure

    Chest

    (1999)
  • TuggeyJM et al.

    Titration of non-invasive positive pressure ventilation in chronic respiratory failure

    Respir Med

    (2006)
  • JanssensJP et al.

    Changing patterns in long-term noninvasive ventilation: a 7-year prospective study in the Geneva Lake area

    Chest

    (2003)
  • OlsonAL et al.

    The obesity hypoventilation syndrome

    Am J Med

    (2005)
  • BergerKI et al.

    Obesity hypoventilation syndrome as a spectrum of respiratory disturbances during sleep

    Chest

    (2001)
  • MasaJF et al.

    The obesity hypoventilation syndrome can be treated with noninvasive mechanical ventilation

    Chest

    (2001)
  • Chouri-PontarolloN et al.

    Impaired objective daytime vigilance in obesity-hypoventilation syndrome: impact of noninvasive ventilation

    Chest

    (2007)
  • PiperAJ et al.

    Effect of short-term NIPPV in the treatment of patients with severe obstructive sleep apnea and hypercapnia

    Chest

    (1994)
  • StorreJH et al.

    Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial

    Chest

    (2006)
  • FerrierK et al.

    Sleep-disordered breathing occurs frequently in stable outpatients with congestive heart failure

    Chest

    (2005)
  • ArztM et al.

    Nocturnal continuous positive airway pressure improves ventilatory efficiency during exercise in patients with chronic heart failure

    Chest

    (2005)
  • JohnsonKG et al.

    Bilevel positive airway pressure worsens central apneas during sleep

    Chest

    (2005)
  • Mc CoolFD et al.

    Nonpharmacological airway clearance therapies: ACCP evidence-based clinical practice guidelines

    Chest

    (2006)
  • SanchoJ et al.

    Efficacy of mechanical insufflation-exsufflation in medically stable patients with amyotrophic lateral sclerosis

    Chest

    (2004)
  • MiskeLJ et al.

    Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough

    Chest

    (2004)
  • KerbyGR et al.

    Nocturnal positive pressure ventilation via nasal mask

    Am Rev Respir Dis

    (1987)
  • HillNS

    Noninvasive positive-pressure ventilation

    (2006)
  • HessDR

    Noninvasive ventilation in neuromuscular disease: equipment and application

    Respir Care

    (2006)
  • When should respiratory muscles be exercised?

    Chest

    (1983)
  • HillN

    Noninvasive ventilation: does it work, for whom, and how?

    Am Rev Respir Dis

    (1993)
  • DiazO et al.

    Effects of noninvasive ventilation on lung hyperinflation in stable hypercapnic COPD

    Eur Respir J

    (2002)
  • HillNS et al.

    Efficacy of nocturnal nasal ventilation in patients with restrictive thoracic disease

    Am Rev Respir Dis

    (1992)
  • AnnaneD et al.

    Mechanisms underlying the effects of nocturnal ventilation on daytime blood gases in neuromuscular diseases

    Eur Respir J

    (1999)
  • NickolAN et al.

    Mechanisms of improvement of respiratory failure in patients with restrictive thoracic disease treated with non-invasive ventilation

    Thorax

    (2005)
  • JimenezJFM et al.

    Nasal intermittent positive pressure ventilation: analysis of its withdrawal

    Chest

    (1995)
  • GordonP et al.

    Sleep 7: positive airway pressure therapy for obstructive sleep apnoea/hypopnoea syndrome

    Thorax

    (2005)
  • HirshkowitzM et al.

    Positive airway pressure therapy of OSA

    Semin Respir Crit Care Med

    (2005)
  • KushidaCA et al.

    Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders: an American Academy of Sleep Medicine report

    Sleep

    (2006)
  • Reeves-HocheMK et al.

    Continuous versus bilevel positive airway pressure for obstructive sleep apnea

    Am J Respir Crit Care Med

    (1995)
  • GayPC et al.

    A randomized, double-blind clinical trial comparing continuous positive airway pressure with a novel bilevel pressure system for treatment of obstructive sleep apnea syndrome

    Sleep

    (2004)
  • Cited by (56)

    • Noninvasive Positive Pressure Ventilatory Support Begins During Sleep

      2017, Sleep Medicine Clinics
      Citation Excerpt :

      In the conventional NIV to tracheotomy paradigm, patients with progressive inspiratory muscle dysfunction are referred for polysomnograms to evaluate for SDB and treated with CPAP or low-span bilevel PAP with the least expensive CPAP interfaces and often without giving the patient a choice of interfaces. Some have recommended initiation of bilevel PAP with Pco2 of 45 mm Hg.32 Because Pco2 increases about 4 mm Hg during sleep, Pco2 of 49 to 55 mm Hg has also been proposed as threshold to indicate introduction of sleep bilevel PAP for the NMD population.33,34

    • Effect of arterial puncture on ventilation

      2017, Heart and Lung: Journal of Acute and Critical Care
    • The Respiratory System and Neuromuscular Diseases

      2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
    • The Respiratory System and Chest Wall Diseases

      2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
    • Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: A randomised feasibility trial

      2013, The Lancet Oncology
      Citation Excerpt :

      In specific groups of patients, NIV might improve sleep quality by decreasing the difficulty of breathing and the severity of obstructive sleep apnoea, at least in those patients who do not require endotracheal intubation. We were, therefore, not surprised by our finding that perceived quality of sleep was better in the NIV group than in the oxygen group.32 We estimate that about 400 randomly allocated patients would allow a future randomised trial to detect a clinically meaningful difference in dyspnoea amelioration and morphine use between NIV and oxygen.

    • Intensive Care Unit Ventilators Some Aspects in Noninvasive Mechanical Ventilation

      2022, Teaching Pearls in Noninvasive Mechanical Ventilation: Key Practical Insights
    View all citing articles on Scopus

    The authors have no conflicts of interest to disclose.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text