Chest
Volume 99, Issue 2, February 1991, Pages 408-415
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Clinical Investigations
Influence of Noninvasive Positive Pressure Ventilation on Inspiratory Muscles

https://doi.org/10.1378/chest.99.2.408Get rights and content

Intermittent positive pressure ventilation reduces inspiratory muscle electromyographic activity among patients with restrictive ventilatory failure. It has therefore been suggested that the reduction of energy expenditure at night could result in improved inspiratory muscle function during the day. Reported successes with nocturnal ventilation have not included measurements of inspiratory muscle endurance. We therefore electively ventilated six (five female, one male) patients (mean ± SD) aged 36 ± 13 years in whom respiratory failure (room air PaCO2, 60 ± 13 mm Hg; PaO2, 44 ± 11 mm Hg; SaO2, 75 ± 12 percent) was consequent on restrictive ventilatory disease (vital capacity, 25 ± 7 percent predicted; FEV1/FVC, 81 ± 12 ercent; total lung capacity, 40 ± 5 percent predicted; MIPRV −42 ± 10 cm H2O; MEP, 81 ± 28 cm H2O). Positive pressure ventilation was administered with a customized closely fitting nasal mask attached to a volume-cycled pressure-limited ventilator. Full respiratory Polysomnographic measurements as well as arterial blood gases, pulmonary function, distance walked in six minutes, and inspiratory muscle endurance were measured at baseline and after 3 and 14 months of ventilation. Ventilation improved saturation (baseline on O2; SWS 87 ± 10, REM 79 ± 14, ventilator on R/A; SWS 90 ± 6, REM 89 ± 5 percent) and transcutaneous Pco2 (baseline on O2; SWS 85 ± 26, REM 94 ± 39, ventilator on R/A; SWS 53 ± 9, REM 58 ± 9 mm Hg). During ventilation, the quantity and distribution of sleep was similar to that observed prior to ventilation. Daytime gas exchange improved as did the six-minute walking test (initial test = 429 ± 120 m, three months after ventilation = 567 ± 121 m), both of these improvements being sustained at 14 months. Inspiratory muscle endurance measured using a pressure threshold load (mean mouth pressure = 45 percent MIPRV) improved from 7.1 ± 3.4 minutes at baseline to 14.8 ± 7.6 minutes at 3 months, an improvement sustained at 14 months. There was no change in measured lung volumes or respiratory muscle strength. We conclude that the improvement in nocturnal gas exchange, daytime functioning, and arterial blood gases resulting from nocturnal positive pressure ventilation is associated with an increase in inspiratory muscle endurance sustained at 14 months.

Section snippets

PATIENTS AND METHODS

Six patients (five female, one male) with respiratory failure consequent upon restrictive ventilatory disease consented to the study. Four patients had idiopathic thoracic restrictive disease (kyphoscoliosis), one patient had postpolio kyphoscoliosis, and one patient had neuromuscular disease associated with a peripheral neuropathy of undetermined origin. All patients had required acute ventilatory support on one or more previous occasions. They had received close clinical supervision for a

RESULTS

Each of the subjects had respiratory failure (mean ± SD: PaCO2, 60 ± 13 mm Hg; PaO2, 43 ± 11 mm Hg; SaO2 75 ± 12 percent) consequent on restrictive ventilatory disease with a reduced vital capacity (VC) and total lung capacity and flow rates appropriate to the observed lung volumes (Table 1). Maximum inspiratory pressures at residual volume and functional residual capacity were reduced as was maximum expiratory pressure and maximum voluntary ventilation (Table 2). Although subjects received

DISCUSSION

Long-term nocturnal mechanical ventilation in patients with restrictive respiratory failure will prevent the nocturnal worsening of their gas exchange and improve their daytime ABG values. Intermittent positive pressure breathing through a closely fitting nasal mask is an effective way to assist ventilation among this population. Despite the mask and associated straps, the quantity and distribution of sleep in our experience is no worse than that measured on the initial night prior to

ACKNOWLEDGMENT

This study was supported by a grant from The Physicians' Services Incorporated Foundation. The authors acknowledge, with appreciation, the technical support provided by J. Popkin and R. Rutherford in carrying out the sleep studies. The authors acknowledge the assistance of D. Mills in preparing this manuscript.

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