ABSTRACT
M ech a n ica l V e n tila tio n Endotracheal intubation should be performed in patients with severe respiratory failure. Specific indications are listed in Table 9. Unfortunately, intubation is associated with a number of complications, including laryngeal and tracheal injury, barotrauma, and nosoco mial pneumonia!. In addition, although most patients are successfully extubated, a small minority will develop prolonged ventilator dependence. Recently, NIPPV, using devices that allow the independent selection of inspiratory (IPAP) and expiratory (EPAP) positive airway pressure (e.g., BiPAP), has been shown to significantly reduce the eventual need for endotracheal intubation in patients with milder forms of respiratory failure. By preventing intubation, NIPPV also decreases hospital stay, the overall rate of complications, and patient mortality; it has become an important adjunct to the therapy of patients with decom pensated COPD. NIPPV should be initiated at an IPAP of 10 cmH20 and an EPAP of 2.5 to 5.0 cmH20 via a nasal mask. The IPAP is then gradually increased as needed based on arterial blood-gas measurements and clinical evidence of persistent respiratory distress. Supplemental oxygen is added via a mask port and adjusted to maintain Sa02 greater than 90%. An oronasal face mask is substituted when excessive air leakage occurs through the mouth. Initially, patients are maintained on continuous NIPPV with only short breaks for conversation and meals. As the patient’s respiratory status improves, daily duration is gradually decreased until ventilatory support is no longer needed. Endotracheal intubation is required when patients fail to improve or worsen despite NIPPV.
