Circumstances and Indications for Noninvasive Positive Pressure Ventilation

In clinical practice, NIPPV is initiated either electively or in the context of acute ven-tilatory failure initially treated invasively with translaryngeal intubation or nonin-vasively with facial interfaces (61). In the latter circumstances, the long-term necessity for NIPPV should be re-evaluated after weeks or months during follow-up since the indications for NIPPV may change as the clinical conditions improve or not. In cases of chronic and stable awake hypoventilation, the cornerstone to foresee use of NIPPV is an advanced severity with clinical symptoms of hypoventilation plus a balance of several other issues: (i) the main primary process explaining the hypoventilation: mechanical or lung deficit; (ii) the natural rate of progression appreciated as a few years or dozens of years; (iii) the clinical severity at the time of decision-making: actual symptoms and history of acute-subacute failure in the previous months; and (iv) the patient's willingness, including the family and social environment, to undertake this therapy. Indications are outlined in Table 3. NIPPV is strongly indicated in patients with chest-wall and neuromuscular disorders in the presence of clinical symptoms attributable to diurnal hypoventilation (18,62-67). There are no validated values above which NIPPV is definitely indicated; however,

TABLE 3 Typical Indications for Nocturnal Noninvasive Positive Pressure Ventilation According to Disease Process and Severity
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