Noninvasive Ventilator Devices and Modes

N o n i n v a s i v e Ve n t i l a t o r
D e v i c e s an d M o d e s
Gaurav Singh, MD, MPHa,b, Michelle Cao, DOc,d,*
KEYWORDS
Noninvasive positive pressure ventilation (NIPPV) Home mechanical ventilation Pressure control
Volume-assured pressure support (VAPS) Chronic respiratory failure Hypoventilation
Neuromuscular disease
KEY POINTS
Noninvasive ventilation is increasingly being used to treat patients with chronic respiratory failure,
including neuromuscular diseases, restrictive thoracic disorders, obstructive lung diseases, and
other hypoventilation conditions.
A thorough understanding of advanced respiratory devices and, in particular, modes of ventilation
and other relevant settings aids in managing such patients.
Pressure-limited modes of ventilation such as spontaneous/timed and pressure control are more
commonly used with noninvasive ventilation because of enhanced patient comfort and leak
compensation.
Volume-assured pressure support is a supplementary volume-targeted and pressure-limited func-
tion available on certain devices that maintains a target ventilation by continuously adjusting inspi-
ratory pressure.
Evidence supporting superiority of particular ventilation modes for different diseases is limited, but
spontaneous/timed is commonly used in practice and in studies showing efficacy for relevant clin-
ical outcomes.
INTRODUCTION exponential increase in the number and sophisti-

cation of ventilator devices for home use. This in-
Although domiciliary mechanical ventilation has crease has matched the growing indications for
been implemented in the care of patients with NIPPV, including neuromuscular diseases
chronic respiratory failure (CRF) for nearly a cen- (NMDs), restrictive thoracic disorders, obstructive
tury, initially with negative pressure ventilators lung diseases, and other hypoventilation condi-
and subsequently with positive pressure applied tions. The prevalence of home mechanical ventila-
invasively via tracheostomy, use of noninvasive tion has steadily increased worldwide in the past
positive pressure ventilation (NIPPV) is a modern few decades.8–13 The basis for this evolution in-
paradigm.1 Following the introduction of nasal cludes not only improvements in gas exchange,
continuous positive airway pressure (CPAP) for hospitalizations, mortality, symptoms, quality of
obstructive sleep apnea (OSA),2 the first descrip- life, and health care costs but also patient prefer-
tions of home NIPPV for CRF ensued in the ence and comfort. The growing need for NIPPV
1980s.3–8 Since then, there has been an
a
Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto
Health Care System, 3801 Miranda Avenue, Mail Code 111P, Palo Alto, CA 94304, USA; b Division of Pulmonary,
sleep.theclinics.com
Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, Palo Alto,
CA 94304, USA; c Division of Neuromuscular Medicine, Department of Neurology, Stanford University, 213
Quarry Road, Mail Code 5979, Palo Alto, CA 94304, USA; d Division of Sleep Medicine, Department of Psychi-
atry, Stanford University, 213 Quarry Road, Mail Code 5979, Palo Alto, CA 94304, USA
* Corresponding author. Stanford University, 213 Quarry Road, Mail Code 5979, Palo Alto, CA 94304.
E-mail address: [email protected]
Sleep Med Clin 15 (2020) 545–555

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546 Singh & Cao
necessitates a more comprehensive understand- appropriate than RADs include need for daytime
ing of these devices, including selection of modes use in addition to nocturnal or intermittent use,
of ventilation and additional settings required to requirement for an internal battery in case of po-
effectively and safely care for patients with CRF wer outages, alarms for closer monitoring (ie, res-
in the outpatient setting. piratory rate, minute ventilation, apneas,
This article provides an overview of home NIPPV pressures, leak, and disconnect), and need for
devices and modes. Given the rapidly increasing higher pressures than RADs are capable of sup-
number of manufacturers and devices capable of plying. In addition, ventilators may be indicated
NIPPV, it is beyond the scope of this focused re- for patients with overlap syndrome with alveolar
view to cover specific details of each manufacturer hypoventilation and OSA, where a volume-
or device. The goal is to provide a foundation for targeted mode of ventilation combined with auto-
NIPPV modes, from which practitioners can titrating expiratory PAP (EPAP) feature to maintain
extrapolate applications to various devices. For dynamic upper airway patency.
illustrative purposes, the focus is on 2 common Prior criteria stipulated that RADs were indi-
manufacturers in the United States, Philips Respir- cated in situations in which intermittent and short
onics and ResMed, along with their most current durations of respiratory support were deemed
devices indicated for NIPPV. These manufacturers feasible, with disruption or failure of therapy not
are specifically discussed because they use being immediately life threatening. In contrast,
volume-assured pressure support (VAPS) technol- ventilators were indicated for scenarios in which
ogy in some of their devices. Readers are encour- more continuous or prolonged use was deemed
aged to contact these and other manufacturers necessary, with interruption or failure of therapy
along with durable medical equipment providers placing the patient at risk of serious harm or
to learn more about the specifics of different avail- death.15 Revised CMS criteria for ventilators do
able NIPPV devices. not include such language. Instead, the decision
to use a ventilator is based on the specific circum-
DISTINGUISHING PORTABLE VENTILATORS stances and details of the individual patient’s med-
FROM RESPIRATORY ASSIST DEVICES ical condition. The clinician must ensure there is
sufficient information in the medical record to
It is important to differentiate portable ventilators justify use of a portable ventilator.14 Documenta-
from respiratory assist devices (RADs), because tion should incorporate essential objective and
this has implications for patient care, as well as historical elements, including some, but not
for insurance approval, reimbursement, and health necessarily all, of the following: spirometry, blood
care costs. Although the size and weight of gases showing hypercapnia, exacerbations, ad-
portable ventilators have traditionally exceeded missions, desaturation and dyspnea with activity/
those of RADs, they have progressively become ambulation, prior/current treatments, and tried/
more compact. Likewise, RADs have evolved failed treatments including RADs devices (or an
expanded functionality. Consequently, the differ- explanation indicating that a RAD device would
ences among these devices are increasingly be inappropriate if not tried previously).
becoming blurred.
According to the Centers for Medicare and NONINVASIVE VENTILATION VERSUS
Medicaid Services (CMS), RADs are bilevel posi- INVASIVE VENTILATION
tive airway pressure (PAP) devices that are used
for restrictive thoracic disorders, NMD, chronic Modes of ventilation are similar with regard to
obstructive pulmonary disease (COPD), other invasive ventilation and NIPPV, so the same gen-
hypoventilation conditions, and central sleep ap- eral principles used with invasive ventilation in
nea. Ventilators are indicated for restrictive the intensive care unit setting can be applied in
thoracic disorders, NMD, and CRF consequent the outpatient setting with NIPPV. However,
to severe hypercapnic COPD.14 Thus, there is an some key differences need to be kept in mind
overlap in the medical conditions for which RADs when considering noninvasive ventilation instead
and ventilators can be used, although there is a of invasive mechanical ventilation. NIPPV typically
wide spectrum of disease for the indicated disor- uses a single-limb or passive respiratory circuit.
ders. In general, portable ventilators can be The single-limb tubing connects the ventilator to
considered rather than RADs based on increasing a mouthpiece or a mask interface that is donned
severity of disease, including progressive nature of by the patient. Mask options include nasal pillows,
the ailment, for which more prolonged use and nasal, oronasal or full face, total face, and helmet
closer monitoring may be required. Specific indi- mask. Because NIPPV is designed as an open sys-
cations for which ventilators may be more tem, there is an intentional leak that occurs
Noninvasive Ventilator Devices and Modes 547
through an exhalation port located in the mask ventilation, mandatory breaths are either time trig-
interface or respiratory circuit tubing (ie, venting), gered, or patient triggered. The target or limit var-
which minimizes rebreathing of carbon dioxide iable is typically either volume (ie, tidal volume) or
(CO2). There is also potential for unintentional pressure (ie, inspiratory pressure). With a volume
leak with use of a mask, either around the mask target, the inspiratory pressure is determined by
or caused by mouth opening when using a nasal the mechanics of the lung and chest wall. With a
interface. Intentional leak with an open circuit pressure target, the tidal volume is determined
makes measurements of end-tidal CO2 unreliable, by the compliance of the respiratory system and
although transcutaneous CO2 (TcCO2) can be patient assistance. The cycle or termination vari-
used with improved accuracy.16 Pressure modes able causes cessation of the inspiratory phase
are better at accommodating leak (ie, leak and is determined most commonly by flow or
compensation) compared with volume modes of time, but volume and pressure are also possible.
ventilation.17 Older modes of ventilation remain on these de-
Although a passive circuit may be used with vices, although they are no longer used, such as
invasive ventilation, another option includes controlled ventilation, where mandatory breaths
double-limb or active circuit, consisting of inspira- are time triggered.
tory and expiratory limbs, with the latter being Alternating with the inhalation phase of mechan-
used for elimination of CO2. This closed system al- ical ventilation is an exhalation phase that is gov-
lows better control of leak; more precise moni- erned by an expiratory phase variable referred to
toring of ventilatory parameters, including tidal as EPAP, PEEP, or CPAP, depending on the
volumes and end-tidal CO2; higher and more pre- particular RAD or ventilator and mode of ventila-
cise delivery of the fraction of inspired oxygen; and tion used. This variable is a constant pressure
increased ventilatory capacity. An active dual-limb applied throughout the exhalation phase that
circuit with volume cycled ventilation and a posi- maintains upper airway patency (eg, for OSA or
tive end expiratory pressure (PEEP) of 0 occasion- NMD) and improves oxygenation by recruiting
ally may be used noninvasively in patients with and preventing collapse of alveoli, with both
respiratory muscle weakness, such as NMD.18 mechanisms also permitting adequate ventilation
and elimination of CO2. It also decreases respira-
AVAILABLE DEVICES FOR NONINVASIVE tory work to trigger inspiration in patients with
POSITIVE PRESSURE VENTILATION IN THE intrinsic PEEP (eg, COPD). After inhalation is trig-
OUTPATIENT SETTING gered, the amount of time it takes to transition
from EPAP or PEEP to the target inspiratory PAP
This article focuses on the most current models (IPAP) is called the rise time (the pressurization
from 2 major manufacturers of RADs and home time). The inspiratory time (Ti) is the total amount
ventilators suitable for domiciliary NIPPV, Philips of time spent in the inhalation phase of respiration,
Respironics and ResMed. Table 1 lists such until cycling to the exhalation phase. The clinician
RADs and portable ventilators for ambulatory typically sets the duration of both rise time and Ti
uses, along with available modes of ventilation. based on disease state (eg, shorter for COPD
Ventilator modes and specific differences between and longer for NMD) and patient comfort, and
Philips Respironics and ResMed are discussed rise time can only be a certain fraction of Ti. In
later. addition, the difference between IPAP and EPAP
is the pressure support (PS) or driving pressure,
IMPORTANT/GENERAL SETTINGS/CONCEPTS which is the main factor assisting in ventilation
and elimination of CO2. Caution should be applied
Before a detailed discussion of ventilation modes, to distinguish IPAP and PS, because either may be
a basic understanding of relevant ventilation pa- set as the higher pressure in relation to EPAP,
rameters is informative. Three phase variables in depending on the specific RAD or ventilator.
mechanical ventilation control the inspiratory com-
ponents of a mechanical breath: trigger, target, MODES OF NONINVASIVE VENTILATION
and cycle. The trigger variable determines the initi-
ation of a mechanical breath, which is prompted This article discusses in detail only the commonly
either by the patient (referred to as a spontaneous used pressure-targeted modes, because they are
breath and may be triggered by flow, volume, or used with more regularity compared with
pressure) or ventilator (termed a mandatory volume-targeted modes with NIPPV because of
breath, which is triggered by time). In assisted enhanced patient comfort, patient-ventilator syn-
ventilation, the device augments spontaneous chrony, and leak compensation with the former.17
patient-triggered breathing. In assist/control (AC) These modes are all fundamentally bilevel forms of
548 Singh & Cao
Table 1
Common respiratory assist devices, portable ventilators, and modes of ventilation
Mode of Ventilation
Device Pressure Modes Volume Modes Hybrid/Additive Modes
RADs
Philips Respironics CPAP, S, ST NA NA
Dream Station
BiPAP ST
Philips Respironics CPAP, S, ST, PC NA NA
Dream Station
BiPAP-AVAPS
ResMed AirCurve CPAP, S, ST, T NA NA
10 ST
ResMed AirCurve CPAP, S, ST, T NA iVAPS
10 ST-A
ResMed Stellar CPAP, S, ST, T, PAC NA iVAPS
100/150
Portable Ventilators
Philips Respironics CPAP, S, ST, T, PC, AC, SIMV, VC, AC-MPV AVAPS, AVAPS-AE
Trilogy 100 PC-SIMV, PC-MPV
Philips Respironics CPAP, PSV, ST, SIMV-PC, AC-VC, SIMV-VC, MPV-VC AVAPS, AVAPS-AE
Trilogy Evo AC-PC, MPV-PC
ResMed Astral CPAP, ST, PAC, PAVC, AVC, V-SIMV, MPV:AVC iVAPS
100/150 P-SIMV, PS, MPV:PAVC, Auto-EPAP
MPV:PS/SVt
Abbreviations: AC, assist control; AVAPS, average VAPS; AVC, volume control assist control; BiPAP, bilevel positive airway
pressure; iVAPS, intelligent VAPS; MPV, mouthpiece ventilation; NA, not available; P, pressure; PAC, pressure control assist
control; PAVC, pressure-assist volume control; PC, pressure control; PS, pressure support; PSV, pressure support ventilation;
S, spontaneous; SIMV, synchronized intermittent mandatory ventilation; ST, spontaneous/timed; SVt, safety tidal volume;
T, timed; V, volume; VC, volume control.
ventilation (Table 2). Other modes are mentioned manufacturers may still use a Ti minimum and Ti
briefly for completeness, including volume modes, maximum with S mode (discussed later).
which are more commonly used with invasive
ventilation. Spontaneous/Timed Mode
Similar to S mode, inspiratory effort by the patient
Spontaneous Mode
initiates a ventilator-assisted breath that in-
Spontaneous (S) mode is the simplest mode on creases the pressure from EPAP to IPAP at a
bilevel PAP. Inspiratory effort by the patient initi- rate determined by the rise time, with flow cycling
ates a ventilator-assisted breath that increases back to EPAP. In contrast with S mode, ST mode
the pressure from EPAP to IPAP at a rate deter- ensures delivery of mandatory, timed breaths by
mined by the rise time, with flow cycling back to the device if the patient’s spontaneous respira-
EPAP. There is no backup respiratory rate in the tory rate decreases below a set backup rate. In
event that the patient’s spontaneous respiration this case, the rise time determines the rate at
decreases. IPAP and EPAP are fixed pressures which the pressure increases from EPAP to
and therefore tidal volume is variable breath by IPAP, but the Ti controls the duration of time
breath. Although considered a noninvasive ventila- spent at IPAP, before cycling back to EPAP.
tory mode, without the backup respiratory rate, it There are some relevant functional differences
is not recommended for patients with chronic res- in Ti for different manufacturers in the ST mode
piratory insufficiency or failure, or for patients in (discussed later). The purpose of the ST mode is
whom control of ventilation is recommended. S to ensure a minimum number of breaths per min-
mode is similar to S/timed (T) mode without the ute (ie, minute ventilation) if a patient is unable to
backup rate or a fixed Ti, although some do so spontaneously.
Table 2
Settings for common pressure modes of ventilation used with noninvasive positive pressure
ventilation devices
Philips Respironics ResMed

S EPAP, IPAP, rise time EPAP, IPAP, rise time, Ti min, Ti
max
ST EPAP, IPAP, rise time, Ti, BUR EPAP, IPAP, rise time, Ti min, Ti
max, BUR
PC EPAP, IPAP, rise time, Ti, BUR EPAP, IPAP, rise time, Ti, BUR
VAPS Vt, EPAP, IPAP min, IPAP max, Va, EPAP, PS min, PS max, rise
rise time, Ti, BUR, AVAPS time, Ti min, Ti max, BUR
rate
VAPS-AE Vt, EPAP min, EPAP max, IPAP Va, EPAP min, EPAP max, PS
min, IPAP max, rise time, Ti, min, PS max, rise time, Ti
BUR, AVAPS rate min, Ti max, BUR
Abbreviations: AVAPS, average volume-assured pressure support; BUR, backup rate; max, maximum; min, minimum; Ti,
inspiratory time; Va, alveolar ventilation; Vt, tidal volume.
Pressure Control Mode manufacturer. Therefore, typically a flow, pres-

sure, or time trigger increases pressure from a
When used with NIPPV devices, pressure control
fixed EPAP to an inspiratory pressure between a
(PC) mode is similar to ST mode, with the excep-
set IPAP or PS minimum and IPAP or PS
tion being that the set Ti is applied to every deliv-
maximum, with rise time and Ti elements deter-
ered breath, whether triggered spontaneously by
mined by the underlying pressure-limited mode.
the patient or mandatory and timed by the de-
The IPAP or PS constantly adjust within the set
vice. Consequently, the length of inhalation
range to achieve targeted ventilation goals. Similar
phase is consistent, and the cycle variable is
to ST and PC modes, a backup rate may be used
time rather than flow. The advantage of PC
with VAPS. The unique advantage of VAPS is
compared with ST mode is ensuring a guaran-
ensuring at least a minimum target ventilation
teed Ti with every breath and thus relatively con-
with the minimum necessary inspiratory pressure
stant tidal volume from breath to breath, which
needed, regardless of lung compliance, airway
may better support patients who do not have
resistance, or patient dyssynchrony.
adequate respiratory muscle strength to
generate sufficient Ti and hence tidal volume
on their own (ie, NMD). Disadvantages of a fixed
Auto-Expiratory Positive Airway Pressure
Ti with every breath include air trapping in those
prone to it (ie, COPD), and patient-ventilator dys- The feature that autotitrating EPAP (AE) provides in
synchrony if Ti is set shorter or longer than the addition to VAPS is an automatically titratable
patient’s desired Ti. EPAP. An EPAP minimum and EPAP maximum
are programmed with proactive pressure adjust-
ments to maintain upper airway patency. This
Volume-Assured Pressure Support
method may be beneficial in hypercapnic patients
Although sometimes classified as a hybrid mode with CRF with concomitant OSA, such as individ-
of ventilation because it incorporates features of uals with overlap syndrome and obesity hypoven-
both volume and pressure ventilation, VAPS is tilation syndrome (OHS). However, patients with
more precisely described as a supplementary restrictive lung disease or weakness, as with
volume-targeted and pressure-limited function. NMD, may not tolerate AE because of sensitivity
This feature is available with some RADs or venti- to pressure variations and potential for glottis
lators only when using a passive circuit and S, ST, closure.17 AE may avoid the need to obtain
T, or PC modes (ie, exclusive to pressure-limited, laboratory-based polysomnography to titrate
open ventilation). Rather than using a fixed IPAP EPAP or to gradually titrate it in the outpatient
with these modes of ventilation, addition of VAPS setting. Another advantage is ensuring adequate
allows an IPAP or PS range to be programmed, but comfortable pressures to maintain upper
with the goal of achieving a specific tidal volume airway patency in various sleep positions and
or alveolar ventilation, depending on the stages.
550 Singh & Cao
Mouthpiece Ventilation PS or PS ventilation (PSV) may be identical to S

mode, but it can also be used with a guaranteed
Mouthpiece ventilation (MPV) is a strictly daytime
tidal volume.
mode of noninvasive ventilation. It is exclusively
T mode is a pressure-limited and time-cycled
available on various portable ventilators, and not
modality that uses a fixed respiratory rate and Ti,
available on RADs. MPV has been best used in
with spontaneous breaths not being supported.
neuromuscular disease, in particular Duchenne
This mode is uncommonly used in clinical practice,
muscular dystrophy. Its application has been
because it is uncomfortable in awake, spontane-
shown to successfully avoid or delay tracheos-
ously breathing patients.
tomy in patients with progressive respiratory fail-
AC uses a set respiratory rate, Ti, and either a
ure by improving respiratory mechanics and
pressure limit (ie, PC-AC) or volume limit, which
hypercapnia.19,20 In contrast with nocturnal modes
is termed volume control (VC; used with AC it is
of NIPPV, which deliver continuous airflow by
VC-AC). As opposed to T mode, additional
mask interface, MPV is an on-demand or intermit-
patient-triggered breaths are permitted and are
tent mode of ventilation and allows patient auton-
identical to mandatory breaths (ie, supplying the
omy, whereby the patient initiates a breath
set volume or pressure).
supported by the device when the patient feels
Synchronized intermittent mandatory ventilation
that additional ventilatory support is needed.
(SIMV) is similar to AC, but mandatory breaths are
MPV uses a plastic mouthpiece rather than a
synchronized with the patient’s inspiratory effort,
mask interface. Unlike daytime nasal ventilation,
and additional breaths are generally assisted
the mouthpiece allows the face to be free from a
spontaneous breaths that are pressure supported
mask interface, and the patient may engage in ver-
(ie, tidal volume determined by patient effort and
bal communication as long as speech is not signif-
lung mechanics). The mandatory breaths with
icantly impaired (ie, severe bulbar weakness). MPV
SIMV may be pressure limited (ie, SIMV-PC) or vol-
also allows breath staking as a means of lung vol-
ume limited (ie, SIMV-VC).
ume recruitment in neuromuscular disease. MPV
can be used with pressure (PC) or volume modes
(AC), and can be programmed to timed inspiration, IMPORTANT DIFFERENCES BETWEEN PHILIPS
or on-demand ventilation in which the patient initi- RESPIRONICS AND ResMed
ates the breath as much or as little as needed per It is important to highlight some key differences
patient’s preference. In general, the inspiratory pertinent to ventilation settings among the manu-
pressure is titrated to deliver about 2 to 3 times a facturers, current devices, and primary modes dis-
normal tidal volume if set in PC mode, or, if in AC cussed earlier.
mode, the determined volume is programmed.
Inspiratory time can be used to ensure a full inha- Rise Time and Inspiratory Time
lation cycle before spontaneous exhalation. MPV
on Philips Respironics home ventilator is called Philips Respironics uses a single-digit numerical
kiss trigger, in which inspiratory airflow is delivered scale for rise time (the lower the setting, the shorter
when the patient’s lip touches the mouthpiece. the rise time), whereas ResMed uses absolute
MPV is an on-demand mode and inspiratory effort values in milliseconds. Philips Respironics uses a
is not required to deliver a breath. Similarly, MPV fixed, programmed Ti for only mandatory breaths
on ResMed home ventilator is called touch trigger, in ST mode and all delivered breaths (ie, manda-
where engagement of the mouthpiece by the pa- tory and spontaneous) in PC mode, including
tient’s lip triggers the device to deliver a breath. with the VAPS feature activated (the new Trilogy
In both devices, patient effort is not required to Evo by Philips is an exception that can use a min-
initiate a breath, but initiation is triggered by kiss- imum and maximum Ti). This manufacturer does
ing or touching the mouthpiece. not provide Ti for S mode. ResMed uses a Ti range
(ie, Ti minimum and Ti maximum) for S and ST
Other Modes modes, including with its VAPS feature. Therefore,
inhalation cannot cease before Ti minimum, nor
CPAP is a constant pressure applied throughout the
can it persist for longer than Ti maximum. ResMed
respiratory cycle, both during inspiration and expira-
uses a fixed Ti with T and PC modes.
tion. It is rarely used for CRF, because it does not
assist in ventilation, and it is more appropriate for
Trigger and Cycle Sensitivity
OSA (a sleep-related upper airway patency disor-
der). It is important not to confuse OSA or use the Philips Respironics RADs do not have the ability to
term loosely with conditions causing hypercapnic program trigger or cycle sensitivity, because these
respiratory insufficiency or failure. functions are automated (ie, Digital Auto-Trak).
The portable ventilators from this manufacturer do SELECTING APPROPRIATE NONINVASIVE

have an adjustable flow trigger using absolute POSITIVE PRESSURE VENTILATION MODE
values in liters per minute or Auto-Trak (with 2 BASED ON DISEASE STATE
different sensitivity options). The Philips Respir-
onics ventilators also have a flow cycle sensitivity There is limited evidence available to guide the se-
based on percentage of peak inspiratory flow. lection of optimal noninvasive mode for various
ResMed RADs use a qualitative measure for both disease states. Most available data suggest that
trigger and cycle sensitivity, ranging from very there are no differences in relevant outcomes,
low to very high (the higher the setting, the more particularly between volume and pressures modes
readily triggering and cycling occur). ResMed ven- of ventilation,21 as well as with use of VAPS
tilators have an adjustable flow trigger using abso- compared with traditional fixed pressure
lute values in liters per minute, and there is also a modes.22,23 Factors that should be considered
flow cycle sensitivity based on percentage of include patient comfort, patient-ventilator syn-
peak inspiratory flow. chrony, maintenance of CO2 levels within an
appropriate range, and avoidance of harm. The
most recent and best available evidence for venti-
Volume-Assured Pressure Support lation modes and relevant clinical outcomes based
Both Philips Respironics and ResMed devices on randomized controlled trials (RCTs), meta-
have VAPS functionality on some RADs, along analyses, and society guidelines are discussed
with the option of AE on the ventilators, but there next.
are some notable differences between the manu-
facturers. Philips Respironics uses average VAPS
Neuromuscular Diseases and Restrictive
(AVAPS) to achieve a target tidal volume by
Thoracic Disorders
adjusting inspiratory pressure between a set
IPAP minimum and IPAP maximum. AVAPS is a Most of the evidence for NIPPV for NMD is derived
PS function that can be activated on the primary from studies investigating its effects on patients
modes discussed earlier and it is not a stand- with amyotrophic lateral sclerosis (ALS). Even so,
alone mode (with the exception of AVAPS-AE, a data from RCTs are limited, with the most robust
stand-alone mode on the Philips Trilogy venti- study being published nearly 15 years ago. This
lator). ResMed uses intelligent volume-assured study by Bourke and colleagues24 showed a sur-
PS (iVAPS) to target alveolar ventilation (ie, vival benefit and improvement in quality-of-life
excluding anatomic dead space), which is deter- measures with use of NIPPV in patients with ALS
mined by patient height and thus ideal body without severe bulbar weakness. The mode of
weight, by adjusting PS between PS minimum ventilation used in this study was ST. Guidelines
and PS maximum. The rapidity by which the for management of Duchenne muscular dystrophy
IPAP changes on Philips Respironics devices is advocate using devices with a backup rate to pre-
determined by the AVAPS rate, which has a nu- vent apneas.25 As such, the most commonly used
merical range (the higher the rate, the greater mode of ventilation for NMD is ST. However, use of
the change in IPAP) and can be set based on dis- PC or VAPS with either ST or PC modes may alter-
ease state. ResMed devices do not have an natively be used, although evidence is limited.
equivalent feature. Regarding backup respiratory Retrospective data have been published that a
rate, Philips Respironics is capable of using either sufficient Ti time with extended Ti minimum can
a set rate or automatic rate, which is 2 breaths/ be beneficial in ALS.26
min less than the average of the patient’s most Similar to NMD, rigorous evidence evaluating
recent spontaneous respiratory rate. ResMed’s the efficacy of NIPPV for restrictive thoracic disor-
intelligent backup rate targets the patient’s spon- ders is sparse. A meta-analysis of small clinical tri-
taneous respiratory rate and automatically ad- als that included 6 studies with at least some
justs the backup rate based on whether the participants having chest wall deformities (ie,
patient is breathing less often than two-thirds of kyphoscoliosis, postpoliomyelitis, and thoraco-
the targeted spontaneous respiratory rate or is plasty) evaluated the effect of NIPPV on various
apneic (in which case it is the set rate) versus outcome measures, including gas exchange,
effectively triggering (in which case it is two- lung function, sleep parameters, and tolerance of
thirds the set rate). Thus, the backup rate is not PAP.27 Although there was significant heterogene-
activated until the patient’s respiratory rate de- ity, outcomes were not significantly different in
creases below two-thirds of the targeted studies comparing volume with pressure modes
threshold, thereby maintaining spontaneous of ventilation. All these studies used the ST mode
triggering. for NIPPV. As with NMD, PC or VAPS with either
552 Singh & Cao
ST or PC modes may be acceptable alternatives, E. Orr and colleagues’ article, “Management of

but, again, data are sparse. Chronic Respiratory Failure in Chronic
Obstructive Pulmonary Disease: High-Intensity
and Low-Intensity Ventilation,” in this issue.
Chronic Obstructive Pulmonary Disease
In prior decades, the evidence regarding efficacy
of NIPPV for COPD has been conflicting but mostly Obesity Hypoventilation Syndrome
unsupportive of any benefits.28,29 However, more Recent guidelines recommend using CPAP
recent RCTs using high-intensity PS with the spe- rather than NIPPV as the initial PAP modality of
cific goal of reducing the arterial partial pressure of choice during sleep in stable outpatients with
CO2 (PaCO2) in chronically hypercapnic patients OHS and concomitant severe OSA (ie, apnea
with COPD have shown improvement in survival30 hypopnea index 30 events/h).34 These recom-
and hospital readmissions.31 Both of these studies mendations, which are derived to a great extent
used high PS (ie, approximate EPAP of 4–5 cm from Pickwick Study results,34 are based on lack
H2O and IPAP of 22–24 cm H2O) as well as high of significant, consistent, sustained differences
backup rates (ie, about 14–16 breaths/min) to in adherence, sleepiness, health-related quality-
maintain control of patient ventilation and achieve of-life measures, exercise capacity, waking gas
significant reductions in CO2 levels. Therefore, the exchange, cardiovascular events, and mortality
ST mode of ventilation using high-intensity PS between CPAP and NIPPV. However, CPAP
showed improvements in clinically meaningful out- may be less effective in patients with less severe
comes among patients with COPD with compen- OSA, advanced age, worse lung function, and
sated hypercapnic respiratory failure. A small more pronounced ventilatory failure on presenta-
randomized crossover trial comparing high- tion. Accordingly, patients who are hospitalized
intensity (high pressure, high backup rate) with with respiratory failure thought to be caused by
high-pressure (high pressure, low backup rate) OHS should be discharged with NIPPV for at
NIPPV did not show superiority with a high- least 3 months, followed by further diagnostic
intensity rather than high-pressure strategy with testing and sleep laboratory–based PAP titration
regard to treatment compliance, gas exchange, in the outpatient setting. Optimal NIPPV settings
or sleep quality.32 Although sample size was small, are uncertain and should be the same as those
it raises the question of whether high-pressure used during hospitalization.35
NIPPV may be as effective as high-intensity NIPPV NIPPV can also be considered for CPAP failure
in improving ventilatory and clinical end points. In (ie, worsening hypercapnia or persistent hypox-
the United States, initial coverage for hypercapnic emia despite use of CPAP). Studies comparing
COPD starts with a bilevel PAP device in S mode ST with VAPS, including with AE, do not show sig-
(no backup rate). A backup rate device is nificant differences in gas exchange, quality-of-life
approved if the provider can provide supportive measures, or sleep quality.36,37 OHS is discussed
evidence that hypoventilation or nocturnal hypox- in detail in Roop Kaw and Marta Kaminska’s
emia (requires facility-based polysomnogram or article, “Obesity Hypoventilation: Traditional
home sleep study on bilevel PAP in S mode) per- Versus Nontraditional Populations,” in this issue.
sisted despite treatment with bilevel PAP in S
mode. This policy precludes implementation of
high-intensity NIPPV as the initial treatment INITIAL SETTINGS AND TITRATION
approach.
Although use of VAPS may provide minor Table 3 provides general recommended modes
improvement in CO2 reduction compared with and settings for different disorders. Note that pol-
conventional fixed pressure modes, enhance- ysomnography is not required for management of
ments in adherence, tolerance, comfort, quality- these conditions or for prescription of a RAD or
of-life measures, or sleep quality have been com- ventilator, but it may help with titration of settings.
parable. Because of the lack of certainty about Alternatively, titration can be accomplished in the
the effects of the newer hybrid modes, heteroge- outpatient setting by analyzing device down-
neity across studies for algorithms and brands of loads, TcCO2, blood gases analysis, and serum
devices, and potential for leak causing inaccuracy bicarbonate levels. This S/T may be necessary
in measurements of tidal volume and thus resulting for patients with limited mobility, such as those
in hypoventilation, recent guidelines advocate us- with NMD, and there are studies showing the
ing a fixed PS as the initial choice of ventilation feasibility of this practice in patients with NMD,
mode among patients with COPD requiring home restrictive thoracic disorder, OHS,38 as well as
NIPPV.33 COPD is discussed in detail in Jeremy COPD.39
Table 3
General recommended settings based on disease state
NMD, Restrictive
Setting Thoracic Disorders Hypercapnic COPD OHS with CPAP Failure
Mode ST, PC, VAPS ST S or ST
EPAP Low (4–6 cm H2O) Low (4–6 cm H2O) Medium-high (7 cm H2O, or
minimum EPAP needed to
maintain upper airway
patency)
Auto-EPAP No Optional Optional
IPAP/PS or Vt IPAP minimum IPAP 18 cm H2O or PS 15 IPAP 10 cm H2O or PS 10
5 more than
EPAP
PS 10
Vt 6–8 mL/kg
(ideal body
weight)
Rise time Medium or slow Fast Medium or slow
Ti 1.0–1.5 s 0.5–1.0 s 1.0–2.0 s
BUR 12–14 breaths/min 12–18 breaths/min Optional (12–14 breaths/min)
AVAPS rate Medium or fast Medium Medium or fast
Trigger High Medium Medium
sensitivity
Cycle Low High Medium
sensitivity
SUMMARY home mechanical ventilation. Am J Respir Crit

Care Med 2017;195(9):1140–9.
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The authors have no financial conflicts of interest. tive pressure ventilation via nasal access in the man-
agement of respiratory insufficiency. Chest 1987;
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Noninvasive Ventilator Devices and Modes

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Noninvasive Ventilator Devices and Modes

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N o n i n v a s i v e Ve n t i l a t o r

INTRODUCTION exponential increase in the number and sophisti-

Sleep Med Clin 15 (2020) 545–555

Philips Respironics ResMed

Pressure Control Mode manufacturer. Therefore, typically a flow, pres-

Mouthpiece Ventilation PS or PS ventilation (PSV) may be identical to S

The portable ventilators from this manufacturer do SELECTING APPROPRIATE NONINVASIVE

ST or PC modes may be acceptable alternatives, E. Orr and colleagues’ article, “Management of

SUMMARY home mechanical ventilation. Am J Respir Crit

ventilation by nasal or oral-nasal interface. Am J syndromes: an advance in-home ventilation or just

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