Protocol for initiation of noninvasive positive pressure ventilation in patients with neuromuscular and chest wall disease in the chronic setting

IPAP: inspiratory pressure; EPAP: maximum expiratory pressure; bpm: breaths per minute; Vt: tital volume; PEEP: positive end-expiratory pressure; IPAP_min: minimum inspiratory pressure; IBW: ideal body weight; IPAP_max: maximum inspiratory pressure; ms: millisecond; ABG: arterial blood gas; AVAPS: average volume assured pressure support; IVAPS: intelligent volume assured pressure support; NIV: noninvasive ventilation.
* The initial trial of noninvasive nocturnal ventilatory support is often conducted at home by a respiratory therapist employed by a home medical equipment company, but can also occur in an outpatient office setting, in a sleep laboratory, or during a hospital admission depending on the patient's acuity of illness, facility and confidence with adapting to new equipment, and patient/caregiver preferences. Arterial blood gas analysis has typically been done in advance. If not, one should be obtained prior to initiation of noninvasive ventilation. Obtain baseline vital signs if in a monitored location and the patient is typically fitted with a peripheral pulse oximeter regardless of the location.
¶ Masks can be nasal, oronasal, full face, or occasionally oral. Selection of mask should be individualized, and is dependent upon factors including patient comfort, mask availability, and the patients' or caregivers' ability to remove the mask quickly if there is a potential for aspiration. Finding a comfortable mask is of paramount importance.
Δ The ventilator type is typically preselected but in monitored settings may be changed if intolerance is noted during the trial of NIV. Selection is usually dependent upon the patient's underlying medical disorder and comorbidities (eg, obstructive sleep apnea or obesity) and clinician experience. Most ventilators provide warmed humidified flow (air or oxygen) or a humidifier can be supplied.
◊ The settings below can be used for both average and intelligent-volume assured pressure support (AVAPS, IVAPS) devices. However, IVAPS devices require adjustment in trigger sensitivity and end of cycle sensitivity.
§ Although a tidal volume of 8 mL/kg is chosen as the goal, this may vary with patient tolerance (eg, patients with neuromuscular disease may prefer lower initial volumes).
¥ Since some diseases progress more rapidly than others over time (eg, amyotrophic lateral sclerosis) pressure increases may be needed to maintain the desired tidal volume.
‡ Patients with obstructive sleep apnea may require higher EPAP which may need to be determined in the sleep lab.
† The rise time often varies with patient comfort and is generally slower in restrictive diseases versus obstructive diseases.