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Is It Safe for Patients With Chronic Hypercapnic Respiratory Failure Undergoing Home Noninvasive Ventilation To Discontinue Ventilation Briefly?^*

^* From the Department of Pulmonary and Critical Care Medicine (Dr. Karakurt), Marmara University, Istanbul, Turkey; the Division of Pneumology (Dr. Fanfulla), Fondazione S. Maugeri, Istituto Recovero e Cura a Corattere Scientifico, Centro Medico di Montescano, Italy; and the Respiratory Intensive Care Unit (Dr. Nava), Fondazione S. Maugeri, Istituto Recovero e Cura a Corattere Scientifico, Centro Medico di Pavia, Italy.

Correspondence to: Stefano Nava, MD, Respiratory Intensive Care Unit, Centro Medico di Pavia, Fondazione S. Maugeri, Via Ferrata 8, 27100 Pavia, Italy; e-mail: snava{at}fsm.it

Study objectives: A brief discontinuation (< 1 week) of long-term ventilation may be necessary in patients who are not totally ventilator-dependent in cases of technical problems, intolerable nasal irritation, upper airway congestion, or travel. We examined the incidence, timing, and causes of possible clinical deterioration after a brief withdrawal of ventilation in patients with chronic respiratory failure (CRF) who were well-established on long-term noninvasive mechanical ventilation (NIMV).

Study design: Prospective clinical study.

Patients: Eleven inpatients in clinically stable condition (COPD, 6 patients; and restrictive thoracic disease [RTD], 5 patients) who had severe CRF (PaCO₂, > 50 mm Hg) and had been receiving NIMV for (mean ± SD) 19.3 ± 5.3 months were enrolled.

Interventions and measurements: Arterial blood gas (ABG) levels, maximal inspiratory pressure (PImax), breathing pattern, dyspnea rating, and life symptoms (measured by a questionnaire) were recorded daily after NIMV withdrawal for 6 days or until the patients showed clinical and/or ABG level deterioration. Pulmonary function tests were performed and neuromuscular drive was measured at the beginning and the end of the study.

Results: Five of the 11 patients (45.4%) [COPD, 3 patients; and RTD, 2 patients] were reconnected to a ventilator before the scheduled time because of ABG level deterioration. Despite these changes, none of the patients reported severe worsening of symptoms or other medical complications. The patients whose ABG levels worsened had statistically significant decreases in tidal volume and PImax, suggesting that the development of alveolar hypoventilation was related to respiratory muscle weakness.

Conclusions: A brief discontinuation of NIMV in patients who were affected by chronic hypercapnic respiratory failure and were well-established on NIMV is associated with a relatively high incidence of ABG level worsening due to the development of alveolar hypoventilation. If NIMV must be briefly interrupted for clinical reasons, the patient should be monitored closely for abrupt worsening, and prompt technical intervention should be provided if a ventilator fails.

Key Words: COPD • hypoventilation • noninvasive mechanical ventilation • respiratory insufficiency • restrictive thoracic disease • ventilator failure

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