Abstract
Background
Location
The cost and experience needed to initiate NPPV limit its use to the hospital setting, with some exceptions (see below). Most NPPV use occurs in intensive care units (ICUs) or transitional care (step-down) units, and at some institutions continuous NPPV is not allowed outside of these settings. While the use of NPPV for palliation can occur at home or a hospice facility, it requires adequate nursing, respiratory therapy, and physician support to employ it safely. This can be a practical barrier to its use, and NPPV should not be offered unless one is sure it can be provided appropriately. Ensuring adequate respiratory therapist support is particularly crucial, as they have unique expertise in initiating and troubleshooting the machines. Continuing NPPV for palliation in patients and families who are already comfortable managing home NPPV (e.g., for chronic obstructive pulmonary disease [COPD] or amyotrophic lateral sclerosis [ALS]) can be practical in the home or hospice facility setting, as long as it is consistent with care goals. Initiating NPPV in the home setting for dying patients is impractical and, given how uncertain its real benefits are (see Fast Fact #230), is not advised.
Starting NPPV
Monitoring
Monitoring of pulse oximetry and arterial blood gases are not needed for patients using NPPV only for symptom control. Rather, the effect of NPPV should be assessed based on subjective improvement of dyspnea and decrease in respiratory rate. It is important to reassess patients frequently (looking specifically for respiratory rate, use of accessory muscles, and signs of anxiety), and to ask them if they are comfortable with the NPPV and deriving any benefit from it. Breaks from NPPV to eat, drink, and more freely communicate should be encouraged as much as patients desire.
Contraindications
Contraindications are facial surgery/trauma/deformities that limit placement of the NPPV mask and patients with active nausea and vomiting. Decreased mental status is also considered a contraindication as it increases the risk of aspiration from NPPV.
Discontinuing NPPV
NPPV should be discontinued if it does not provide relief from dyspnea within an hour of the maximally tolerated setting, once a patient is no longer alert, or at any point when it is no longer meeting a patient's goals. If the patient does not tolerate the mask, or feels claustrophobic, a small dose of a benzodiazepine can be administered to alleviate anxiety. If the patient is still uncomfortable, then NPPV should be stopped as it is then not adding to patient comfort. Opioids and benzodiazepines should be used to decrease dyspnea once NPPV is stopped. Remember that NPPV provides ventilatory support to patients and the work of breathing can dramatically increase without it. Be prepared to rapidly control any distressing symptoms, just as you would with discontinuing invasive mechanical ventilation (see Fast Facts #27, 33, 34).
Footnotes
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Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.