INVITED REVIEW SERIES:

NON-INVASIVE VENTILATION
SERIES EDITORS: AMANDA PIPER AND CHUNG-MING CHU

Non-invasive ventilation: Essential requirements and clinical skills

for successful practice
MARK W. ELLIOTT

Department of Respiratory Medicine, St James’s University Hospital, Leeds, UK

ABSTRACT raised about the way that NIV is delivered in routine

Audits and case reviews of the acute delivery of non- practice. In a 2008 national audit of the acute care,
invasive ventilation (NIV) have shown that the results including NIV, of patients admitted to hospital with
achieved in real life often fall short of those achieved in AECOPD,3 a total of 232 hospital units collected data
research trials. Factors include inappropriate selection on 9716 patients. Disappointingly, acidotic patients
of patients for NIV and failure to apply NIV correctly. receiving NIV had a worse prognosis than acidotic
This highlights the need for proper training of all patients who did not receive NIV. Contrary to guide-
involved individuals. This article addresses the different lines, 42% of patients with progressive or acute respira-
skills needed in a team to provide an effective NIV ser- tory acidosis did not receive NIV. Use of oxygen with
vice. Some detail is given in each of the key areas but it an unrestricted fractional inspired oxygen concentra-
is not comprehensive and should stimulate further
tion (FIo2) was common and associated with the need
learning (reading, attendance on courses, e-learning,
etc.), determined by the needs of the individual. for ventilation (22% of the patients who received >35%
oxygen vs 9% of those who received <35% oxygen) and
mortality (11.1% of the patients who received >35%
Key words: communication skills, education, non-invasive oxygen vs 7.2% of those who received <35% oxygen).
ventilation, physiology, training. National audits were repeated by the British Thoracic
Society (BTS) in consecutive years from 2010 to 2013.4
INTRODUCTION: WHY IS THIS ISSUE These showed high mortality rates. There are a number
IMPORTANT? of potential explanations for this including exclusion of
high-risk patients in most RCT and NIV being offered
Non-invasive ventilation (NIV) has become part of rou- to patients with end-stage disease for whom there is lit-
tine care for patients with acute respiratory failure.1,2 It tle chance of success. However, the results suggest that
should usually be the first-choice modality of ventila- poor patient selection rather than inappropriate techni-
tory support for patients with acute-on-chronic hyper- cal application of NIV is the main problem explaining
capnic respiratory failure, particularly due to an acute worse outcomes in these audits compared to the RCT.
exacerbation of chronic obstructive pulmonary disease The National Confidential Enquiry into Patient Out-
(AECOPD). Although lacking the same evidence base, come and Death (NCEPOD) in the UK undertook a
in terms of randomized controlled trials (RCT), domi- review of the delivery of acute NIV in AECOPD.5 This
ciliary NIV is well established in the management of report raised several major concerns about the way in
patients with chronic respiratory failure due to chest which NIV is delivered and lessons learnt from this are
wall deformity, neuromuscular diseases, AECOPD and the subject of a recent review.6 Particular concerns
obesity. It can also be used in hypoxic respiratory fail- raised were:
ure, but usually only in a high-intensity, intensive care 1. Patient selection: ward-based NIV is not recom-
environment, with careful monitoring and rapid mended for patients with pneumonia but consolida-
recourse to invasive ventilation if the patient is tion was present in 40% and when present mortality
deteriorating. was higher.
The excellent results obtained in clinical trials are 2. Possible treatment delay: delay in starting NIV was
often not seen in everyday clinical practice. Audit is identified in 27.4% of patients
uncommon, but when it is done the results raise signif- 3. Location of NIV delivery: despite the fact that
icant concerns. However, concerns have also been median pre-NIV pH was 7.24, 91% of patients were
not treated in a high dependency unit and mortality
was highest for patients who started NIV in general
Correspondence: Mark Elliott, Department of Respiratory
Medicine, St James’s University Hospital, Beckett Street, Leeds
medical wards (59%)
LS9 7TF, UK. Email: mwelliott@doctors.org.uk 4. High mortality rates and low rates of intubation if
Received 10 October 2018; accepted 18 October 2018. NIV failed.

© 2018 Asian Pacific Society of Respirology Respirology (2018)

doi: 10.1111/resp.13445
2 MW Elliott

In most patients the decision to start NIV in AECOPD can develop in a patient with COPD is shown in
was made by a non-specialist (65% of patients). In Figure 2. It can be seen that there are a number of
18.8% of patients the use of NIV was considered inap- potentially interrelating vicious cycles and explains
propriate. The quality of NIV was considered good in how respiratory failure can evolve rapidly in the at-risk
27.5%, adequate in 48.5%, poor in 19.6% and unaccept- patient, and also how interrupting one downward spi-
able in 4.4%. In 33%, monitoring was considered not to ral and replacing it with a virtuous cycle can also lead
be frequent enough. These data confirm that training to a rapid improvement. For example, a reduction in
of all clinical staff working in the acute sector in how to respiratory rate, by offloading the inspiratory muscles
select the right patient for NIV, to apply it at the right means more time for expiration, which leads to a
time and in the right way is crucial. The same princi- reduction in hyperinflation, which in turn improves the
ples apply with regard to the provision of long-term mechanical advantage of the respiratory muscles of the
home ventilation. inspiratory muscles, leading to an improvement in the
capacity of the respiratory muscle pump and a further
reduction in respiratory rate. Alveolar ventilation
WHAT SKILLS ARE NEEDED TO improves, bringing the pH back to normal, thereby
BECOME AN NIV EXPERT? removing the deleterious effect of acidosis upon mus-
cle function, with a further improvement in capacity.
As with any practical intervention, the skill of the oper- There are however factors which will not respond
ator and knowledge of when it is appropriate to use the directly to ventilation (e.g. secretions and bronchocon-
intervention, and when it is not, is key to a successful striction), emphasizing the need for maximal medical
outcome. Although training and competency assess- therapy, in addition to ventilatory support (it is how-
ment are frequently recommended, there is little pub- ever pertinent to note that effective NIV may help
lished and no internationally agreed competency patients e.g. with cystic fibrosis, to cooperate with
framework. Indeed, the NCEPOD review5 found that in physiotherapy7–9 and therefore clear secretions more
45.4% of hospitals staff without a defined competency effectively; also positive pressure may have a direct
directly supervised patients on NIV. In this paper, we effect upon the airways themselves10).
explore the skills needed for a clinician to be a success- Contrast this with a patient with motor neurone dis-
ful NIV operator, both in the acute environment and in ease (MND), both medical management and the way
chronic home care. These are summarized in Figure 1. the ventilator is set will be very different. There is no
role for bronchodilators, but secretion management is
much more important. Because lung compliance is not
AN UNDERSTANDING OF increased low inflation pressures generally suffice, but
PHYSIOLOGY IS IMPORTANT external positive end expiratory pressure (PEEP) is
required to recruit atelectatic lung at the lung bases,
Respiratory failure results when there is an imbalance which has occurred as a result of extrapulmonary
between the load against which the respiratory muscle restriction due to the weak inspiratory muscles.
pump must act and/or the drive to the system. It is It is a useful exercise to work out how load, drive
important to understand how the load/drive/capacity and capacity can be impacted by any condition requir-
inter-relationships of the respiratory system might be ing NIV and then work out the implications of this for
affected by different conditions and the implications of both the way that the ventilator should be set and what
this both for standard medical therapy and also for other aspects of therapy are important. Table 1 shows
how a ventilator should be used in the management of the relative contribution of each component in two
respiratory failure. A schema for how respiratory failure conditions in which NIV is commonly used.
Together with an understanding of respiratory physi-
Clinical Academic ology, knowledge of how a ventilator works and inter-
acts with abnormal patient physiology is vital. First, it is
Diagnostic skills Leadership skills
important to understand the nomenclature for different
Chronic disease management Research types of ventilator as unfortunately there is no agreed
standardization of ventilator modes and refinements
Physiology with different terms and acronyms being used to
• Respiratory muscles
• Control of breathing
describe the same thing. A detailed discussion of all
Sleep • Lung mechanics the different types of ventilators and their nomencla-
NIV ture is beyond the scope of this article but it is key that
the operator should understand how the ventilator(s)
they are using works.
An understanding of the way that the ventilator tran-
Mechanical ventilation sitions between inspiration and expiration is important
Acute care
as the respiratory cycle of the machine should mirror
Palliative and end of life care Education that of the patient, to ensure both comfort and optimal
ventilatory support. The machine blowing air in when
Communication skills the patient is trying to breathe out is uncomfortable
and inefficient.
Figure 1 A Venn diagram of the integrated skills and knowl- Timing of ventilation can be set by the operator
edge required for non-invasive ventilation (NIV). (‘controlled’ or ‘timed’) or determined by the patient,
© 2018 Asian Pacific Society of Respirology Respirology (2018)
NIV: what skills are needed? 3

Airways disease Airflow obstruction

Secretions

Upper airway resistance

Mechanical disadvantage Hyperinflation Inspiratory threshold load

+ve +ve
–ve
Capacity +ve Load
Fluid retention
–ve –ve

Malnutrition

Abnormal arterial blood gas tensions

–ve
–ve
Drive Sleep deprivation
–ve

Figure 2 The inter-relationships Loss of wakefulness drive

between load, drive and capacity Chronic nocturnal hypoventilation
in COPD and how vicious, and vir-
Sedative drugs
tuous, cycles may develop.

‘spontaneous’ or ‘assisted’ ventilation. The ventilator respiratory failure is actually due to obesity or undiag-
‘triggers’ into inspiration and ‘cycles’ into expiration nosed neuromuscular disease (e.g. MND),13 or the
based upon changes in airflow. A failure to trigger into patient does have COPD, but it is not sufficiently severe
inspiration may be either because the patient cannot to explain the respiratory failure which is caused by
generate sufficient inspiratory airflow, that is a patient something else.
with severe muscle weakness, or because of intrinsic It is important that patients receive appropriate
PEEP in COPD; the initial part of the inspiratory effort medical therapy; this may improve symptoms, but
is spent overcoming positive pressure in the alveoli occasionally may obviate the need for NIV (for
with inspiratory airflow only occurring when alveolar instance, appropriate diagnosis and treatment of
pressure drops below the pressure at the mouth/nose. myasthenia gravis). When attempting to transition a
The answer to ineffective triggering is different. In a patient from invasive to NIV after an acute episode, a
patient with neuromuscular disease, it is particularly clear understanding of what is causing the respiratory
important to have the trigger set as sensitive as possi- failure and then correcting that which is reversible
ble. In a patient with COPD, appropriate setting of leads to the best chance of getting a patient on to the
extrinsic PEEP (or expiratory positive airway pressure least ventilatory support possible. This includes no
(EPAP)) improves effective trigger sensitivity, patient support; the less the better in terms of patient, and
ventilator synchrony and also leads to a greater reduc- very importantly family, quality of life, independence
tion in the work of breathing than with pressure sup- and cost. Figure 3 indicates some of the factors to con-
port alone.11 The ventilator cycles into expiration when, sider. A multidisciplinary approach involving doctors,
usually, inspiratory airflow falls to a percentage of peak; nurses, physiotherapists, speech and language thera-
if there is excessive leak airflow is maintained and pists, dietician, psychologist, etc. is key. Involvement
inspiration, as determined by the ventilator, continues of other specialists (e.g. neurologist and cardiologist)
even though the patient has started to breathe out.12 is also important. If in doubt involve others.
Again, this is uncomfortable and inefficient.

WHY SOME KNOWLEDGE OF SLEEP

DIAGNOSTIC SKILLS MEDICINE IS IMPORTANT

NIV is indicated when the patient develops respiratory Domiciliary NIV is usually applied during sleep and
failure/sleep-related hypoventilation. Diagnostic skills therefore some knowledge of the physiology of sleep is
and an understanding of the natural history of a condi- important. For the patient at risk of developing chronic
tion are important both in the chronic situation to respiratory failure, abnormalities first become apparent
identify patients at risk for hypoventilation proactively during rapid eye movement (REM) sleep, followed by
and to institute NIV before there is an acute crisis, and non-REM sleep and ultimately with the development of
also when patients present acutely to identify correctly daytime respiratory failure. Transient hypoventilation
why they have respiratory failure. Although it is often leads to a rise in arterial carbon dioxide tension
obvious, misdiagnosis occurs in patients with a heavy (PaCO2) which in turn causes acidosis. The kidneys
smoking history misdiagnosed with COPD, when the respond by retaining bicarbonate to return pH to
Respirology (2018) © 2018 Asian Pacific Society of Respirology
4 MW Elliott

Table 1 An analysis of primary and secondary effects on load, drive and capacity in two common conditions and the
implications for NIV

Consequences Load Drive Capacity

Motor Primary Unchanged Unchanged Reduced because of muscle

neurone weakness
disease Secondary Increased due to excessive Reduced due to injudicious Reduced due to poor nutrition
secretions use of respiratory
Increased during sleep due to depressant drugs
upper airway obstruction Reduced as a consequence of
Increased due to atelectasis bicarbonate retention due to
NH
Implications EPAP to recruit atelectatic lung Control of NH (reduced CO2) NIV provides the ventilation
for NIV NIV prior to physiotherapy restores central drive which the weakened
EPAP during sleep to prevent respiratory muscles cannot
UAO achieve—low levels of IPAP
usually suffice
Trigger set to as sensitive as
possible to ensure that
triggering occurs. If
inspiratory muscles too
weak, ensure back up rate
set appropriately
COPD Primary Increased due to airways Unchanged Reduced due to mechanical
obstruction and the intrinsic disadvantage of inspiratory
threshold load due to PEEPi muscles
Secondary Increased due to excessive Reduced due to injudicious Reduced due to poor nutrition
secretions use of respiratory and steroids
Increased during sleep due to depressant drugs
upper airway obstruction Reduced as a consequence of
bicarbonate retention due to
NH
Implications Adequate EPAP to Control of NH (reduced CO2) NIV provides the ventilation
for NIV counterbalance PEEPi restores central drive which is reduced due to the
Higher IPAP reduces airways combination of increased
resistance load and reduced capacity—
EPAP during sleep to prevent higher levels of IPAP usually
UAO required

EPAP, expiratory positive airway pressure; IPAP, inspiratory positive airway pressure; NH, nocturnal hypoventilation; NIV,
non-invasive ventilation; PEEPi, intrinsic positive end expiratory pressure; UAO, upper airway obstruction.

normal, which leads to a blunting of the central che- patients receiving NIV, because of mixing of gases
mosensitivity to CO2, but also manifests in a rise in the within the mask and the nasopharynx.15 Transcutaneous
standard bicarbonate and base excess. An elevated CO2 (TcCO2) monitoring using modern monitors does
bicarbonate and base excess, in the absence of hypoka- accurately reflect PaCO2, with the sensor preferentially
laemia, suggests nocturnal hypoventilation (NH) and applied to the ear lobe16 and can be used for monitoring
should prompt appropriate monitoring during sleep. the effectiveness of NIV, but the equipment is signifi-
The symptoms of NH are very non-specific and it is cantly more costly and will usually require an overnight
important to have a high index of suspicion in at-risk stay in hospital. It can also be used in the acute situa-
individuals; in particular, these should include all tion and for weaning.17,18
patients with neuromuscular disease and chest wall In some patients, more detailed respiratory variable
deformity. sleep studies are required to disentangle the relative con-
Full polysomnography is not required to diagnose tribution of upper airway obstruction and sleep-related
NH. Pulse oximetry, provided that the patient is not hypoventilation to the development of respiratory failure.
receiving supplemental oxygen, provides very useful It is important to understand how each may lead to
information and has the great advantage of simplicity hypercapnia (Fig. 4). During an obstructive apnoea,
and low cost.14 It can easily be performed in the PaCO2 rises but is usually returned to normal by the brief
patient’s home, over several nights, with equipment hyperventilation that accompanies arousal. However, if
sent out and returned by post. End-tidal CO2 (EtCO2) the apnoea is prolonged, or the increase in ventilation
monitoring is cheaper and easy but should never be with arousal is attenuated for instance due to coexistent
used as a measure of PaCO2 in a spontaneously breath- respiratory muscle weakness or severe obesity, more
ing patient with lung disease. It is even less reliable in CO2 is retained during the apnoea than can be excreted

© 2018 Asian Pacific Society of Respirology Respirology (2018)

NIV: what skills are needed? 5

Weaning from invasive ventilation – hierarchies of ventilatory support

Dependence Quality of life
and expense and independence

1. Invasive ventilation • Make a diagnosis of all conditions

(endotracheal intubation or leading to respiratory failure—
tracheostomy there maybe more than one

• Address psychological issues, build

confidence
– Get the patient vocalizing as soon
as possible

2. Non-invasive ventilation • Treat infection

• Optimal secretion management
• Exclude / address aspiration (a
tracheostomy only partially protects
the lower airway)
• Adequate nutrition
• Appropriate fluid management
3. No ventilatory support
• Correct metabolic abnormalities
Figure 3 Factors to consider when • Consider possibility of occult
transitioning a patient from inva- cardiac disease
sive ventilation to non-invasive ven- • Improve physical function – early
tilation or no ventilatory support. rehabilitation

with arousal, PaCO2 rises and acidosis develops which CPAP, there will be no carbon dioxide retention— a
stimulates renal retention of bicarbonate (see above). reduction in apnoea–hypopnoea index (AHI), easily
This is best described as hypercapnic obstructive sleep obtainable from machine’s built-in software is the appro-
apnoea (OSA); if the upper airway is controlled, using priate therapeutic target. This probably explains why in

(A)

(B) 10 s 30 s
Figure 4 (A) Transcutaneous CO2
(TcCO2) and oxygen saturation
recorded over night. The TcCO2
rises progressively through the Airflow
night with transient peaks, associ-
ated with more pronounced oxy-
gen desaturation occurring during
episodes of rapid eye movement
(REM) sleep. (B) During normal
breathing, CO2 excretion by the
CO2 excretion
lungs equals metabolic CO2 pro-
duction. The CO2 retained during a B D
10-s apnoea can be excreted dur-
ing the arousal-associated hyperp-
noea (A + B). However, during a
more prolonged apnoea, the A
period of hyperventilation is not CO2 production C
sufficient to excrete the CO2 pro-
duced during the apnoea (C > D).
PaCO2 will rise over the night with
repeated prolonged apnoeas.

Respirology (2018) © 2018 Asian Pacific Society of Respirology

6 MW Elliott

Table 2 The key importance of NH: Know in which patients to look for it, how to record it and to ensure that NIV is
being delivered effectively

Skills needed

I. Identify that patient at risk for NH 1. An understanding of natural history of conditions which may lead to NH
2. Recognition of symptoms of NH
3. Ability to measure, and interpret, spirometry, mouth and sniff pressures
4. Interpretation of blood gas measurements, in particular appreciate the importance of
a raised HCO3 or BE
II. Identify NH in the patient 1. Understand the role and limitations of monitoring techniques during sleep
2. Learn to recognize different patterns of over night oximetry
III. Ensure that ventilation being 1. Understand how to interpret data provided by (most) ventilators’ software
delivered effectively during 2. Learn to recognize different patterns of overnight oximetry on NIV and when more
sleep and if not what detailed respiratory variable sleep studies are needed
adjustments are required

BE, base excess; NH, nocturnal hypoventilation; NIV, non-invasive ventilation.

patients with obesity hypoventilation syndrome, even during NIV. An algorithm is provided suggesting how
with significant hypercapnia (mean 60 mm Hg) at base- the effectiveness of overnight NIV should be moni-
line CPAP can improve the CO2 to the same degree as tored.20 This series is essential reading for any practi-
with NIV.19 In contrast, with hypoventilation that occurs tioner looking after patients on domiciliary ventilation.
throughout sleep, but is most marked in REM sleep, Table 2 highlights the steps in the recognition of NH
such as is seen in patients with neuromuscular disease, and its successful control with NIV.
the CO2 rises progressively over the night with the most
marked rises seen during REM sleep. For these patients,
an increase in ventilation breath-by-breath is required COMMUNICATION SKILLS
and NIV is needed to correct respiratory failure. The tar-
get parameter now is the CO2 overnight; the AHI is easily Clinicians delivering NIV will often be involved in diffi-
obtained from the ventilator but a low AHI does not cult discussions with patients who have life-limiting con-
mean that the therapy is being delivered appropriately. ditions. This will be true both in domiciliary ventilation
The difference between hypercapnic OSA and NH can (e.g. discussions about tracheostomy) and in the acute
be usually determined from the pattern of oximetry. For situation (e.g. escalation to invasive ventilation or pallia-
OSA alone to cause hypercapnia, it will always be severe tion). It is always easier to do something and as a clini-
and easily diagnosed by oximetry alone. cian you are less likely to be criticized for doing
To ensure that NIV is being applied effectively, it is something than not doing it. However, because you can
very important to monitor the effect of ventilation dur- does not mean you should; inappropriate use of a treat-
ing sleep and sometimes the way that the patient is ment which is futile can cause unnecessary suffering.
interacting with the ventilator. A reduction in carbon For the patient to make a properly informed decision,
dioxide is the most important end point and this is best they must be presented with accurate information in a
monitored continuously using a modern transcutane- way that they can understand. This requires an under-
ous monitor. The aim of NIV is ideally to normalize standing of the natural history of a condition and the
TcCO2 or at the very least to bring about an improve- way this can be impacted by treatment. Sometimes,
ment. This will almost always bring about a substantial patients want everything done without realizing that
improvement in oxygen saturation. Provided that the there is a downside and that the intervention is not
FiO2 is normal (i.e. NIV with no added oxygen), contin- going to return them to a normal life, but may rather, at
uous monitoring of oxygen saturation is a useful surro- best, return them to their baseline in the recent past.
gate marker for improved ventilation. If any oxygen is Conversely, patients may have declined an intervention
added to the circuit, its use as a surrogate for improved because of inappropriate pessimism or overemphasis of
ventilation will be lost. the negatives. In these situations, it is important to listen.
The SOMNO NIV group20–23 has suggested how the In one study, doctors and patients rated how well a diffi-
delivery of NIV should be monitored. This starts with cult discussion had gone; if the doctor spoke more their
an understanding of how ventilators work and in par- satisfaction was higher but that of the patients less. If the
ticular how different ventilator modes impact upon doctor spoke less, they thought the consultation had not
monitoring systems. Information available from the gone so well whereas patient satisfaction was higher.24
ventilator is very helpful. A failure to use NIV at all may The clinician should not impose their values on their
explain no change in symptoms, daytime blood gas patients. Very disabled patients can still enjoy a good
tensions etc., and problems such as excessive leak, a quality of life. Indeed in one study,25 patients rated their
high AHI etc., are easily obtained. This can then be quality of life better than that of the healthcare workers
supplemented with simple tools, such as oximetry etc., looking after them in some domains. The healthcare
with respiratory polygraphy, and very occasionally full workers also underestimated the quality of life of the
polysomnography, needed to troubleshoot problems patients and overestimated the burden of ventilation.
© 2018 Asian Pacific Society of Respirology Respirology (2018)
NIV: what skills are needed? 7

LEADERSHIP SKILLS applications should, when possible, be underpinned by

RCTs, which not only prove efficacy, but can also high-
NIV is a multidisciplinary endeavour involving a team. light, unexpected, important adverse effects, such as
This requires leadership and while this will usually be was seen in the SERVHF trial.26 Even though most
a doctor, this is not always the case. It is important that practitioners will not be actively involved in initiating
someone takes final responsibility for decisions and clinical research opportunities for participation in clini-
actions and ensures that the whole team is functioning cal trials abound. Time spent during training in a
together appropriately. They should also ensure that research environment is important both for under-
staff members are adequately trained, competencies standing the strengths and limitations of the research
assessed and that the quality of delivery of the service of others, and also giving a more detailed understand-
is good. Some individuals are natural leaders, others ing of the field.
will require specific training.

AUDIT AND QUALITY ASSURANCE

EDUCATION
The assumption is generally made that any medical
Training is key to the successful implementation of any intervention is applied appropriately. However, audit
clinical skill. This is particularly true for NIV. It is rela- frequently demonstrates that this is not the case and
tively easy to access training as short courses are com- this is certainly true for NIV delivered acutely (see
monly provided. However, having been on a course above). Any service should be subject to regular audit
does not mean that an individual is competent. There and clinicians need to understand the principles of
should be a formal assessment of competency audit. Unfortunately, comprehensive audit can be time-
(e.g. http://nipecportfolio.hscni.net/compro/ReadOnly/ consuming and is often unfunded. Purchasers of
rCAT/view.asp?compID=72 or https://www.e-lfh.org. healthcare services should insist on being provided
uk/programmes/acute-niv/). It is very important that with evidence that what they are paying for is being
any formal learning is supplemented by on-the-job delivered appropriately and they should build funding
training and refresher sessions. Simulators are also a for this into reimbursement. Although in many coun-
useful resource (e.g. https://www.ers-education.org/e- tries standards are provided for what is needed to
learning/simulators.aspx). deliver an acute NIV service, this is not always the case.
Some clinicians will only be involved in NIV when That an organization is adhering to these standards is
covering on call etc., whereas others will be very only confirmed by self-certification, often based on lit-
actively involved on a day-to-day basis. It is very tle hard evidence, with no peer review or quality assur-
important to make a distinction between these two ance from an outside body.
groups in terms of the skills that are needed. Training With regard to domiciliary ventilation and weaning
curricula are constantly expanding, as medical knowl- services, things are a little better with some countries
edge increases, and there is a tendency for each sub- having nationally agreed standards and certification of
specialty to insist that all trainees have extensive units, usually by the national respiratory society. Ide-
knowledge within their niche area. As a result, trainees ally, all services should be externally quality assured,
can end up as a ‘jack of all trades and master of none’. however it is probably unrealistic to expect this as it is
It becomes impossible for any trainee to satisfy all time-consuming and expensive. It is therefore incum-
these criteria with the result that competency assess- bent on providers of NIV services to have an under-
ment is diluted and to some extent becomes meaning- standing of audit and quality assurance and to be able
less. The NIV community needs to establish the core to document to their own satisfaction and to that of
competencies necessary to select patients for NIV and others that they are providing a quality service. Useful
how it is applied acutely. The acute physician should resources include the NCEPOD self-assessment
know when NIV is indicated in longer term and whom checklist,27 the BTS quality standards for acute NIV28
to refer for more specialist assessment but a detailed and the NCEPOD audit toolkit (https://www.ncepod.
understanding of long-term domiciliary NIV is not org.uk/2017report2/toolkit/NIVauditTool.xlsx).
required. The practitioner only involved in chronic care
must have some understanding of acute illness and its
implications for NIV, as some of their patients will at CONCLUSION
times decompensate.
The successful NIV team needs to have individuals
with many different skills. One person does not need to
ACADEMIA AND CLINICAL RESEARCH be able to do everything, but the team requires a
named individual responsible for leadership and ensur-
It will not be for everybody and opportunities are lim- ing that all the issues are covered. Every clinician look-
ited, but it is vital that some individuals working in the ing after patients with respiratory failure must be aware
field are actively involved in academia and research. of which patients should receive NIV, when it should
Although there is a lot that we now know and under- be started and ensure this happens without delay.
stand there is so much more that we do not. New tech- Frontline staff delivering NIV must understand how to
niques are evolving and it is very important that we use the ventilator in different conditions and to trouble
understand the physiological basis and implications to shoot when the patient is not improving. Training
ensure that they are implemented optimally. All clinical should be tailored to the individual. Competency must
Respirology (2018) © 2018 Asian Pacific Society of Respirology
8 MW Elliott

Table 3 Key points and misconceptions Brozek J, Conti G et al.; Raoof S Members Of The Task Force. Offi-
cial ERS/ATS clinical practice guidelines: noninvasive ventilation
Always make a diagnosis—respiratory failure always has a for acute respiratory failure Eur. Respir. J. 2017; 50: pii: 1602426.
cause(s) 3 Roberts CM, Stone RA, Buckingham RJ, Pursey NA, Lowe D,
End-tidal CO2, while easy to measure, is unreliable and National Chronic Obstructive Pulmonary Disease Resources and
should not be used to monitor respiratory failure/assess Outcomes Project Implementation Group. Acidosis, non-invasive
ventilation and mortality in hospitalised COPD exacerbations. Tho-
adequacy of ventilation
rax 2011; 66: 43–8.
Understand ventilator nomenclature and how the machines
4 BTS audit reports 2010 to 2013. Available from URL: https://
that are being used work. When moving a patient from wwwbrit-thoracicorguk/publication-library/bts-reports/
one device to another, consider differences in how 5 The National Confidential Enquiry into Patient Outcome and
pressures are set, the machine triggers into inspiration Death (NCEPOD). 2017 Inspiring change. A review of the quality
and cycles into expiration of care provided to patients receiving acute non-invasive ventila-
Complex, and expensive, monitoring during sleep is seldom tion. Available from URL: http://www.ncepod.org.uk/2017report2/
necessary: a great deal can be done with an oximeter, a downloads/InspiringChange_FullReport.pdf
good history and some common sense 6 Davies MG, Juniper MC. Lessons learnt from the National Confi-
A tracheostomy only provides partial protection for the dential Enquiry into Patient Outcome and Death: acute non-
invasive ventilation. Thorax 2018; 73: 904–7.
lower respiratory tract
7 Holland AE, Denehy L, Ntoumenopoulos G, Naughton MT,
Communication with patient and family—in difficult and/or
Wilson JW. Non-invasive ventilation assists chest physiotherapy in
sensitive situations, try to listen as much as you speak adults with acute exacerbations of cystic fibrosis. Thorax 2003; 58:
Multidisciplinary working is very important—no professional 880–4.
group has all the necessary skills 8 Rodriguez Hortal MC, Nygren-Bonnier M, Hjelte L. Non-invasive
Never stop learning and share what you know with others ventilation as airway clearance technique in cystic fibrosis. Physi-
other. Res. Int. 2017; 22; https://doi.org/10.1002/pri.1667.
9 Rodriguez Hortal MC, Hedborg A, Biguet G, Nygren-Bonnier M.
be assessed and assured. Table 3 summaries key points
Experience of using non-invasive ventilation as an adjunct to air-
and misconceptions. way clearance techniques in adults with cystic fibrosis-a qualitative
study. Physiother. Theory Pract. 2018; 34: 264–75.
10 De Backer L, Vos W, Dieriks B, Daems D, Verhulst S, Vinchurkar S,
Disclosure statement Ides K, De Backer J, Germonpre P, De Backer W. The effects of
I have received honoraria, travel and subsistence expenses from
long-term noninvasive ventilation in hypercapnic COPD patients: a
Resmed, Philips Respironics and Fisher and Paykel.
randomized controlled pilot study. Int. J. Chron. Obstruct. Pulmon.
Dis. 2011; 6: 615–24.
11 Appendini L, Purro A, Gudjonsdottir M, Baderna P, Patessio A,
The Author
Zanaboni S, Donner CF, Rossi A. Physiological response of
M.W.E., MA, MB BChir, MD, FERS, is a Respiratory Consultant at ventilator-dependent patients with chronic obstructive pulmonary
St James’s University Hospital, Leeds, UK. His clinical and disease to proportional assist ventilation and continuous positive
research interests are in acute and chronic NIV, OSA and weaning airway pressure. Am. J. Respir. Crit. Care Med. 1999; 159: 1510–7.
of patients with prolonged ventilator dependence. He was trea- 12 Calderini E, Confalonieri M, Puccio PG, Francavilla N, Stella L,
surer of the European Respiratory Society during 2013–2016, Gregoretti C. Patient-ventilator asynchrony during noninvasive
President of the British Thoracic Society during 2018–2019 and ventilation: the role of expiratory trigger. Intensive Care Med. 1999;
core member of the Guidelines Writing Group for British Thoracic 25: 662–7.
Society and ERS/ATS acute NIV Guidelines. 13 Lad TS. An ’acute’ presentation of motor neuron disease. Acute
Med. 2011; 10: 140–1.
14 Fu ES, Downs JB, Schweiger JW, Miguel RV, Smith RA. Supple-
Abbreviations: AECOPD, acute exacerbation of COPD; AHI, mental oxygen impairs detection of hypoventilation by pulse oxim-
apnoea–hypopnoea index; BTS, British Thoracic Society; EPAP, etry. Chest 2004; 126: 1552–8.
Expiratory positive airway pressure; FiO2, Fractional inspired 15 Sanders MH, Kern NB, Costantino JP, Stiller RA, Strollo PJ,
oxygen concentration; IPAP, Inspiratory positive airway Studnicki KA, Coates JA, Richards TJ. Accuracy of end-tidal and
pressure; MND, motor neurone disease; NCEPOD, National transcutaneous Pco2 monitoring during sleep. Chest 1994; 106:
Confidential Enquiry into Patient Outcome and Death; NH, 472–83.
nocturnal hypoventilation; NIV, non-invasive ventilation; OSA, 16 Conway A, Tipton E, Liu WH, Conway Z, Soalheira K, Sutherland J,
obstructive sleep apnoea; PaCO2, Arterial carbon dioxide Fingleton J. Accuracy and precision of transcutaneous carbon diox-
tension; PEEP, positive end expiratory pressure; PEEPi, Intrinsic ide monitoring: a systematic review and meta-analysis. Thorax
positive end expiratory pressure; RCT, randomized controlled 2018; https://doi: 10.1136/thoraxjnl-2017-211466.
trial; REM, rapid eye movement; TcCO2, transcuta-neous CO2; 17 van Oppen JD, Daniel PS, Sovani MP. What is the potential role of
UAO, Upper airway obstruction. transcutaneous carbon dioxide in guiding acute noninvasive venti-
lation? Respir. Care 2015; 60: 484–91.
18 Lermuzeaux M, Meric H, Sauneuf B, Girard S, Normand H,
Lofaso F, Terzi N. Superiority of transcutaneous CO2 over end-
REFERENCES tidal CO2 measurement for monitoring respiratory failure in non-
intubated patients: a pilot study. J. Crit. Care 2016; 31: 150–6.
1 Davidson AC, Banham S, Elliott M, Kennedy D, Gelder C, 19 Howard ME, Piper AJ, Stevens B, Holland AE, Yee BJ,
Glossop A, Church AC, Creagh-Brown B, Dodd JW, Felton T et al. Dabscheck E, Mortimer D, Burge AT, Flunt D, Buchan C et al. A
BTS/ICS guideline for the ventilatory management of acute hyper- randomised controlled trial of CPAP versus non-invasive ventila-
capnic respiratory failure in adults. Thorax 2016; 71(Suppl. 2): tion for initial treatment of obesity hypoventilation syndrome. Tho-
ii1–35. rax 2017; 72: 437–44.
2 Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, 20 Janssens JP, Borel JC, Pepin JL; SomnoNIV Group. Nocturnal mon-
Navalesi P Members Of The Steering Committee, Antonelli M, itoring of home non-invasive ventilation: the contribution of

© 2018 Asian Pacific Society of Respirology Respirology (2018)

NIV: what skills are needed? 9
simple tools such as pulse oximetry, capnography, built-in ventila- 24 Tulsky JA, Chesney MA, Lo B. How do medical residents discuss
tor software and autonomic markers of sleep fragmentation. Tho- resuscitation with patients? J. Gen. Intern. Med. 1995; 10: 436–42.
rax 2011; 66: 438–45. 25 Bach JR, Campagnolo DI, Hoeman S. Life satisfaction of individ-
21 Elliott MW. Non-invasive ventilation during sleep: time to define uals with Duchenne muscular dystrophy using long-term mechan-
new tools in the systematic evaluation of the technique. Thorax ical ventilatory support. Am. J. Phys. Med. Rehabil. 1991; 70:
2011; 66: 82–4. 129–35.
22 Rabec C, Rodenstein D, Leger P, Rouault S, Perrin C, Gonzalez- 26 Cowie MR, Woehrle H, Wegscheider K, Angermann C,
Bermejo J; SomnoNIV Group. Ventilator modes and settings dur- d’Ortho MP, Erdmann E, Levy P, Simonds AK, Somers VK,
ing non-invasive ventilation: effects on respiratory events and Zannad F et al. Adaptive servo-ventilation for central sleep apnea
implications for their identification [Review]. Thorax 2011; 66: in systolic heart failure. N. Engl. J. Med. 2015; 373: 1095–105.
170–8. 27 NCEPOD self assessment checklist. Available from URL: http://
23 Gonzalez-Bermejo J, Perrin C, Janssens JP, Pepin JL, Mroue G, www.ncepod.org.uk/2017niv.html
Leger P, Langevin B, Rouault S, Rabec C, Rodenstein D. Proposal 28 Davies M, Allen M, Bentley A, Bourke SC, Creagh-Brown B,
for a systematic analysis of polygraphy or polysomnography for D’Oliveiro R, Glossop A, Gray A, Jacobs P, Mahadeva R et al. Brit-
identifying and scoring abnormal events occurring during non- ish Thoracic Society quality standards for acute non-invasive venti-
invasive ventilation. Thorax 2012; 67: 546–52. lation in adults. BMJ Open Respir. Res. 2018; 5: e000283.

Respirology (2018) © 2018 Asian Pacific Society of Respirology