Titration of non-invasive positive pressure ventilation in chronic respiratory failure

Non-invasive ventilation (NIV) is widely used for acute and chronic respiratory failure. If arterial blood gas tensions do not improve, the level of support can be increased. However, there may be a limit above which increasing ventilatory support leads only to greater interface leak with no improvement in ventilation. The aim of this study was to establish whether there is such a limit. During a daytime study in 24 ventilated stable patients (10 with chronic obstructive pulmonary disease (COPD), 14 with chest wall deformity, CWD), inspiratory pressures up to 20 cm H(2)O and set tidal volumes up to 10 ml kg(-1) were associated with mask leak of <5 l min(-1). Although leak increased with higher levels of support, there was still an increase in minute ventilation. The mean (2 sd) tolerated pressure was 24 cm H(2)O (8-40) in both groups, and set tidal volume 12.7 ml kg(-1) (5.0-20.4) in CWD and 9.6 ml kg(-1) (3.9-14.8) in COPD. Measures of respiratory effort were significantly reduced at all levels with both forms of ventilatory support. There is debate about whether the therapeutic aim of NIV should be to reduce respiratory muscle effort, or to reverse nocturnal hypoventilation. We conclude that if the primary aim is to improve arterial blood gas tensions and this is not achieved, higher levels of ventilation can be obtained using greater pressure or volume, despite additional interface leak. If the aim is to abolish muscle effort completely, there is little to be gained by increasing the level of inspiratory pressure above 20 (CWD) or 25 (COPD) cm H(2)O.