Advances in non-invasive positive airway pressure technology

Non-invasive ventilation (NIV) has become the standard of care for patients with a range of respiratory and sleep breathing disorders. Technological advances have enabled the development of several newer modes of automatically adapting NIV suitable for patients with more complex breathing abnormalities that may be difficult to manage effectively with more traditional positive airway pressure therapy. These modes allow for more stable ventilation when fluctuating ventilation requirements occur such as in positional upper airway obstruction or state-related variations in respiratory mechanics and drive. Adaptive servoventilation (ASV) is designed for patients with periodic breathing and central apnoeas in whom carbon dioxide levels are normal to low, with the goal of therapy to dampen and stabilize ventilation. In contrast, volume-assured pressure support is used in diagnostic groups characterized by hypoventilation, where targeting an effective level of ventilation irrespective of sleep stage or body position is required. These newer modes have the potential to simplify and optimize ventilation, although at present there is no evidence that they are clinically superior to standard home ventilation techniques. The complexity and differences in algorithms and features of various device brands, along with a limited evidence base documenting longer term outcomes, complicate decisions around which patient phenotypes are best suited to these newer modes. In-built sensor and data storage capabilities of newer home ventilation devices provide the opportunity for earlier recognition of issues with ventilation and to guide corrective action. Further work is needed to determine how this impacts longer term clinical outcomes.