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Critical Care Medicine

Answer 3
  1. Immunosuppressed patients with acute respiratory failure benefit from NIPPV. Although intubation with invasive mechanical ventilation is often necessary for patients with ALI/ARDS, immunosuppressed patients benefit greatly by avoiding an endotracheal tube and its attendant risk of infection. Immunosuppressed patients with early respiratory failure randomized to NIPPV versus high-flow oxygen alone demonstrated decreased rates of intubation, ICU mortality, and hospital mortality.5 Thus, a brief trial of NIPPV with close monitoring is appropriate. Adequate noninvasive ventilation for ALI often requires IPAP of at least 15 cm H2O and PEEP of 6 cm H2O to 8 cm H2O.5 Skin necrosis may be a problem, particularly at the bony prominences of the face in contact with the NIPPV mask (eg, bridge of the nose, chin). Skin necrosis occurs when IPAP exceeds capillary perfusion pressure; therefore, IPAP should not exceed 22 cm H2O. Aerophagia, or swallowing of air, is also a potential problem with NIPPV and is generally an issue when IPAP exceeds 20 cm H2O. Immunosuppressed patients do not have a higher rate of aspiration than other hospitalized patients.

    5. Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 2001;344: 481-7.

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