Critical Care Medicine

Answer 3 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. REFERENCES 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. Click here to return to the questions

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