Initiation of Non-invasive Ventilation for Sleep Related Hypoventilation Disorders: Advanced Modes and Devices.

Although non-invasive ventilation (NIV) has been used since the 1960's in the polio epidemic, the development of modern bilevel PAP devices did not become a reality until the 1990's. Over the last 25 years bilevel PAP technology options have exponentially increased. The number of patients receiving this treatment both in the acute setting as well as at home is steadily growing. However, a knowledge gap exists in the way these device settings are adjusted to achieve synchrony and match patient's unique respiratory failure physiology. This issue is further complicated by differences in pressure and flow dynamic settings among different types of NIV devices available for inpatient and home care. Prevalent alveolar and sleep related hypoventilation disorders include patients with chronic obstructive pulmonary disease (COPD) presenting with acute on chronic hypercapnic respiratory failure, overlap syndrome (COPD plus obstructive sleep apnea), obesity hypoventilation syndrome and progressive restrictive pulmonary disorders such as thoracic cage abnormalities and neuromuscular diseases. Careful selection of NIV mode and settings should be based on patient's distinctive needs and acuity level. This review focuses on providing a practical approach to NIV in prevalent stable sleep related alveolar hypoventilation syndromes, both in non-ICU hospital setting and at home, with emphasis on customizing NIV settings to patient's unique respiratory failure physiology.