Noninvasive auto-titrating ventilation (AVAPS-AE) versus average

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Keywords Noninvasive ventilation · Noninvasive auto-titrating ventilation ... ment of BIPAP S/T + AVAPS [4] and AVAPS-AE. Even ... and ventilatory settings [5].
Internal and Emergency Medicine https://doi.org/10.1007/s11739-018-1866-2

CE - LETTER TO THE EDITOR

Noninvasive auto‑titrating ventilation (AVAPS‑AE) versus average volume‑assured pressure support (AVAPS) ventilation in hypercapnic respiratory failure patients: comment Killen Harold Briones Claudett1,2,3,4 · Michelle Grunauer5 Received: 21 March 2018 / Accepted: 23 April 2018 © SIMI 2018

Keywords  Noninvasive ventilation · Noninvasive auto-titrating ventilation · Average volume-assured pressure support Abbreviations NIV Noninvasive ventilation AVAPS-AE Noninvasive auto-titrating ventilation AVAPS Average volume-assured pressure support (AVAPS) AHRF Acute hypercapnic respiratory failure Dear Editor, We have read with interest the original article titled “Noninvasive auto-titrating ventilation (AVAPS-AE) versus average volume-assured pressure support (AVAPS) ventilation in hypercapnic respiratory failure patients”. In this paper, the authors evaluated 28 subjects randomized to a group that was managed with noninvasive auto-titrating ventilation (AVAPS-AE) versus 21 subjects randomized to a group treated with average volume-assured pressure support (AVAPS) ventilation. All cases were matched. The main observation in this study reported a * Killen Harold Briones Claudett [email protected]; [email protected]; [email protected] Michelle Grunauer [email protected] 1



Facultad de Ciencias Médicas, Universidad de Guayaquil, Guayaquil, Ecuador

2



Centro Fisiológico-Respiratorio Briones-Claudett, Guayaquil, Ecuador

3

Intensive Care Unit, Panamerican Clinic, Guayaquil, Ecuador

4

Intensive Care Unit, Ecuadorian Institute of Social Security (IESS), Babahoyo, Ecuador

5

School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador



diminution of P ­ CO2 levels within the first 6 h in subjects enrolled in the noninvasive AVAPS-AE group. This study is of importance as it is the first of its kind to evaluate noninvasive auto-titrating ventilation (AVAPS-AE) in critical care patients who have hypercapnic respiratory failure [1]. We have some remarks on this study that might lead to practical implications. 1. Sample selection The authors include a group that combines patients with alveolar hypoventilation syndrome, chronic obstructive pulmonary disease, congestive heart failure and infection as well as two patients diagnosed with kyphoscoliosis, who failed to be included in the NIMV group (AVAPS-AE) and received NIV during post-extubation.   This heterogeneity in the selected group of patients leads to difficult interpretation of the results, since the prognostication differs within entities. Furthermore, studies have shown that auto-titrating NIV mode (AVAPS-AE) might be more useful in patients with alveolar hypoventilation syndrome or sleep apnea syndrome [2]. 2. There is no clear definition of the parameters that led to acute hypercapnic respiratory failure s(AHRF) in this group of selected patients. Additionally, approximately 75% of patients in the NIV-AVAP-AE group, while 62% on the NIV-AVAPS group received LTOT. On the other hand, 50% of patients in the NIV-AVAP AE group, while 42% of the NIV AVAPS group received home mechanical ventilation [3]. 3. The authors express high values of VTE in both groups, however, neither tidal volume (VT) nor weight (kg) was reported in these patients.

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It is clinically relevant to maintain an adequate VT in patients with obstructive pathologies, (between 6 and 8 ml/ kg), and even in the acute stage of illness, VT can exceed these values depending on the clinical observation (correction of alveolar hypoventilation, or rapid elimination of C ­ O2 to avoid narcosis), and in the evaluation and needs assessment of BIPAP S/T + AVAPS [4] and AVAPS-AE. Even though, non-invasive AVAPS-AE might sustain a protective ventilation and provide advantages; the results describe total VT in absolute terms and not adjusted by weight. Moreover, EPAP levels can vary according to the degree of hyperinflation or airway obstruction depending on the type of pathology. COPD, alveolar hypoventilation syndrome, sleep apnea syndrome, and extrapulmonary restrictive disorders in patients with variable airway resistances, represent heterogeneous pathologies with different criteria of exacerbation and ventilatory settings [5]. We highlight the importance of the results reported by the authors and the ventilatory mode AVAPS-AE’s indication in patients with high airway resistances; however, we believe that these considerations should be taken into account before determining the true effect of this ventilatory mode in this subpopulation of patients with exacerbated acute hypercapnic respiratory failure.

Compliance with ethical standards  Conflict of interest   The authors declare that they have no conflict of interest. Statement of human and animal rights   This article does not contain any studies with human participants or animals performed by any of the authors. Funding  This includes any financial arrangements authors have with a company whose product figures prominently in the submitted manuscript or with a company making a competing product.

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Internal and Emergency Medicine Informed consent None.

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