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Noninvasive Mechanical Ventilation FREE TO VIEW

Lee K. Brown
Chest. 2004;125(2):803-804. doi:10.1378/chest.125.2.803-a
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By John R. Bach, ed. Philadelphia, PA: Hanley & Belfus, 2002; 348 pp; $39.95

A number of years ago, when noninvasive mechanical ventilation had just emerged into the consciousness of the pulmonary community, I had the opportunity to attend the yearly scientific sessions of one of the major pulmonary medicine professional societies. Dr. John R. Bach was scheduled to lecture on this new (for us) concept of ventilation, and I made it a point to attend that session. The importance of this subject, and the perception of Dr. Bach’s expertise in this area, could be well appreciated by the crowds attempting to hear his presentation. It was not just “standing room only”; rather, the crowd spilled out the door, with many of us latecomers attempting to hear the speaker by craning our necks over the multitudes in front of us. Thus was my introduction to Dr. Bach and his work on noninvasive ventilation, now the subject of his latest book.

Noninvasive Mechanical Ventilation is organized into 15 chapters; although Dr. Bach is listed as editor, he is also credited as the sole author of 8 chapters and coauthor of 5 more. The first two chapters contain introductory material covering the attributes of various disorders resulting in chronic ventilatory failure and the pathophysiology of ventilatory failure contrasted with oxygenation failure. This information does not present anything terribly novel for the pulmonary practitioner, and with respect to pathophysiology there are other chapters in other texts that are far more organized and clearly written. The third chapter covers the history of mechanical ventilation, and will be of significant interest to those of a historical bent. I was unsure of the purpose of the next chapter, entitled “Noninvasive Ventilation: Mechanisms for Inspiratory Muscle Substitution,” which did not seem to have a cohesive theme that could be described by its title. It starts out by making the point that neuromuscular disease patients supported by positive pressure ventilation via tracheotomy are often hyperventilated, and that their chronically hypocapnic state then interferes with any subsequent attempts at autonomous breathing. However, the mechanisms given are contradictory: the text seems to suggest that the patient’s inspiratory drive is increased, thus overtriggering the ventilator and resulting in hypocapnia, but also states that all of the patients studied “… were unable to trigger the ventilator.” I suspect he was making a case for these patients experiencing excessive dyspnea during weaning attempts due to their usual state of iatrogenically induced hypocapnia, but this was still difficult to discern after several re-readings. The rest of the chapter deals with various noninvasive patient/ventilator interfaces and why they work (much of which is repeated in later chapters) and concludes with a discussion of the putative benefits of maximal insufflations on lung and chest wall mechanics.

The next chapter, also by Dr. Bach, discusses so-called “conventional” approaches to home ventilation. Assuming that the naïve reader has not yet discerned Dr. Bach’s point of view, this chapter makes it clear that he considers positive pressure ventilation via tracheotomy to be anathema for neuromuscular disease patients. In fact, the introductory quote by Gustav Mahler translates as “tradition is nothing other than negligence.” What follows is a somewhat muddled discussion of ventilator modes, and a litany of horror stories concerning poor patient outcomes from invasive ventilatory approaches. Included also is gratuitous criticism of a review article coauthored by Mark Sanders, one of the world’s most expert proponents of noninvasive positive pressure ventilation.

From that point on, the book improves considerably. The following chapter contains excellent reviews of the various noninvasive ventilatory modes, including negative pressure body ventilation as well as positive pressure ventilation through a variety of interfaces. A table comprehensively summarizes the various interfaces available; comments concerning the specific attributes of some of the devices are included, but such material on many more of the interfaces would have been welcomed. Dr. Bach also makes the key point that “No patient should be offered and expected to use only one nasal interface… .” Several topics not usually presented in pulmonary training programs or textbooks will be of particular value to pulmonologists: mechanical insufflation-exsufflation and glossopharyngeal breathing. Later chapters explain Dr. Bach’s protocol for managing patients on noninvasive positive pressure ventilatory support; his approach to various specific disease categories; noninvasive ventilation of children and of patients in acute care settings and at home; physical therapy in patients receiving noninvasive support (including techniques for managing respiratory secretions); and nutritional support in such patients. A final chapter contains case histories of patients with ventilatory failure illustrating some of the perils, pitfalls, and successes of invasive and noninvasive ventilatory support.

Noninvasive Mechanical Ventilation is very much a personal work of Dr. Bach, and as such shares the iconoclastic, proselytizing style for which he is known. While that manner can be somewhat off-putting, it never fails to hold one’s attention, and there is no arguing with the fact that he has made seminal contributions to this field. With each seemingly controversial statement, I found myself attempting to justify the conventional approach, and not infrequently I concluded that Dr. Bach’s approach carried greater merit. Overall, I could not help but conclude that, although not without flaws, this volume should be “must reading” for any clinician managing patients with chronic ventilatory failure.




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