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Olivier Contal, PhD, PT; Jean-Louis Pépin, MD, PHD; Jean-Paul Janssens, MD
Author and Funding Information

From the Division of Pulmonary Diseases (Drs Contal and Janssens), Geneva University Hospitals; HP2 Laboratory, Hypoxia: Pathophysiology (Dr Pépin), INSERM U1042; and Sleep Laboratory (Dr Pépin), EFCR, Grenoble University Hospital.

Correspondence to: Olivier Contal, PhD, PT, Division of Pulmonary Diseases, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1211 Geneva 14, Switzerland; e-mail: olivier.contal@hcuge.ch


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1693-1694. doi:10.1378/chest.12-2082
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To the Editor:

We agree with the conclusions of Dr Esquinas and colleagues. There is a substantial variability in reliability of ventilator software, in modes of data reporting as detailed in our study,1 and also in ventilator pressurization capabilities.2 For these reasons, clinicians must become familiar with the performance and the limitations of the devices they choose among those that are commercially available for home noninvasive ventilation (NIV). This is, however, a problem, since independent testing and validation of ventilator software or new ventilator modes are either not always available or not necessarily conclusive. For instance, ventilators proposing volume-targeted bilevel pressure support have been commercialized for several years, yet the evidence concerning the clinical relevance of this mode remains inconclusive.3-5 Although volume targeting may improve nocturnal transcutaneous Pco2 by a few mm Hg, it may be at the expense of a decrease in quality of sleep; furthermore, the short- or long-term clinical benefit in adults is not established.3 In sleep-disordered breathing, the option of auto-CPAP is present in most or all CPAP devices on the market, without having shown its superiority in terms of efficiency or compliance.6 Another example concerns interfaces for NIV. Borel et al7 showed that the type of mask chosen by the clinician has a direct and significant impact on volume delivered to the patient as well as on the effective pressurization by home ventilators.

One could also argue that this type of study shows that it is crucial to have an independent evaluation of home ventilators and their performance before their commercialization. This evaluation should include not only basic functioning and safety but also reliability of built-in software for monitoring and relevance of new ventilator modes or “gadgets” proposed. Commercial competition puts conceivers of medical devices under enormous pressure to propose new and attractive options, and the ingenuity and creativity of conceptors and technicians in this field is remarkable. However, a new medication must prove not only its safety but also its efficacy and its benefit compared with already existing treatments. Similarly, new ventilators, ventilator modes, or ventilator software should be subjected to premarketing testing based on recommendations made by scientific societies in this field. Moreover, pivotal studies should demonstrate the interest of these innovations not only on surrogate markers, such as sleep quality or nocturnal transcutaneous Paco2, but also in terms of long-term outcomes (ie, morbidity, mortality, and quality of life).

We also agree with Dr Esquinas and colleagues on the point that monitoring can significantly impact NIV effectiveness. We need comparative effectiveness studies that include cost effectiveness as an outcome to allow decision-makers to develop health-care policies regarding the clinical application of NIV monitoring for the ambulatory management of patients on long-term NIV. Until this is implemented, we must, as clinicians, keep in mind that among the ingenious options offered by ventilator conceivers, all that glitters is not gold.

References

Contal O, Vignaux L, Combescure C, Pepin J-L, Jolliet P, Janssens J-P. Monitoring of noninvasive ventilation by built-in software of home bilevel ventilators: a bench study. Chest. 2012;141(2):469-476. [CrossRef] [PubMed]
 
Battisti A, Tassaux D, Janssens JP, Michotte JB, Jaber S, Jolliet P. Performance characteristics of 10 home mechanical ventilators in pressure-support mode: a comparative bench study. Chest. 2005;127(5):1784-1792. [CrossRef] [PubMed]
 
Janssens JP, Metzger M, Sforza E. Impact of volume targeting on efficacy of bi-level non-invasive ventilation and sleep in obesity-hypoventilation. Respir Med. 2009;103(2):165-172. [CrossRef] [PubMed]
 
Storre JH, Seuthe B, Fiechter R, et al. Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial. Chest. 2006;130(3):815-821. [CrossRef] [PubMed]
 
Windisch W, Storre JH. Target volume settings for home mechanical ventilation: great progress or just a gadget?. Thorax. 2012;67(8):663-665. [CrossRef] [PubMed]
 
Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2009;(4):CD003531.
 
Borel JC, Sabil A, Janssens J-P, et al. Intentional leaks in industrial masks have a significant impact on efficacy of bilevel noninvasive ventilation: a bench test study. Chest. 2009;135(3):669-677. [CrossRef] [PubMed]
 

Figures

Tables

References

Contal O, Vignaux L, Combescure C, Pepin J-L, Jolliet P, Janssens J-P. Monitoring of noninvasive ventilation by built-in software of home bilevel ventilators: a bench study. Chest. 2012;141(2):469-476. [CrossRef] [PubMed]
 
Battisti A, Tassaux D, Janssens JP, Michotte JB, Jaber S, Jolliet P. Performance characteristics of 10 home mechanical ventilators in pressure-support mode: a comparative bench study. Chest. 2005;127(5):1784-1792. [CrossRef] [PubMed]
 
Janssens JP, Metzger M, Sforza E. Impact of volume targeting on efficacy of bi-level non-invasive ventilation and sleep in obesity-hypoventilation. Respir Med. 2009;103(2):165-172. [CrossRef] [PubMed]
 
Storre JH, Seuthe B, Fiechter R, et al. Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial. Chest. 2006;130(3):815-821. [CrossRef] [PubMed]
 
Windisch W, Storre JH. Target volume settings for home mechanical ventilation: great progress or just a gadget?. Thorax. 2012;67(8):663-665. [CrossRef] [PubMed]
 
Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2009;(4):CD003531.
 
Borel JC, Sabil A, Janssens J-P, et al. Intentional leaks in industrial masks have a significant impact on efficacy of bilevel noninvasive ventilation: a bench test study. Chest. 2009;135(3):669-677. [CrossRef] [PubMed]
 
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