Introduction: Although patients with an acute increase in airflow resistance may require aerosol therapy and noninvasive positive pressure ventilation (NIPPV), the efficiency of different aerosol devices and masks during NIPPV is not well understood. The purpose of this study was to determine the efficiency of a jet nebulizer (JN), a vibrating mesh nebulizer (VMN) and a pressurized metered-dose inhaler (pMDI) and three different masks during NIPPV. Method: An in vitro lung model consisted of the upper airway of an adult teaching manikin with a collecting filter at the level of the bronchi attached to a passive test lung. NIPPV was administered via full face mask for the first experiment (AF531 oro-nasal) with an IPAP/EPAP of 20/5 cm H2O and a respiratory rate of 15 Breath per minute (BPM). Aerosol generators were placed between the leak in the circuit and the mask. Albuterol sulfate (2.5 mg/ 3 ml) was nebulized with the JN (Micromist) and the VMN (Aeroneb Solo). Four puffs (108 µg/puff) were administered with the pMDI (ProAir HFA) with a spacer (Aerovent) that first was placed in the recommended normal position (pMDI-N) with aerosol plume directed towards patient, and then in the reversed position (pMDI-R), with aerosol directed away from patient (n=3). In the second experiment, three masks were used 1) the Performax mask, 2) the AF531 oro-nasal mask, and 3) the Performa track mask. Performa track mask was tested with only Aeroneb solo while other masks were tested with both Aeroneb solo and NIVO VMNs. In both experiments, filters were eluted with 0.1 HCl and analyzed by a spectrophotometer at 276 nm. Residual volumes were determined gravimetrically. Result: Descriptive statistics, one-way analysis of variance (ANOVA), and independent t tests were used. Statistical significance was set at p<0.05. During NIPPV, inhaled mass (IM) and inhaled mass percent (IM %) varied significantly (p=0.042 and p=0.028, respectively). Aerosol delivery with the JN was the lowest during NIPPV. The VMN has a significantly lower residual volume than the JN (p=0.0001). No statistical difference in efficiency was found between the two pMDI orientations (p=0.253). In the second experiment, oro nasal mask with Aeroneb Solo VMN results in the highest IM which was significant when compared with all other masks(p=0.0001). No statistical difference can be found between other masks. Conclusion: The JN was less efficient than the VMN and the pMDI in either orientation. The type of aerosol device used during NIPPV influenced aerosol delivery in this simulated adult lung model. Oro nasal mask with Aeroneb Solo VMN provided the highest IM.

UA Open Access Publishing Fund / Background: Noninvasive positive-pressure ventilation (NIPPV) use has increased in the treatment of patients with respiratory failure. However, despite decreasing the need for intubation in some patients, there are no data regarding the risk of intubation-related complications associated with delayed intubation in adult patients who fail NIPPV. The objective of this study is to evaluate the odds of a composite complication of intubation following failed NIPPV compared to patients intubated primarily in the medical intensive care unit (ICU). Methods: This is a single-center retrospective cohort study of 235 patients intubated between 1 January 2012 and 30 June 2013 in a medical ICU of a university medical center. A total of 125 patients were intubated after failing NIPPV, 110 patients were intubated without a trial of NIPPV. Intubation-related data were collected prospectively through a continuous quality improvement (CQI) program and retrospectively extracted from the medical record on all patients intubated on the medical ICU. A propensity adjustment for the factors expected to affect the decision to initially use NIPPV was used, and the adjusted multivariate regression analysis was performed to evaluate the odds of a composite complication (desaturation, hypotension, or aspiration) with intubation following failed NIPPV versus primary intubation. Results: A propensity-adjusted multivariate regression analysis revealed that the odds of a composite complication of intubation in patients who fail NIPPV was 2.20 (CI 1.14 to 4.25), when corrected for the presence of pneumonia or acute respiratory distress syndrome (ARDS), and adjusted for factors known to increase complications of intubation (total attempts and operator experience). When a composite complication occurred, the unadjusted odds of death in the ICU were 1.79 (95% CI 1.03 to 3.12). Conclusions: After controlling for potential confounders, this propensity-adjusted analysis demonstrates an increased odds of a composite complication with intubation following failed NIPPV. Further, the presence of a composite complication during intubation is associated with an increased odds of death in the ICU.

Acid maltase deficiency (AMD) is a rare autosomal recessive genetic disorder that results in an accumulation of glycogen in the lysosomal storage vacuoles. It is classified as a glycogen storage disease (type II) and is also known as Pompe's disease. The prognosis of the patient with AMD is poor and the main cause of death is respiratory failure. We report a female patient whose respiratory insufficiency was documented to occur most severely during rapid eye movement sleep and who benefited clinically from the institution of nocturnal noninvasive bilevel positive airway pressure.