Running head: NONINVASIVE POSITIVE PRESSURE VENTILATION 1
Noninvasive Positive Pressure Ventilation Compared to
Noninvasive Mechanical Ventilation in Respiratory Failure Patients
Alice Pinyan
Maryville University
2NONINVASIVE POSITIVE PRESSURE VENTILATION
Chapter I
Introduction
Chronic obstructive pulmonary disease (COPD) is a severe and debilitating disease
characterized by the progression of an individual’s inability to have normal breathing related to
the obstruction of airflow and is not fully reversible (World Health Organization, 2016).
According to the World Health Organization (2017), 65 million people have COPD. The
prevalence of chronic obstructive pulmonary disease is astounding. According to the Centers for
Disease Control and Prevention (2017a), 15.7 million Americans are diagnosed with COPD.
There are approximately eight per 100,000 individuals in Tennessee who have COPD (Centers
for Disease Control and Prevention, 2017b).
Chronic obstructive pulmonary disease patients often develop high carbon dioxide (CO2)
levels and low oxygen (O2) levels that are diagnosed as hypercapnic respiratory failure with
hypoxia. The clinic where the data will be collected, East Tennessee Pulmonary and Sleep
Medicine, serves patients with pulmonary and sleep disorders. Education and treatment provided
at the author’s clinical practice site provide a holistic approach to using education, counseling,
and treatment regimens to prevent deterioration of symptoms in COPD patients with hypercapnic
respiratory failure (HRF).
This disease affects individuals, families, communities, and the economy emotionally,
physically and financially. According to estimates from the World Health Organization (2017),
“65 million people have moderate to severe chronic obstructive pulmonary disease” and “more
than 3 million people died of COPD in 2005.” According to the Centers for Disease Control and
Prevention (CDC), “Almost 15.7 million Americans (6.4%) reported that they had been
diagnosed with COPD.” The CDC (2017) also reported that COPD “was the third leading cause
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of death in the United States in 2014.” There are 7.06-9.29 per 100,000 individuals in Tennessee
that are reported to have COPD (Centers for Disease Control and Prevention, 2011). The 2012
hospitalization rates for COPD were higher for women, and the age range for those hospitalized
most was 70-79 years (Tennessee Department of Health, 2017). As the disease progresses, the
patient can develop hypercapnic respiratory failure (HRF). Hypercapnia is having high carbon
dioxide (CO2) levels in the arterial blood. This study will explore the effectiveness of
noninvasive positive pressure (NIPPV) compared to noninvasive mechanical ventilation (NMV)
in respiratory patients.
The incidence of COPD is high and using oral and nebulized medications are not always
enough. Chronic obstructive pulmonary disease patients are put on noninvasive positive air
pressure devices to assist in keeping airways open, but a newer device is the noninvasive
mechanical ventilator (NMV) (e.g., Trilogy and Astral). The devices work differently, and the
effects of the two types of devices warrant a comparison in the treatment of HRF patients.
There are two types of noninvasive positive pressure modes. The continuous positive air
pressure (CPAP) device has one setting for the continuous inspiratory pressure that the patient
breathes and the bilevel positive air pressure (BiPAP) device has an inspiratory and an expiratory
(I/E) pressure. In more advanced noninvasive positive pressure ventilation (NIPPV) devices,
there are more settings that can be used to better support the hypercapnic respiratory failure
patients. One of these devices is the bilevel positive air pressure with spontaneous timed
(BiPAP-ST) mode. This device automatically senses when spontaneous respiration does not
occur, and a forced breath is triggered after a specified amount of time. The average volume
assured pressure support (AVAPS) has the same modes as the BiPAP but has volume cycled
positive pressure or tidal volume control (Hyzy, 2017). This setting ensures that the lungs fill
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with a specific volume of air during inspiration. Noninvasive mechanical ventilation (NMV) can
provide any of the mentioned modes, separately, or in combination as in a mechanical ventilator
(Hyzy, 2017). This project aims to improve patient outcomes by comparing the results of the
NIPPV and noninvasive mechanical ventilation (NMV) and determining which device will be
most effective in the treatment of COPD patients with hypercapnic respiratory failure. Then,
advanced practice nurses will have the knowledge to select the device most appropriate for their
patients.
Purpose
The use of noninvasive positive pressure ventilation (NIPPV) and noninvasive mechanical
ventilation (NMV) have positive effects on patients. The purpose of this project is to answer the
question: In respiratory patients, what is the effect of utilizing traditional noninvasive positive
pressure ventilation devices (CPAP, BiPAP, BiPAP-ST) compared to newer noninvasive positive
pressure ventilation devices (Trilogy, Astral)? The project will take place in an office setting at
East Tennessee Pulmonary and Sleep Medicine clinic in Tennessee, and will compare traditional
noninvasive positive pressure devices to the new noninvasive mechanical ventilation devices in
patients with hypercapnic respiratory failure (HRF) due to chronic obstructive pulmonary disease
(COPD). Pulmonary function test (PFT) and arterial blood gas (ABG) results will be used as
quality indicators to compare the effectiveness of the devices.
Background
The idea for this project came about by the recurring denials of coverage for noninvasive
positive pressure ventilation devices (BiPAP, AVAPS) and mainly the noninvasive mechanical
ventilation devices (Trilogy, Astral). The primary researcher observed that patients started on
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the noninvasive mechanical ventilation devices had an overall improvement in health status, and
when the devices were denied, the therapy was stopped, and the patients deteriorated.
Noninvasive positive pressure ventilation is controversial. Literature is limited on the effects
of NIPPV in HRF and literature is also limited on noninvasive mechanical ventilation devices.
The use of the acronym NIPPV is often used in the literature to describe all types of ventilation
support devices. The NMV provides continuous or intermittent ventilatory support and has
multiple modes like a mechanical ventilator.
Patients with COPD who develop hypercapnic respiratory failure benefit from using NIPPV
and NMV. Using NIPPV improves respiratory status by decreasing CO2 levels, stabilizing or
improving lung function, and exercise tolerance. A systematic review and meta-analysis by
Struik, Lacasse, Goldstein, Kerstjens, and Wijkstra (2013) reported improvement in partial
arterial carbon dioxide (PaCO2) and an increase in walking distance. Zamzam, Azab, El Wahsh,
Ragab, and Allum (2013) indicated that activity is affected by the severity of COPD.
Patients that were previously on the noninvasive positive pressure ventilation had a decline in
respiratory status when the device was not used. Oscroft, Quinnell, Shneerson, and Smith
(2010b) stated that stopping NIPPV at night made breathing worse. They reported that the
patient had an increase in CO2 levels.
Even with the controversy about using NIPPV/NMV for the treatment of HRF in COPD
patients, studies showed there is an improvement in CO2 levels, patient symptoms, and exercise
endurance with the use of these devices. The research findings will compare the effects of the
noninvasive treatment modalities in respiratory failure patients who have severe or very severe
COPD.
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Significance
Nursing
The role of nurses is crucial in the care of respiratory patients, namely COPD and respiratory
failure patients. Knowledge about COPD exacerbations and types of respiratory failure is the
key to prompt and adequate care. Chronic obstructive pulmonary disease decreases airflow in
patients, and the reduction of airflow leads to Type 1 respiratory failure. Type 1 respiratory
failure is a decrease in oxygenation. Type 2 respiratory failure is a decrease in ventilation which
causes increased CO2 and low oxygen (Hunter 2009). Nurses play a vital role in this study
because they are responsible for patient assessments and communicating the findings to the
physician or nurse practitioners in order to implement the best interventions for the patient. The
use of NIPPV has also been reported to prolong survival in patients with COPD and hypercapnic
respiratory failure (Hanna, Dominelli, Chen, Reid, & Road, 2013).
Advanced Practice Nursing
The significance of this project for advanced practice nursing comes from the tertiary level of
care. Advanced practice nurses (APN) have advanced knowledge to care for patients at this
level. Tertiary care is the level of care where the APN has the knowledge to diagnose and treat
disease and disabilities. With proper education, the APN can diagnose COPD, COPD
exacerbations, respiratory failure, and provide care to improve patient outcomes. APN’s starting
the NIPPV or NMV as a treatment in COPD patients with respiratory failure can improve patient
outcomes and possible decrease mortality rates. Galli et al. (2014) indicated findings of
increased survival in patients with NIPPV use compared to patients with no NIPPV (µ2 = 23.8, p
< 0.0001) and found a reduction in hospitalizations (40% vs. 75%, p < 0.0001) through 180 days.
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Advanced practice nurses use all levels of care for the patients, but using NIPPV at the tertiary
level can provide a benefit for the COPD patients who have hypercapnic respiratory failure.
Healthcare
Chronic obstructive pulmonary disease affects healthcare, and one significant burden to
healthcare is the costs for treatment of COPD patients. According to the Centers for Disease
Control and Prevention (2017a), by 2020 the cost of medical care for COPD patients will be
more than $90 billion. The use of NIPPV decreases the cost of hospital stays and does not
increase cost when used at home (Clini, Magni, Crisafulli, Viaggi, & Ambrosino, 2009). There
needs to be more studies to determine if home use of NIPPV and NMV decreases hospitalization
rates in COPD hypercapnic respiratory patients and benefits healthcare.
Practice Support
The pulmonary practice where the project will be completed will provide excellent support.
The supervising physician and the staff understand the importance of this project on a
professional and personal level. The supervising physician is a committee member who is
willing to provide guidance for the project. The office manager has agreed to access of the
charts with the understanding that permission is required from the facility officials and the
Institutional Review Board before the data is extracted by the primary investigator. The
supervising physician and the office manager have approved weekend visits to the office for the
investigator to review the charts and obtain information. Having internal support increases
confidence that the project on the effects of NIPPV compared to NMV in COPD patients with
hypercapnic respiratory failure can be accomplished.
Benefit of Project to Practice
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The benefit of this project will assist in determining the most effective ventilation methods for
COPD hypercapnic respiratory patients. Trying to determine the appropriate device to use for
patients and the process for approval is time-consuming. Having more knowledge about the
effects of the NIPPV and the NMV will decrease the paperwork, stress, and time to get approval
for the appropriate devices. The greatest benefit of this project to practice is practitioners will
know the patients will be receiving the treatment that is most beneficial for them.
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Chapter II
Literature Review
Chronic obstructive pulmonary disease (COPD) is a progressive disease that causes
dysfunction in respiratory gas exchange. Many patients with COPD progress to develop
respiratory failure. The treatments for COPD patients are limited to medications in pill, inhaler,
and nebulizer form. Patients with respiratory failure are also treated with noninvasive positive
pressure ventilation. Noninvasive positive pressure ventilation (NIPPV) and noninvasive
mechanical ventilators (NMV) are controversial. The purpose of this research study is to answer
the question: In patients with COPD, what is the effect of utilizing traditional noninvasive
positive pressure ventilation compared to newer noninvasive mechanical ventilation devices.
This project aims to determine if newer NMVcompared to traditional NIPPV treatment
modalities provide improved patient outcomes as measured by pulmonary function testing (PFT)
and arterial blood gas carbon dioxide (CO2) levels.
A comprehensive review of the literature identified articles on noninvasive positive pressure
ventilation and noninvasive mechanical ventilation in COPD, acute respiratory failure (ARF),
chronic respiratory failure (CRF), and exercise capacity. This chapter will explore literature on
the effects of noninvasive ventilation devices on lung function. Also, a comparison of traditional
and newer NIPPV treatment modalities will be presented.
Search History
A computerized search of several electronic databases was utilized to identify published
research articles. These databases included the Cochrane, Medline, and Cumulative Index to
Nursing and Allied Health Literature (CINAHL). The search terms included: chronic obstructive
pulmonary disease, acute respiratory failure, chronic respiratory failure, hypercapnia, exercise
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capacity, noninvasive positive pressure ventilation, and noninvasive mechanical ventilation. The
search was restricted to articles in English from January 1995 to July 2018. Articles that
contained reports on pulmonary function test (PFT), arterial blood gases (ABG) and exercise
capacity were included in the review. The studies that were included in the search centered on a
diagnosis of COPD, acute respiratory failure, chronic respiratory failure, hypoxia, and exercise
tolerance with the use of NIPPV devices. Articles that focused on educational information and
did not include PFT and ABG measurements or were specific to quality of life were excluded.
Relevant information from 38 articles from 2006-2018 was included in the literature review.
COPD
An explanation of COPD, acute respiratory failure, and chronic respiratory failure is
important for understanding the use of noninvasive positive pressure ventilation in respiratory
failure. Using NIPPV assists in keeping small airways open, maintaining tidal volume, and
maintaining CO2 and oxygen levels.
The abnormalities that occur in COPD affect the airways, lung parenchyma, and pulmonary
vasculature. According to Han, Dransfield, and Martinez (2017), changes in the airway include
inflammation, increased size of goblet cells, fibrosis, and airway collapse. The problem with air
exchange relates to permanent dilation of the lung parenchyma, hyperplasia of the pulmonary
vasculature, and smooth muscle hypertrophy. These pathological changes with COPD also
affect the alveolar structures and disrupt gas exchange (Han, Dransfield, and Martinez, 2017)
Acute Respiratory Failure
Patients with chronic obstructive pulmonary disease can develop acute respiratory failure.
Acute respiratory failure is the sudden onset of elevated partial pressure of arterial carbon
dioxide (PaCO2) and low partial pressure arterial oxygen (PaO2). Researchers suggest that the
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use of NIPPV lowers the risk of mechanical ventilation and decreases the risk of death (Liu,
Zhao & Tang, 2016). Information is presented on the effects of using noninvasive positive
pressure ventilation in out-of-hospital patients and according to Mal, McLeod, Iansavichene,
Dukelow, and Lewell (2014), using NIPPV during emergency medical service transport of
respiratory failure patients revealed a decreased risk of death and intubation. The patients also
have a better event-free survival rate (Galli et al., 2014). Vasquez et al. (2017) reported that
large numbers of COPD patients had not been prescribed positive air pressure devices for
respiratory failure. The risk of changes in gas exchange and serious complications are increased
as the disease progresses (Liao et al., 2017).
Acute hypercapnic respiratory failure can recur in chronic hypercapnic respiratory failure
(HRF) patients. The process of gas exchange malfunction causes the oxygen level to drop and
the carbon dioxide level to increase. Although acute respiratory failure is a severe form of
respiratory malfunction, mechanical ventilation is not always the first-line treatment (Liu et al.
2016). Patients stabilized with noninvasive positive pressure ventilation or noninvasive
mechanical ventilation for severe respiratory distress have decreased use of invasive mechanical
ventilation and decreased mortality (Mal et al. 2014). Patients who use NIPPV at home are
reported to have fewer readmissions for exacerbations of COPD and respiratory failure (Galli et
al., 2005). Everyone with chronic obstructive pulmonary disease is at risk for developing
chronic hypercapnic respiratory failure.
Chronic Hypercapnic Respiratory Failure
Chronic hypercapnic respiratory failure is a consistent elevation in the patient’s carbon
dioxide level that has occurred over time. Patients adapt to the elevated CO2 levels and are
asymptomatic of acute respiratory failure symptoms. Chronic obstructive pulmonary disease
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patients with hypercapnic respiratory failure are still at risk for acute HRF. There is an increased
risk of respiratory acidosis which decreases the central drive of respirations and could be reduced
with the use of noninvasive devices in the home (Zhou et al. 2017). A decrease in carbon
dioxide levels and improved patient survival is also supported (Liao et al., 2017).
Lung Function
Using noninvasive positive pressure ventilation in respiratory disease patients is important to
the health of the patient. According to Kolodziej, Jensen, Rowe, and Sin (2007), using bilevel
NIPPV shows a carbon dioxide reduction, but no improvement in lung function, work of
breathing, or exercise capacity. The studies on chronic respiratory failure in COPD patients
provide different information. Struik et al. (2013) found that after using the NIPPV for three
months, CO2 levels improved. There is an indication that improvement in CO2 levels, lung
function, work of breathing, and exercise capacity correlates to higher pressure levels on the
bilevel NIPPV and longer use time on the NIPPV (Kolodziej et al., 2007).
Not all studies indicated improvements in patients using the NIPPV. The study by Dretzke et
al. (2016) did not show significant changes in CO2, lung function, or exercise capacity. Hanna,
Dominelli, Chen, Reid, and Road (2013) did not indicate positive findings in other chronic
respiratory diseases namely amyotrophic lateral sclerosis, Duchenne muscular dystrophy,
restrictive thoracic disease, and obesity hypoventilation syndrome. Hanna et al. (2013) did
indicate the use of NIPPV in COPD patients was successful in past studies. There is an
indication of some improvement in CO2 levels in regards to better patient compliance with
NIPPV therapy (Bhatt, Peterson, Wilson, & Durairaj, 2013).
Patients who have severe stable COPD with hypercapnic respiratory failure (HRF) and use
the NIPPV have a reduction in exacerbations with decreasing costs from hospitalizations and
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intubations (Clini, Magni, Cristafulli, Viaggi, & Ambrosino, 2008). Clini et al. (2008) also
determined in a cost comparison that there was a reduction in the cost of hospital stay with the
implementations of NIPPV therapy.
The use of NIPPV can have a positive effect on patients in several ways. Decreases in CO2
levels, stabilized lung function, and decreased work of breathing, are positives of the NIPPV.
Another use of NIPPV is to increase exercise capacity for patients with respiratory failure.
Another consideration is in the past ten years; it has been recognized that inflammatory
responses can lead to comorbidities. These comorbidities include “ischemic heart disease, heart
failure, diabetes mellitus (DM), metabolic syndrome, osteoporosis, anemia and depression” and
improvement was seen in COPD patients with hypercapnic respiratory failure who used the
NIPPV (Dimoulis et al., 2015).
Studies on the use of noninvasive bilevel positive pressure interventions at night in stable
hypercapnic COPD patients are limited. One study by Struik et al. (2013) showed no significant
change with nocturnal NIPPV until three months and then it is recommended for higher pressure
usage whereas, McEvoy et al., (2009) found there may be an improvement in survival. Another
study found that the use of nighttime NIPPV in patients receiving pulmonary rehabilitation has
been shown to improve CO2 levels, maintain PaO2 levels, and improve the amount of gases
inhaled or exhaled in a minute (Duiverman et al. 2008).
Another study by Ciftci et al. (2017) reported increased mortality in older adults on NIPPV in
the hospital but accredited this to increased comorbidities. Patients who had an admission to the
hospital for acute respiratory failure and were discharged home on the NIPPV on oxygen had a
prolonged time until an exacerbation or death (Murphy et al., 2017). Moreover, Jaber et al.
(2016) stated that NIPPV is proven to be effective in acute exacerbations of COPD. Even
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though most of the studies in the literature are about the use and effectiveness of NIPPV in acute
hypercapnic respiratory failure, home NIPPV is commonly indicated for COPD (Crimi et al.,
2016). The evidence reports that the use of NIPPV in COPD patients with hypercapnic
respiratory failure is beneficial for decreasing carbon dioxide levels, decreasing readmissions for
exacerbations, and decreasing mortality. Further research comparing NIPPV to NMV in COPD
patients with hypercapnic respiratory failure would provide evidence on the statistical
significance of one device over the other.
Exercise Capacity
Activity in patients with COPD is limited by shortness of breath from pathophysiological
factors. Respiratory failure patients gradually adapt to worsening shortness of breath by
decreasing activity levels (Lahaije, Van Helvoort, Dekhuijzen, & Heijdra, 2010). Activity
limitations in patients with COPD lead to decreased ability to perform activities of daily living
due to physiological changes in COPD. Lahaije et al. (2010) showed that exercise is limited for
various reasons such as lack of energy, motor dysfunction, and hyperinflation. Oscroft et al.
(2010b) indicated there is a significant improvement in exercise capacity, gas exchange, and
improved survival with use of the NIPPV and Salturk et al. (2015) stated the use of noninvasive
mechanical ventilation at home improved exercise capacity in the six-minute walk test.
On further review of the literature, there is information on improvement in respiratory failure
patients using hi intensity NIPPV. A study by Dreher, Storre, & Windisch (2007) indicated that
the use of hi intensity NIPPV with activity increases oxygen levels, yields less shortness of
breath, and increases exercise capacity. The ability of patients to ambulate and use lung function
to its fullest capacity is important to survival and decreasing complications. The use of NIPPV
with activity helped patients not only with gas exchange and lung function, but also improved
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health-related quality of life, mood, dyspnea, and exercise tolerance (Duiverman et al., 2011).
One negative indication on the use of NIPPV in COPD patients was no change in oxygen levels
with the device during ambulation (Walker et al., 2015). The use of specific devices in research
studies is limited, but research is necessary for showing the effect of the devices on COPD and
hypercapnic respiratory failure.
Device Comparison
The findings in the literature for comparisons of standard NIPPV devices and NMV are
limited. This study will help to fill the gaps in the literature. The comparisons are related to
continuous positive air pressure (CPAP), bilevel positive air pressure (BPAP), and volume-
assured pressure support (VAPS) devices (Pluym, Kabir, & Gohar, 2015). Studies indicated the
use of NIPPV could improve survival, reduce hypercapnia, and improve gas exchange (Bhatt,
Peterson, Wilson, & Durairaj 2013; Kolodziej, Jensen, Rowe, & Sin 2007). Shebl and
Abderaboh (2015) stated that the use of noninvasive positive pressure ventilation could assist
COPD patients with breathing at night by decreasing end-expiratory lung volume and improving
CO2 levels by the enhancement of respiratory functions. A further consideration for NIPPV is
the use of high-intensity devices for improvement in respiratory function, exercise capacity, and
gas exchange (Altintas, 2016).
Although noninvasive positive pressure ventilation continues to be controversial in treating
COPD, the NIPPV is efficiently used for patients with COPD that experience respiratory failure
in hospital settings but is controversial in regards to the effectiveness of in-home use (Altintas,
2016). NIPPV indicates improvement in pulmonary function and arterial blood gases with the
goal of lowering PaCO2 levels and increasing survival related to improvement in hypercapnia
(Bhatt, Peterson, Wilson, & Durairaj, 2013).
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In a randomized crossover trial by Oscroft et al. (2010a) on the use of volume-assured
compared to pressure preset devices, the results did not indicate any difference in the effects on
respiratory failure between the two devices as they were equally effective in each group, but
further studies with different inspiratory ventilation settings may be useful. Windisch, Haenel,
Storre, & Dreher (2009) found that high-intensity NIPPV improved CO2 levels, lung function,
and exacerbation rates as evidenced by decreased hospitalizations for exacerbation in the first
year with using the device compared to previous studies with lower inspiratory settings. The use
of positive air pressure devices namely CPAP, BiPAP, and NIPPV showed a reduction in
hospitalization of COPD patients (Vasquez et al., 2017). In a newer device, that is an NIPPV
with built-in software; there is a reduction in PaCO2 and improved exercise tolerance and
compliance with therapy (Zhou et al., 2017).
The use of mechanical ventilation increases a patient’s risk of complications such as
baroreceptor damage, ventilator-associated pneumonia, tracheal damage, and death (Liu et al.
2016). The use of NIPPV can decrease these risk factors. Carbon dioxide levels are reported to
be significantly lower with noninvasive mechanical devices (Ekkernkamp, Storre, Windisch, &
Dreher, 2014). According to Tsai, Lee, Delcos, Hanania, & Camargo, 2013), the guidelines
recommended early use of NIPPV, but use is limited for various reasons. These reasons include
lack of knowledge, insufficient training, lack of equipment, and set up time. An important
finding in the literature was how withdrawing long-term nighttime NIPPV affects COPD
patients. Long-term withdrawal of the NIPPV caused a progressive elevation in CO2, and these
findings were associated with increased mortality (Oscroft, Quinnell, Shneerson & Smith,
2010b).
Literature Critique
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The articles reviewed suggest negative and positive findings, and this information is
important to this project. This project will attempt to fill the gap in the literature that exists in
making the decision of which device is more beneficial to the patient. This project will
hopefully contribute to the body of knowledge about COPD and how it can be managed
effectively.
Strengths
The literature on noninvasive positive pressure ventilation is vast and varies greatly on
obstructive pulmonary diseases. The literature provided information on HRF in COPD patients
and the effects of the NIPPV on CO2 levels, lung function, and exercise capacity. The use of
NIPPV is beneficial with some patients (Dretzke et al. 2016). Hanna et al. (2013) stated that
NIPPV has been used and is effective in patients with hypercapnic respiratory failure. The
primary researcher supports that research that has been done on the positive effects of using the
NIPPV and the NMV in the treatment and maintenance of symptoms in hypercapnic respiratory
failure patients.
Weaknesses
The weaknesses in the literature were many. One weakness was the lack of studies on
specific devices. Several of the researchers discussed COPD and NIPPV, but did not mention
the stages of COPD. According to the Global Strategy for the Diagnosis, Management, and
Prevention of COPD (2017), the Global Initiative for Chronic Obstructive Lung Disease
(GOLD) (2017) categories are labeled one through four and include mild, moderate, severe, and
very severe stages. Most of the researchers described studies done on NIPPV and did not specify
BiPAP, BiPAP-ST, or NMV. The distinction in the devices could provide evidence-based
information on which device is most effective in the different stages of COPD and could identify
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which devices and pressures are needed for treatment of the symptoms of COPD, respiratory
failure, and hypercapnia.
Gaps
Gaps in the literature include the lack of inclusion criteria for comorbidities. This gap makes
the information seem incomplete because the comorbidities along with an established diagnosis
of COPD might impact the results of the intervention. A COPD patient with HRF can have
worsening symptoms related to heart disease, bronchiectasis, diabetes and other diseases.
Another gap in the literature was the use of patients with a diagnosis of alpha-1 antitrypsin
(A1A) deficiency COPD. Alpha-1 antitrypsin is a protease inhibitor. The deficiency of alpha-1
antitrypsin is an inherited disorder and can cause problems with the lungs including chronic
obstructive pulmonary disease which can lead to respiratory failure. Patients with A1A are
classified by the severity of the COPD and should be included if they are treated with NIPPV or
another device. Another gap in the literature are studies that focus on specific devices. This
project will add to the body of knowledge on respiratory devices used to treat COPD. This
project will hopefully help to decrease the gaps in the literature.
Limitations
The articles assessed in this review of literature pointed out several limitations. One of the
limitations is the risk of selection bias with randomized control trials (Hannan et al. 2013).
Selection of participants who are at high risk of acquiring a disease is an example of selection
risk bias. Enrolling patients and not using them in the study is a limitation (Kahan, Rehal & Cro,
2015). Patients who are enrolled in a study and meet inclusion criteria should be used in the
study so that the population can be represented through all participants. The lack of similarities
in patients and the design of studies is a significant limitation according to Liu et al. (2016).
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Patients used in studies should have similar qualities for the study to be accurate and the design
must be appropriate for the aim of the study. Oscroft et al. (2010) stated that the lack of
participants is a limitation as the number of patients should be large enough to represent the
population.
Concepts and Definitions
Chronic Obstructive Pulmonary Disease is described in many ways, but Dretzke et al. (2016)
described it as a “progressive lung disease, characterized by nonreversible airflow obstruction
and intermittent exacerbations” (p. 2269). One important factor with COPD is the nonreversible
factor. The nonreversible factor makes the point that no device repairs the damage to the lungs,
but could improve and maintain the current lung function. Using NIPPV as a treatment for
COPD HRF can assist with lowering carbon dioxide levels and improving exercise tolerance
(Zhou et al., 2017). Management to keep the CO2 levels in a safe range decreases the risks of
exacerbations or acute respiratory failure. COPD has several stages of severity. The severity of
COPD is determined by the forced expiratory volume in one second (FEV1) that is below a
normal range of 80% to 120%. In the Global Initiative for Chronic Obstructive Lung Disease
(GOLD), there are four stages of COPD. This study will center on the third and fourth stages of
COPD. GOLD 3 (severe) COPD with an FEV1 that is 30% of the predicted lung function and in
GOLD 4 (very severe), less than 30% predicted lung function (Global Initiative for Chronic
Obstructive Lung Disease, 2016).
“Respiratory failure is a syndrome in which the respiratory system fails in one or both of its
gas exchange functions” (Liu et al. 2016, p. 514). Patients can have respiratory failure in which
the oxygen level is critically low, or the CO2 level is critically high with low oxygen levels.
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Noninvasive positive pressure ventilation is initiated as a treatment modality for patients
“with or at risk of chronic hypercapnic respiratory failure” (Hannan et al. 2013, p. 230). The use
of the term noninvasive positive pressure ventilation is confusing. The term is used to describe
all devices such as CPAP, BiPAP, BiPAP-ST, VAPS, and NMV when the modes and use of the
devices are different. For example, the CPAP and BiPAP are used to treat sleep apnea and
BiPAP, BiPAP-ST, and VAPS are used to treat central apnea events and COPD. The NMV is
used to treat hypercapnic respiratory failure in patients who need pressure support and tidal
volume control.
Theoretical Framework
Betty Neuman’s Systems Model of Nursing
The Neuman’s Systems Model of Nursing is a mid-range open system-based theory and will
be the theoretical framework guiding this research study. Neuman’s model can be used
holistically and serves as a guide to holistic care (Neuman, 2017). Neuman’s theory focuses on
the client/client system that includes the individual, family, group/aggregate, and community
(Neuman, 2017). Neuman’s model includes physiological, psychological, sociocultural,
developmental, and spiritual variables. Neuman’s model also includes internal, external, and
created environments, and intra-personal, inter-personal, and extra-personal stressors.
The Neuman System Model will assist nurse practitioners in making informed decisions on
treatment modalities for COPD patients with HRF. Understanding the progression of and the
treatments for chronic obstructive pulmonary disease with hypercapnic respiratory failure is
important for health care providers involved with patients.
The interacting variables of Neuman’s model help health care providers and others to
understand the effect the disease can have on the patient. The patient experiences physical
21NONINVASIVE POSITIVE PRESSURE VENTILATION
changes such as shortness of breath, coughing, sputum production, fatigue, and decreased
exercise capacity. They also have psychological problems like anxiety from the increased
shortness of breath, and depression from the changes in their social life. The developmental
stages of COPD patients with HRF are also affected. The detrimental factors of the disease on
some patients bring a positive spiritual outlook or hope, and others have a negative spiritual
outlook or show despair. The model centers on the environments and stressors of the patient.
The environments in this model are internal, external, and created and the stressors are intra-
personal, inter-personal, and extra-personal. This model is important to this project because the
environment and stressors relate to the variables associated with the patient. The variables
include: (a) physiological, (b) psychological, (c) sociocultural, (d) developmental, and (e)
spiritual. The nurse practitioner must have an understanding of the patient’s environment and
stressors. Recognition of problems and the variables will prompt the nurse practitioner to order
appropriate interventions. These interventions include counseling, access to support programs,
further education on the disease, and access to spiritual leaders. Using the information from
Neuman’s model can assist the nurse practitioner to understand the issues that may arise with the
patient and how to intervene when needed.
Neuman also discusses the normal line of defense for the patient (client), the lines of
resistance, and optimal system stability. If the nurse practitioners are knowledgeable about the
disease and the effect it can have on patients, they can assist the patient in reaching the highest
level of health possible. This model uses the three dimensions of primary, secondary, and
tertiary prevention, and this is important to the evidence-based care and management of COPD
HRF patients, so they can maintain the highest level of health possible.
22NONINVASIVE POSITIVE PRESSURE VENTILATION
Chapter III
Methodology
The purpose of the methods chapter is to describe the research plan for this study. This
chapter will describe the steps that were used to address the research question. The research
question is as follows: What is the effectiveness of the NIPPV compared to NMV in respiratory
patients? This study will also address the needs assessment, resources needed, the project
budget, timeline and the protection of human subjects.
Research Design
A descriptive correlational design was utilized for this study in order to gain a better
understanding of the respiratory devices that would be best suited for COPD HRF patients. The
study was conducted using a retrospective chart review for obtaining the data. The data for this
project was extracted from the electronic medical records (EMR) of adult patients with COPD,
hypercapnia, hypoxia, and respiratory failure at the author’s clinic, East Tennessee Pulmonary
and Sleep Medicine. (See Appendix A – Approval Letter from Office Manager and the
Physician). The charts from all patients from January 1, 2008 to July 24, 2018 who received
treatment with NIPPV and NMV were reviewed by the primary investigator for potential
inclusion in the retrospective medical record review.
Sample and Setting
The sample was determined based on a power analysis which indicated the number of
subjects to utilize in the study, which were 128 subjects. The inclusion criteria: (a) 18 to 80
years of age, (b) any gender, (c) any ethnic background, (d) documented diagnosis of COPD
(stages Gold 3 or Gold 4), (e) documented diagnosis of hypercapnia, (f) documented diagnosis of
hypoxia, (g) documented diagnosis of respiratory failure, (h) documented baseline FEV1, PaCO2,
23NONINVASIVE POSITIVE PRESSURE VENTILATION
and PaO2, (i) documented post-treatment FEV1, PaCO2, and PaO2, and (j) documented use of
NIPPV or NMV. The setting, East Tennessee Pulmonary and Sleep Medicine, was founded in
2006 with the purpose of caring for patients from 12 years of age and older with pulmonary and
sleep disorders. The office was started by a physician, and in 2011 a nurse practitioner was added
to the practice. The practitioners see approximately 150 patients a week. The mission of the
clinic is to provide high quality, evidence-based care to all patients seen in the practice.
Measurement
The instrument used in the data collection procedure was a demographic survey that was
created by the primary investigator to collect pertinent data about the subjects. (see Appendix B
Data Collection Sheet). The data included age, gender, diagnosis, device, and pre-device PaO2,
FEV1 and CO2, and post-device PaO2, FEV1 and CO2. The demographic survey was utilized to
create the spreadsheet to assist with data analysis.
Data Collection Procedure
The primary investigator obtained approval from the IRB at Maryville University and
permission from the officials at East Tennessee Pulmonary and Sleep Medicine clinic to conduct
the study (see Appendix A – Approval Letter from Office Manager and the Physician). After
approval from the IRB was granted for the study, the primary investigator accessed the electronic
medical records and there were 39 patients who met the inclusion criteria. The data collected
from the archival charts included age and diagnoses of COPD, hypercapnia, hypoxia, and
respiratory failure. The data collected also included the type of devices, FEV1, PaCO2, and O2
levels. The data was manually exported to the spreadsheet and the primary investigator de-
identified the collected information into numerical codes that will not link the chart to any
participant (see Appendix B – Data Collection Sheet). This information was kept on an
24NONINVASIVE POSITIVE PRESSURE VENTILATION
encrypted computer in which the primary investigator was the only person who was familiar with
the password.
This research study was conducted through a retrospective chart review. There were no active
participants. A descriptive correlational study was utilized for this project. Electronic medical
records were obtained on-site from the clinic for data collection (See Appendix A - Approval
Letter from Office Manager and the Physician). The researcher recorded the selected data for
this project, which included: gender, device, pre- and post FEV1, pre- and post CO2, and pre- and
post O2 levels. (See Appendix B Data Collection Sheet). All potential patient identifiers were
removed, and the data were cleaned and coded for analysis.
Data Analysis
Following data collection and prior to data analysis, all data were cleaned and coded. All
statistical analysis was conducted using SPSS version 25 statistical package. The SPSS
statistical package allowed the researcher to reduce the data. The data were reported using
frequencies and percentages and displayed in tables. Descriptive statistics were calculated for
age, gender, diagnosis, respiratory devices, pre-device and post-device use for O2, CO2, and
FEV1 levels. Independent samples t-tests were utilized to compare the different devices by
assessing means of the O2, CO2, and FEV1 variables.
Needs Assessment
According to the World Health Organization (2017), 65 million people have COPD. The
prevalence of chronic obstructive pulmonary disease is astounding. According to the Centers for
Disease Control and Prevention (2017a), 15.7 million Americans are diagnosed with COPD.
There are approximately eight per 100,000 individuals in Tennessee who have COPD (Centers
for Disease Control and Prevention, 2017b). Patients with COPD hypercapnic respiratory
25NONINVASIVE POSITIVE PRESSURE VENTILATION
failure need more than medications to control disease symptoms. The elevation of carbon
dioxide can lead to death and needs to be controlled. The uses of NIPPV and NMV devices have
been shown to aid in decreasing the CO2 levels. Determining if the effectiveness of one device
compared to the other is statistically significant will aid in the selection of the most appropriate
device to use for the COPD HRF patients.
Resources
One resource for this project was the electronic medical record that was used on-site at the
clinic for the collection of demographics and data by the primary investigator. The specifically
designed spreadsheet was used for documenting the data that was collected from the EMR.
Other resources included a pulmonologist as a reference person for consultation on diagnosis,
PFT, and ABG results, and a statistician for questions regarding data analysis.
Project Budget
The financial resources needed for this project included personal use resources such as gas for
vehicle use and cost of office supplies. The time and travel to the office location were minimal.
There is no cost for access to the office, consultations with the pulmonologist, statistician, or
office manager. The cost of the project will be estimated at 25 dollars or less.
Timeline
A timeline is necessary for completion of the project. The steps in the timeline included
approval from the IRB and officials at the setting utilized for the project. The timeline also
included the implementation, analysis of the data results, and dissemination of the results into a
final written project and oral presentation. The analysis of the findings was completed in three to
four weeks. Finalizing the chapters and completion of the program will take place until August
26, 2018.
26NONINVASIVE POSITIVE PRESSURE VENTILATION
Protection of Human Subjects
The primary investigator obtained approval from the IRB at Maryville University and
permission from the officials at East Tennessee Pulmonary and Sleep Medicine clinic to conduct
the study (see Appendix A – Approval Letter from Office Manager and the Physician).
There were no foreseen risks for physical, psychological, social/economic, or legal risks that
would result from this study. One identified risk was a breach of confidentiality; however, this
risk is minimal as every effort was taken to maintain confidentiality. All data had all potential
identifiers removed. All data is presented in the aggregate. To minimize the risk of breach of
confidentiality, consent and HIPAA forms from the participating facility were obtained and
signed by the principal investigator. To keep the obtained data safe and confidential, it was
stored on a password protected computer within a secure personal location to which only the
principal investigator is aware and possesses access. The location where the computer was
located was locked inside a personal space with the key residing with the principal investigator
only. After the data was statistically analyzed, it was returned to the participating facility and
shredded in accordance with the facility policy that is already in place to destroy confidential
medical records
The data was recorded and stored on the principal investigator’s personal laptop that is
protected with a secure passcode and stored in a private secure locked location with only the
principal investigator having access to the data obtained. All data was de-identified. The data
was reported and shared during a professional presentation with the instructors and peers in the
DNP (Doctor of Nursing Practice) program at Maryville University, as well as, in a written
scholarly paper. The data will be shared with the East Tennessee Pulmonary and Sleep Medicine
physician, Dr. Mandeep Bakshi, and possibly in a written publication. All data stored on the
27NONINVASIVE POSITIVE PRESSURE VENTILATION
password protected computer was manually deleted after data analysis by the primary
investigator.
Conclusion
Chronic obstructive pulmonary disease with hypercapnic respiratory failure is a respiratory
disease that requires more than traditional treatment. The need for this research project is
important to COPD patients with hypercapnic respiratory failure. The data will be used to
determine the comparisons between noninvasive positive pressure ventilation and noninvasive
mechanical ventilation devices. The data provided will aid in determining if the differences
between the devices are statistically significant, so the proper device can be used to treat
respiratory patients. These findings will add to the current literature on the evidence-based care
of patients with COPD and HRF and explore the potential for further research.
This knowledge will hopefully contribute to improved care, patient outcomes, and increased
patient compliance with visits for health maintenance instead of secondary or tertiary visits. The
results of the project can lead to practice changes for respiratory patients. Changes may provide
the COPD patient with hypercapnic respiratory failure with the most effective noninvasive
treatment for correction or stabilization of hypercapnic respiratory failure.
Chapter IV
Results
28NONINVASIVE POSITIVE PRESSURE VENTILATION
The purpose of this chapter is to present the findings of this research study. The findings are
presented by describing the sample and addressing the research question. The research goal is to
compare the effectiveness of a noninvasive positive pressure ventilator to a noninvasive
mechanical ventilator in respiratory patients. The comparison between the devices will provide
statistical information on the effect of each device on oxygen, forced expiratory volume in one
second, and carbon dioxide levels.
Statistical Analysis
Data was analyzed using SPSS version 25. The study results were expressed as a percentage
or mean plus or minus standard deviation. The statistical tests utilized for this study was a
descriptive analysis of variables and independent samples t-tests. Descriptive statistics were
calculated for age, gender, diagnosis, respiratory devices, pre-device and post-device use for O2,
CO2, and FEV1 levels. Independent samples t-tests were utilized to compare the different
devices to determine if one device indicated a statistical significance to the other device in
effectiveness on the O2, CO2, and FEV1 variables.
Results
Demographic Characteristics of COPD Patients
The sample consisted of 39 charts with patients having a respiratory diagnosis based on
International Classification of Diseases (ICD) ten codes. The patient charts met the following
inclusion criteria: (a) 18 to 80 years of age, (b) any gender, (c) any ethnic background, (d)
documented diagnosis of COPD (stages Gold 3 or Gold 4), (e) documented diagnosis of
hypercapnia, (f) documented diagnosis of hypoxia, (g) documented diagnosis of respiratory
failure, (h) documented baseline FEV1, PaCO2, and PaO2, (i) documented post FEV1, PaCO2,
and PaO2, and (j) documented use of NIPPV or NMV.
29NONINVASIVE POSITIVE PRESSURE VENTILATION
Descriptive Statistics
The mean age was 67.31 years, and there were 26 females and 13 males. The average age of
females is 68 years of age and males average age was 66 years. The ethnicity of the 39 subjects
was white, non-Hispanic. The number of NIPPV devices was 15 and NMV was 24. The
descriptive analysis of pre and post oxygen levels showed the mean difference of -6.38 mm hg.
The pre and post FEV1 levels have a mean difference of 20.18%. The difference between the
pre and post CO2 level had a mean difference of -4.86 mm hg. (See Table 1).
Table 1Descriptive Statistics
N Minimum Maximum Mean Std. DeviationGENDER 39 1 2 1.67 .47
AGE 39 46 80 67.31 8.76DX 39 1 4 3.13 .92
DEVICE 39 1 2 1.23 .98PRE-O2 39 41.60 130.0 75.4 23.9
POST-O2 39 38.4 124.0 69.0 16.93DIFF O2 39 -72.90 47.64 -6.38 25.71
PRE-FEV1 39 .0 72.0 37.33 18.53POST-FEV1 39 .0 64.0 17.14 19.63DIFF FEV1 39 -16.00 72.00 20.18 23.25PRE-CO2 39 35.0 101.0 61.34 13.92
POST-CO2 39 39.4 98.1 56.79 14.75DIFF CO2 39 -57.40 46.90 -4.86 18.99
Valid N (listwise) 39
Statistical Analysis
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An independent samples t-test was calculated to compare the mean difference in O2 levels for
the noninvasive positive pressure ventilation (NIPPV) device (m = - 3.07 %) and the noninvasive
mechanical ventilation (NMV) device (m = -8.45 %). No significant difference was found (p
= .532) (See Table 3). This finding indicated that oxygen levels with both devices were lower
and that neither device was effective in maintaining oxygen levels in the patients. This finding
could be related to the severity of the disease and the need for supplemental oxygen.
The independent samples t-test was calculated to compare the mean difference for forced
expiratory volume in one second (FEV1) for the noninvasive positive pressure ventilation device
(m = 27.29 %), and the noninvasive mechanical ventilation device (m = 15.74). No difference
was found (p = .133). (See Table 3). The findings indicate low FEV1 levels that are the result of
excess mucus production, tissue death, destruction of bronchioles, inflammation, and fibrosis
(Berg & Wright, 2016).
An independent samples t-test was calculated for comparison of the mean difference in CO2
levels with NIPPV device (m = 3.91mm Hg) and the NMV (m = -10.34 mm Hg). There was a
significant difference found (p = .021) (See Table 3). This significant difference indicated that
CO2 levels of patients on the NMV device are improved compared to CO2 levels of patients on
NIPPV.
Table 3Independent Samples Test
Levene's Test for Equality
of Variances t-test for Equality of Means
F Sig. t df Sig. (2-tailed)
Mean Difference
Std. Error Difference
95% Confidence Interval of the
Difference
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Lower Upper
DIFF O2
Equal variances assumed
.019 .890 .631 37 .53 5.38 8.53 -11.90 22.67
Equal variances
not assumed
.619 28.02 .541 5.38 8.69 -12.42 23.19
DIFF FEV
1
Equal variances assumed
.256 .616 1.536 37 .133 11.55 7.5222180
-3.6844899
26.79 778233
Equal variances
not assumed
1.493 27.17 .147 11.55666668
7.73658002
-4.3123017
27.42756354
DIFF CO2
Equal variances assumed
.084 .774 2.420 37 .021 14.24333334
5.8878550
2.3127534
26.17 339133
Equal variances
not assumed
2.461 31.49 .020 14.24333334
5.7880520
2.4402864
26.04 763804
In summary, this chapter has addressed the research question: What is the effectiveness of
noninvasive positive pressure ventilation compared to noninvasive mechanical ventilation in
respiratory patients. This chapter has described the sample of respiratory patients at the clinic.
The study found that there was no statistical difference in oxygen levels or FEV1 levels between
the two devices. However, the study did indicate an improvement in the carbon dioxide levels of
patients on the noninvasive mechanical ventilator. The information from the data analysis
indicated that patients on the NMV have a significant decrease in levels compared to the NIPPV.
32NONINVASIVE POSITIVE PRESSURE VENTILATION
Chapter V
Discussion
Noninvasive positive pressure ventilation compared to noninvasive mechanical ventilation
was assessed to determine if one device was more effective than the other in the treatment of
patients with COPD and hypercapnic respiratory failure. Lowering carbon dioxide levels in
COPD HRF patients is imperative in slowing the progression of the disease. Using NIPPV
improves respiratory status by decreasing CO2 levels, stabilizing lung function, and increasing
exercise tolerance (Struik, Lacasse, Goldstein, Kerstjens, & Wijkstra, 2013). It is reported that
activity is affected by the progressive stages of COPD (Zamzam, Azab, El Wahsh, Ragab, &
Allum, 2013).
Comorbidities
Another consideration was the effect of comorbidities. The literature indicated that
comorbidities are usually present with the diagnosis of COPD and can increase the risk of
exacerbations. Comorbidities such as cardiovascular disease, bronchiectasis, chronic bronchitis,
and depression are indicators for worsening respiratory symptoms (Westerik et al., 2017).
Although data was not collected on comorbidities, there could be a correlation related to the
findings. Comorbidities such as cardiovascular disease are frequently present in COPD patients
and correlates to the common inflammatory process in both diseases (Gunay, Sariaydin, & Acay,
2016). Westerik et al. (2017) stated that patients are more at risk for COPD exacerbation related
to the impact of comorbidities. Keeping in mind the impact that comorbidities can have on
COPD, it is important to recognize that “almost 50% of the COPD patients have 3 or more
comorbidities” (Dursunoglu et al., 2016). The development of hypercapnic respiratory failure
increases the risk of mortality (Liao et al. 2017). The two year rate of death after hypercapnea
33NONINVASIVE POSITIVE PRESSURE VENTILATION
develops is 30-40% (Galli, et al., 2014). Two significant comorbidities that occur in COPD
patients are musculoskeletal decline and cardiovascular disease and they can affect the patient’s
ability to breath properly (Dursuboglu et al., 2016).
Demographic Variables
The more data and understanding of the effectiveness of the devices will help increase
knowledge and ultimately aid in improving COPD HRF patients respiratory status. Descriptive
analysis was used to describe the demographics of the sample and independent t-tests were
performed to compare the effectiveness of the devices.
The descriptive analysis revealed a mean age of 67 years. A study by Westerik et al. (2017)
on COPD exacerbations indicated a mean age (M = 66.5 years) and the mean age (m = 65 years)
was reported in a study by Shebl and Aberaboh (2015). “The prevalence of COPD increases
with age” (Criner & Han, 2018, p. 593). The ethnicity of the 39 subjects was Caucasian and this
is likely because the population of Greene County Tennessee is 68,615 and 93 percent of the
population is Caucasian (Census Reporter, 2016).
NIPPV vs. NMV
The independent samples t-test indicated low oxygen levels with both devices. This finding is
related to the severity of the disease. As COPD progresses the airflow is more limited, and the
capillary bed is destroyed, causing disruption in gas exchange, and the potential for the
development of pulmonary hypertension and right heart failure (Kent, Mitchell, & McNicholas,
2011). Liao et al. (2017) indicated that use of the NIPPV did not improve oxygen levels. The
evidence indicates that the NIPPV and NMV do not improve oxygenation in COPD HRF
patients due to the pathophysiologic change in the lungs.
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The independent samples t-test was calculated to compare the means between devices for
differences in forced expiratory volume in one second (FEV1). The findings suggest a low
FEV1 level. Galli et al., (2014) indicated that there is not a significant change in FEV1 between
patients on the NIPPV compared to those not on a device. This can be explained by
understanding that the damage to the lungs is not reversible and the FEV1 indicates the
percentage of lung capacity and determines the severity of the disease (Lung Institute, 2016).
The main finding in the study was improvement in carbon dioxide levels. The independent
samples t-test was calculated to compare the mean difference in CO2 levels with NIPPV device
(m = 3.91mm Hg) and the NMV (m = -10.34 mm Hg) (see Table 2). There is a significant
difference found (p = .021) (See Table 3). This significant difference indicates that CO2 levels of
patients who use the NMV device were improved compared to CO2 levels of patients on NIPPV.
The damage to the lungs from COPD causes ventilation and perfusion difficulties. This
disruption in gas exchange occurs in COPD HRF patients and is related to a decrease in alveolar
function. The oxygen can get in to the lungs, but the exhalation of carbon dioxide is limited.
This pathology can occur with rapid shallow breathing, over inflation of the lungs, or destruction
of pulmonary capillaries. Patients needing more respiratory support can use the NMV devices at
home. The patients using NMV have decreased carbon dioxide levels and improved survival
rates, improved exercise capacity, and improved quality of life (Duiverman, 2018).
Chronic obstructive pulmonary disease is not only a severe and debilitating disease; it is a
complicated disease. The damage in the lungs is caused by several mechanisms including
inflammation that affects the alveolar, changes in the airways, and inflammatory changes in
vasculature. Patients with COPD have emphysema, chronic bronchitis, or both of them. The
combination of emphysema and chronic bronchitis can make treatment more difficult, and
35NONINVASIVE POSITIVE PRESSURE VENTILATION
patients that develop hypercapnia have a higher risk of death (Nilius, Katamadze, Domanski,
Schroeder & Franke, 2017). The research showed that keeping the carbon dioxide levels down is
imperative to survival of COPD HRF patients.
Limitations
Several limitations are associated with this study. First, this is a retrospective pre and post
comparison study and “is subject to inherent bias” (Coughlin, Liang &, Parthasarathy, 2015) as
this researcher must assume that the information in the electronic medical records is accurate
(Terry, 2015). Next, the devices were not separated by specific modes, comorbidities and
oxygen use were not taken into consideration. The researcher had to assume the data was
correctly recorded in the EMR. The literature did not separate the devices by specific type, and
the researcher did not consider oxygen usage or comorbidities. These limitations must be takent
into consideration with the findings of the study; however, the study can be used in future, larger
studies for better representation of a larger population.
Application to Practice
Nurse practitioners should stay up to date on guidelines for the care of COPD patients
(Bostock-Cox, 2017). The information gathered from this study and the literature has increased
this researcher’s knowledge and the new-found knowledge needs to be shared. The information
from this study will be used in practice to develop a protocol for treatment of COPD HRF
patients with a noninvasive mechanical ventilation device. The data analysis and the literature
suggest improvement in CO2 levels in COPD HRF patients. The findings of the study will be
shared with the clinic physician and initiation of the protocol will begin.
36NONINVASIVE POSITIVE PRESSURE VENTILATION
Another implication to practice is having increased evidence on the efficacy of NMV on
COPD HRF. The findings can be used to strengthen the appeal for NMV through insurance
companies. Providing the information from this study and the literature will be compelling for
the use of this device.
This study can be replicated by other researchers with larger groups to be more representative
of a larger population of COPD patients. It is recommended that further studies be conducted to
include age, gender, ethnicity, diagnosis, device types, and pre-device and post-device levels of
O2, CO2, and FEV1 levels, along with using separate device types, and comorbidities. This would
likely provide stronger evidence for the use of the noninvasive mechanical ventilators in patients
with COPD HRF.
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References
Altintas, N. (2016). Update: non-invasive positive pressure ventilation in chronic respiratory
failure due to COPD. COPD, 13(1), 110–121.
https://doi.org/10.3109/15412555.2015.1043520
Berg, K., & Wright, J. L. (2016). The Pathology of Chronic Obstructive Pulmonary Disease.
Archives of Pathology & Laboratory Medicine, 140(12), 1423-1428.
doi:10.5858/arpa.2015-0455-RS
Bhatt, S. P., Peterson, M. W., Wilson, J. S., & Durairaj, L. (2013). Noninvasive positive pressure
ventilation in subjects with stable COPD: a randomized trial. International Journal of
Chronic Obstructive Pulmonary Disease, 8(12), 581–589.
https://doi.org/10.2147/COPD.S53619
Bostock-Cox, B. (2017). The 2017 GOLD guideline on COPD: implications for practice.
Practice Nurse, 47(1), 30-34.
Census Reporter, (2016). Greene county, TN. Retrieved from
https://censusreporter.org/profiles/05000US47059-greene-county-tn/
Centers for Disease Control and Prevention. (2011). Chronic obstructive pulmonary disease:
COPD among adults in Tennessee [Fact Sheet]. Retrieved from
https://www.cdc.gov/copd/maps/docs/pdf/TN_COPDFactSheet.pdf
Centers for Disease Control and Prevention. (2017a). Chronic obstructive pulmonary disease
(COPD) [Fact sheet]. Retrieved from www.cdc.gov/copd/index/html
Centers for Disease Control and Prevention (CDC). (2017c). NCHS LCWK1: Deaths, percent of
total death, and death rates for the 15 leading causes of death in 5-year age groups, by
38NONINVASIVE POSITIVE PRESSURE VENTILATION
race and sex: Untied States, 1999-2015. Retrieved from
https://www.cdc.gov/nchs/nvss/mortality/lcwk1.htm
Centers for Disease Control and Prevention. (2017b). Increase expected in medical care costs for
COPD [Fact sheet]. Retrieved from https://www.cdc.gov/features/ds-copd-costs/
Ciftci, F., Ciledag, A., Erol, S., Oz, Mirac, D., et al. (2017). Evaluation of the feasibility of
average volume-assured pressure support ventilation in the treatment of acute
hypercapnic respiratory failure associated with chronic obstructive pulmonary disease: A
pilot study. Journal of Critical Care 39, 232-237. doi: 10.1016/j.jcrc.2016.12.023.
Clini, E. M., Magni, G., Crisafulli, E., Viaggi, S., & Ambrosino, N. (2009). Home non-invasive
mechanical ventilation and long-term oxygen therapy in stable hypercapnic chronic
obstructive pulmonary disease patients: comparison of costs. Respiration; International
Review of Thoracic Diseases, 77(1), 44-50. doi:10.1159/000127410
Coughlin, S., Liang, W. E., & Parthasarathy, S. (2015). Retrospective assessment of home
ventilation to reduce rehospitalization in chronic obstructive pulmonary disease. Journal
of Clinical Sleep Medicine, 11(6). doi: 10.5664/jcsm.4780
Crimi, C., Noto, A., Princi, R., Culvelier, A., Masa, J. F., Simonds, A., Eliott, M. W.…Nava, S.
(2019). Domiciliary non-invasive ventilation in COPD: An international survey of
indications and practices. COPD. 13(4), 483-490. doi: 10.3109/15412555.2015.1108960.
Criner, R. N., & Han, M. K. (2018). COPD Care in the 21st Century: A Public Health Priority.
Respiratory Care, 63(5), 591-600. doi:10.4187/respcare.06276
Dimoulis, A., Pastaka, C., Tsolaki, V., Tsilioni, I., Pournaras, S., Liakos, N., . . . Gourgoulianis,
K. (2015). Non-invasive ventilation (NIV) and Homeostatic Model Assessment (HOMA)
39NONINVASIVE POSITIVE PRESSURE VENTILATION
index in stable chronic obstructive pulmonary disease (COPD) patients with chronic
hypercapnic respiratory failure. COPD, 12(4). doi:10.3109/15412555.2014.974738
Dreher M; Storre JH; Windisch W. Noninvasive ventilation during walking in patients with
severe COPD: a randomised cross-over trial 2007 (The Cochrane Controlled Trials
Register (CCTR/CENTRAL)). In: The Cochrane Library, Issue 1, 2012. Oxford: Update
Software. Updated quarterly.
Dretzke, J., Moore, D., Dave, C., Mukherjee, R., Price, M. J., Bayliss, S., & ... Turner, A. M.
(2016). The effect of domiciliary noninvasive ventilation on clinical outcomes in stable
and recently hospitalized patients with COPD: a systematic review and meta-analysis.
International Journal of Chronic Obstructive Pulmonary Disease, 11(1), 2269-2286.
Retrieved from
https://doaj-org.proxy.library.maryville.edu/article/85cc7bb5c94c40868be02f1b40a84fe0
Duiverman, M. L. (2018). Noninvasive ventilation in stable hypercapnic COPD: what is the
evidence. European Respiratory Society Open Research, 2018(4), 1 – 10. Doi:
10.1183/23120541.00012-2018
Duiverman, M. L., Wempe, J. B., Bladder, G., Jansen, D. F., Kerstjens, H. M., Zijlstra, J. G., &
Wijkstra, P. J. (2008). Nocturnal non-invasive ventilation in addition to rehabilitation in
hypercapnic patients with COPD. Thorax, 63(12), 1052-1057.
doi:10.1136/thx.2008.099044
Duiverman, M. L., Wempe, J. B., Bladder, G., Vonk, J. M., Zijlstra, J. G., Kerstjens, H. A. M., &
Wijkstra, P. J. (2011). Two-year home-based nocturnal noninvasive ventilation added to
rehabilitation in chronic obstructive pulmonary disease patients: a randomized controlled
trial. Respiratory Research, 12(1), 112. https://doi.org/10.1186/1465-9921-12-112
40NONINVASIVE POSITIVE PRESSURE VENTILATION
Dursunoglu, N., Kokturk, N., Baha, A., Bilge, A. K., Borejci, S., Çiftçi, F., & ... Akkoca Yıldız,
O. (2016). Comorbidities and their impact on chronic obstructive pulmonary disease.
Tuberkuloz Ve Toraks, 64(4), 289-298.
Ekkernkamp, E., Storre, J. H., Windisch, W., & Dreher, M. (2014). Impact of intelligent volume-
assured pressure support on sleep quality in stable hypercapnic chronic obstructive
pulmonary disease patients: A randomized, crossover study. Respiration, 88(4), 270–276.
https://doi.org/10.1159/000364946
Galli, J. A., Krahnke, J. S., Mamahary, A., Shenoy, K., Zhao, H., & Criner, G. J. (2014). Home
non-invasive ventilation use following acute hypercapnic respiratory failure in COPD.
Respiratory Medicine, 108(5), 722-728. doi:10.1016/j.rmed.2014.03.006
Global strategy for the diagnosis, management, and prevention of COPD, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2017. Available from http://goldcopd.org
Gunay, S., Sariaydin, M., & Acay, A. (2016). New Predictor of Atherosclerosis in Subjects With
COPD: Atherogenic Indices. Respiratory Care, 61(11), 1481-1487.
doi:10.4187/respcare.04796
Han, M. K., Dransfield, M. T., & Martinez, F. J., (2017). Chronic obstructive pulmonary disease:
Definition, clinical manifestations, diagnosis, and staging. In H. Hollingsworth (Ed.),
UpToDate. Retrieved September 29, 2017, from https://www.uptodate.com/
Hanna, L., M., Dominellie, G. S., Chen, Y, Reid, W. D., & Road, J. (2013). Systematic review
of non-invasive positive pressure ventilation for chronic respiratory failure. Respiratory
Medicine, 108(2), 229–243. https://doi.org/10.1016/j.rmed.2013.11.010
Hunter, S. (2009). Holistic assessment of patients with COPD before the use of non-invasive
ventilation. Nursing Times, 105(20), 25-27.
41NONINVASIVE POSITIVE PRESSURE VENTILATION
Hyzy, R. C., (2017). Modes of mechanical ventilation. In G. Finlay (Ed.), UpToDate, Retrieved
October 27, 2017, from https://www.uptodate.com/
Jaber, S., Lescot, T., Futier, E., Paugham-Burtz, C., Seguin, P., Ferrandiere, M., . . . Molinari, N.
(2016). Effect of noninvasive ventilation on tracheal reintubation among patients with
hypoxemic respiratory failure following abdominal surgery: A randomized clinical trial.
Journal of the American Medical Association, 15(13), 1345-1353.
doi:10.1001/jama.2016.2706
Kahan, B. C., Rehal, S., & Cro, S. (2015). Risk of selection bias in randomised trials. Trials,
(16)405. doi:10.1186/s13063-015-0920-x
Kent, B. D., Mitchell, P. D., & McNicholas, W. T. (2011). Hypoxemia in patients with COPD:
cause, effects, and disease progression. International Journal of COPD, 2011(6), 199-
208. doi:10.2147/COPD.S10611
Kolodziej, M. A., Jensen, L., Rowe, B., & Sin, D. (2007). Systematic review of noninvasive
positive pressure ventilation in severe stable COPD. The European Respiratory Journal,
30(2), 293-306. http://erj.ersjournals.com/
Lahaije, A., van Helvoort, H., Dekhuijzen, P., & Heijdra, Y. (2010). Physiologic limitations
during daily life activities in COPD patients. Respiratory Medicine, 10(4) 1152-1159.
doi:10.1016/j.rmed.2010.02.011
Liao, H., Pei, W., Li, H., Luo, Y., Wang, K., Li, R., & ... Chen, X. (2017). Efficacy of long-term
noninvasive positive pressure ventilation in stable hypercapnic COPD patients with
respiratory failure: a meta-analysis of randomized controlled trials. International Journal
Of COPD, 2017(12), 2977-2985. doi; 10.2147/COPD.S148422
42NONINVASIVE POSITIVE PRESSURE VENTILATION
Liu, Y., Zhao, J., & Tang, H. (2016). Non-invasive ventilation in acute respiratory failure: a
meta-analysis. Clinical Medicine, 16(6), 514-523. http://www.clinmed.rcpjournal.org/
Mal, S., McLeod, S., Iansavichene, A., Dukelow, A., & Lewell, M. (2014). Effect of out-of-
hospital noninvasive positive-pressure support ventilation in adult patients with severe
respiratory distress: A systematic review and meta-analysis. Annals of Emergency 63(5).
Medicine. https://doi.org/10.1016/j.annemergmed.2013.11.013
McEvoy, R. D., Pierce, R. J., Hillman, D., Esterman, A., Ellis, E. E., Catcheside, P. G., …
Grunstein, R. R. (2009). Australian trial of non-invasive Ventilation in Chronic Airflow
Limitation (AVCAL) Study Group. Nocturnal non-invasive nasal ventilation in stable
hypercapnic COPD: a randomised controlled trial 2009 (The Cochrane Controlled Trials
Register (CCTR/CENTRAL)). In: The Cochrane Library, Issue 1, 2012. Oxford: Update
Software. Updated quarterly.
MedlinePlus (2016). Blood gases. Retrieved from
https://medlineplus.gov/ency/article/003855.htm
MedlinePlus (2017). Pulmonary function tests. Retrieved from
https://medlineplus.gov/ency/article/003853.htm
Murphy, P. D., Rehal, S., Arbane, G., Bourke, S., Calverley, P. M. A., Crook, A. M., …Hart, N.
(2017). Effect of home noninvasive ventilation with oxygen therapy vs oxygen therapy
alone on hospital readmission or death after an acute COPD exacerbation. Journal of the
American Medical Association, 317(21), p. 2177-2186. doi: 10.1001/jama.2017.4451
Neuman, B. (2017). Neuman Systems Model. Retrieved from
http://neumansystemsmodel.org/index.html
43NONINVASIVE POSITIVE PRESSURE VENTILATION
Nilius G, Katamadze N, Domanski U, Schroeder M, & Franke K. J. (2016). Non-invasive
ventilation with intelligent volume-assured pressure support versus pressure-controlled
ventilation: effects on the respiratory event rate and sleep quality in COPD with chronic
hypercapnia. International Journal of COPD, 2017(12), p. 1039 – 1045.
Oscroft, N. S., Ali, M., Gulati, A., Davies, M. G., Quinnell, T. G., Shneerson, J. M., & Smith, I.
E. (2010a). A randomised crossover trial comparing volume assured and pressure preset
noninvasive ventilation in stable hypercapnic COPD. COPD, 7(6), 398-403.
https://doi:10.3109/15412555.2010.528084
Oscroft, N. S., Quinnell, T. G., Shneerson, J. M., & Smith, I. E. (2010b). The effects of
withdrawing long-term nocturnal non-invasive ventilation in COPD patients. COPD,
7(2), 111-116. doi:10.3109/15412551003631725
Pluym, M., Kabir, A. W., & Gohar, A. (2015). The use of volume-assured pressure support
noninvasive ventilation in acute and chronic respiratory failure: a practical guide and
literature review. Hospital Practice, 43(5), 299-307.
https://doi:10.1080/21548331.2015.1110475
Preston, W. (2013). The increasing use of non-invasive ventilation. Practice Nursing, 24(3), 114-
119.
Salturk, C., Karakurt, Z., Takir, H. B., Balci, M., Kargin, F., Mocin, O. Y., & ... Adiguzel, N.
(2015). Comparison of exercise capacity in COPD and other etiologies of chronic
respiratory failure requiring non-invasive mechanical ventilation at home: retrospective
analysis of 1-year follow-up. International Journal of Chronic Obstructive Pulmonary
Disease, 10, 2559-2569. https:// doi:10.2147/COPD.S91950
44NONINVASIVE POSITIVE PRESSURE VENTILATION
Shebl, R. E., & Abderaboh, M. M. (2015). Bi-level positive airway pressure ventilation for
patients with stable hypercapnic chronic obstructive pulmonary disease. Egyptian Journal
of Chest Disease and Tuberculosis, 64(2),
395-398.https://doi:10.1016/j.ejcdt.2015.02.004
Struik, F. M., Lacasse, Y., Goldstein, R. S., Kerstjens, H. A., & Wijkstra, P. J. (2013). Nocturnal
noninvasive positive pressure ventilation in stable COPD: A systematic review and
individual patient data meta-analysis. Respiratory Medicine, 108(2), 329-337. doi:
10.1016/j.rmed.2013.10.007
Tennessee Department of Health. (2017). Chronic obstructive pulmonary disease. (2017).
Nashville, TN. Retrieved from https://www.tn.gov/health/article/chronic-obstructive-
pulmonary-disease
Terry, A. J. (2015). Clinical research for the Doctor of Nursing practice. (2nd ed.). Burlington,
MA: Jones & Bartlett Learning.
Tsai, C., Lee, W., Delclos, G. L., Hanania, N. A., & Camargo, C. J. (2013). Comparative
effectiveness of noninvasive ventilation vs invasive mechanical ventilation in chronic
obstructive pulmonary disease patients with acute respiratory failure. Journal of Hospital
Medicine, 8(4), 165-172. doi:10.1002/jhm.2014
Vasquez, M. M., McClure, L. A., Sherrill, D. L., Patel, S. R., Krishnan, J., Guerra, S., &
Parthasarathy, S. (2017). Positive airway pressure therapies and hospitalization in chronic
obstructive pulmonary disease. The American Journal of Medicine, 130(7), 809-818.
https://doi:10.1016/j.amjmed.2016.11.045
Walker, D. J., Walterspacher, S., Ekkernkamp, E., Storre, J. H., Windisch, W., & Dreher, M.
(2015). Walking with non-invasive ventilation does not prevent exercise-induced
45NONINVASIVE POSITIVE PRESSURE VENTILATION
hypoxaemia in stable hypercapnic COPD patients. COPD. 12(5), 546-551. doi:
10.3109/15412555.2015.1008690
Westerik, J. M., Metting, E. I., van Boven, J. M., Tiersma, W., Kocks, J. H., & Schermer, T. R.
(2017). Associations between chronic comorbidity and exacerbation risk in primary care
patients with COPD. Respiratory Research, 18(1), 31. doi:10.1186/s12931-017-0512-2
Windisch, W., Haenel, M., Storre, J. H. & Dreher, M. (2009) High-intensity non-invasive
positive pressure ventilation for stable hypercapnic COPD. International Journal of
Medical Science, 6(2), 72-76. http://www.medsci.org/
World Health Organization (2016). Chronic obstructive pulmonary disease (COPD). Retrieved
from http://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-
disease-(copd)
World Health Organization. (2017). Chronic respiratory disease: COPD: Definition [Fact
Sheet]. Retrieved from: http://www.who.int/respiratory/copd/definition/en/
Zamzam, M. A., Azab, N. Y., El Wahsh, R. A., Ragab, A. Z., & Allam, E. M. (2012). Quality of
life in COPD patients. Egyptian Journal of Chest Diseases and Tuberculosis, 61(4), 281-
289. 10.1016/j.ejcdt.2012.08.012
Zhou, L., Li, X., Guan, L., Chen, J., Guo, B., Wu, W., … Chen, R. (2017). Home noninvasive
positive pressure ventilation with built-in software in stable hypercapnic COPD: A short-
term prospective, multicenter, randomized, controlled trial. International Journal of
COPD, 12(1), 1279–1286. https://doi.org/10.2147/COPD.S127540
46NONINVASIVE POSITIVE PRESSURE VENTILATION
Appendix A
Approval Letter from Clinic Manager and the Physician
1404 Tusculum Blvd. Suite 2200 Greeneville, TN 37745
EAST TENNESSEE Tel: 423-798-8052 PULMONARY AND SLEEP MEDICINE Fax: 423-798-8055
July 31, 2017
Re: DNP Candidate / Alice M. Pinyan
To: Whom it may concern
It is to our understanding that our current Nurse Practitioner, Alice M. Pinyan, is a DNP candidate and is working on a scholarly project. We have granted Alice permission to review our patient's charts for use in gaining valuable information to assist her in the completion of her project.
These charts are to be reviewed for clinical information only and the identity of the patients are to remain confidential and unidentifiable in her project.
Sincerely,
Shirley Ball, Office Manager
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Appendix B
Data Collection Sheet