Perspectives on prolonged nocturnal invasive mechanical ventilation

Robert L Vender

Abstract

The utilization of invasive mechanical ventilation (IMV) has become common practice for a large and expanding number of patients with chronic respiratory failure resultant from several medical diseases and disorders. Although protocols and guidelines for the acute management of respiratory failure exist with expansive evidence-based data, the chronic management of similar patients outside the Intensive Care Unit (ICU) setting requiring extended and prolonged durations on invasive mechanical ventilation (IMV) has been much less clearly defined. In addition, the vast majority of such care is administered outside the acute hospital environment. Most adults requiring chronic mechanical ventilatory support include two general populations: 1) patients with severe intrinsic lung disease who have experienced acute respiratory failure initially managed in ICU settings and 2) patients with progressive neuromuscular diseases. When attempts at weaning, ventilator liberation, and achievement of successful full-time continuous spontaneous ventilation fail, mechanical ventilation management often reverts to part-time (predominately nighttime) nocturnal invasive mechanical ventilation (NIMV) with periods of spontaneous breathing duration awake daytime hours. Such a practice pattern has been advocated by peer-reviewed published expert opinions. Yet such a pattern would appear to potentially exclude many patients from eventual total weaning, ventilator liberation and even decannulation and progression to independent sustained life-long spontaneous ventilation.  In addition, such a ventilator management program may not even be indicated for patients with progressive neuromuscular disorders in the absence of an acute concomitant lung disease. The predominate physiological factors prohibiting sustained spontaneous ventilation would appear to be 1) inspiratory muscle (predominantly diaphragmatic) fatigue, which per definition should be correctable with appropriate managment including the concept of ventilatory muscle rest (VMR) and/or 2) inspiratory muscle weakness resultant from a pathological disease entity. However, the elusive nature of defining, appropriately monitoring, and subsequent therapy of diaphragmatic fatigue clearly hinders the practical management of this large volume of patents thus rendering them “Ventilator Dependent”. In addition, the absence of disease modifying therapies for chronic progressive neuromuscular disorders contributes to the eventual outcome of fulminant respiratory failure. The purpose of this narrative review is not to challenge but rather to attempt to validate or not validate the concept that nocturnal invasive mechanical ventilation (NIMV) is a “valid” goal of IMV on a chronic long-term basis.

Keywords: Prolonged mechanical ventilation, Nocturnal mechanical ventilation

References

1. Fan E, Del Sorbo L, Goligher EC. et al. An official American Thoracic Society/European Society of Intensive Care/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 195(6):1253-1263. https://doi.org/10.1164/rccm.201703-0548ST PMid:28459336

2. Lee KG, Roca O, Casey JD, et al. When to intubate in acute hypoxaemic respiratory failure? options and opportunities for evidence-informed decision making in the intensive care unit. Lancet Respir Med 2024; 12:642-654. https://doi.org/10.1016/S2213-2600(24)00118-8 PMid:38801827

3. Miller RG, Jackson CE, Kasarskis EJ, et al. Quality standards subcommittee of the American College of Neurology. Practice parameter update: The care of the patient with amyotrophic lateral sclerosis, drug, nutritional, and respiratory therapies (an evidence-based review): Report of the quality standards subcommittee of the American College of Neurology. Neurology 2009; 73(15):1218-1226. https://doi.org/10.1212/WNL.0b013e3181bc0141 PMid:19822872 PMCid:PMC2764727

4. Hansen-Flaschen J, Ackrivo J. Practical guide to management of long-term noninvasive ventilation for adults with chronic neuromuscular disease. Respir Care 2023; 68(8):1123-1157. https://doi.org/10.4187/respcare.10349 PMid:36922023 PMCid:PMC10353174

5. MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged mechanical ventilation. report of a NAMDRC consensus conference. Chest 2005; 128:3937-3954. https://doi.org/10.1378/chest.128.6.3937 PMid:16354866

6. Make BJ, Hill NS, Goldberg AI, et al. Mechanical ventilation beyond the intensive care unit: Report of a consensus conference of the American College of Chest Physicians. Chest 1998; 113 Supplement 5:289S-344S. https://doi.org/10.1378/chest.113.5_Supplement.289S PMid:9599593

7. Goligher EC, Dres M, Patel BK. Lung- and diaphragm -protective ventilation. Am J Respir Crit Care Med 2020; 202(7):950- 961. https://doi.org/10.1164/rccm.202003-0655CP PMid:32516052 PMCid:PMC7710325

8. Vender RL. The Diaphragm: The forgotten factor in ventilator weaning. The Journal of Lancaster General Hospital 2021; 12:13-16.

9. Vorona S, Sabatini U, Al-Maqbali S, et al. Inspiratory muscle rehabilitation in critically ill adults: A systematic review and meta-analysis. Ann Am Thorac Soc 2018; 15(6):735-744. https://doi.org/10.1513/AnnalsATS.201712-961OC PMid:29584447 PMCid:PMC6137679

10. Dres M, Gama de Abreu M, Merdji H, et al. Randomized clinical study of temporary transvenous phrenic nerve stimulation in difficult-to-wean patients. Am J Respir Crit Care Med 2022; 205(10):1169-1178. https://doi.org/10.1164/rccm.202107-1709OC PMid:35108175 PMCid:PMC9872796

11. Van Hollebeke M, Poddighe D, Hoffman M, et al. Similar weaning success rate with high-intensity and sham inspiratory muscle training. Am J Respir Crit Care Med 2025; 211(3):381-390. https://doi.org/10.1164/rccm.202405-1042OC PMid:39565276

12. Dasgupta A, Rice R, Mascha E, et al. Four-year experience with a unit for long-term ventilation (Respiratory Special Care Unit) at the Cleveland Clinic Foundation. Chest 1999; 116:447-455. https://doi.org/10.1378/chest.116.2.447 PMid:10453875

13. Muir J-F, Girault C, Cardinaud J-P, et al, and the French Cooperative Study Group. Survival and long-term follow-up of tracheostomized patients with COPD Treated by Home Mechanical Ventilation. A multicenter french study in 259 patients. Chest 1994; 106:201-209. https://doi.org/10.1378/chest.106.1.201 PMid:8020273

14. Scheinhorn DJ, Hassenpflug MS, Votto JJ, et al. Post-ICU mechanical ventilation at 23 long-term care hospitals: A multicenter outcomes study. Chest 2007; 131:85-93. https://doi.org/10.1378/chest.06-1081 PMid:17218560

15. Dale CM, King J, Nonoyama M, et al. Transitions to home mechanical ventilation: The experience of Canadian ventilator assisted adults and their family caregivers. Ann Am Thorac Soc 2018; 15:357-364. https://doi.org/10.1513/AnnalsATS.201708-663OC PMid:29283698

16. Windisch W. Home mechanical ventilation. In Martin J. Tobin, editor. Principles and Practice of Mechanical ventilation- Third Edition, New York: McGraw-Hill Medical 2013:683-698.

17. Respiratory muscle fatigue. Report of the Respiratory Muscle Fatigue Workshop Group. Am Rev Respir Dis 1990; 142:474-480. https://doi.org/10.1164/ajrccm/142.2.474 PMid:2382912

18. Levine S, Levy SF, Henson DJ. Effect of negative pressure ventilation on ventilatory muscle endurance in patients with severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1992; 146:722-729. https://doi.org/10.1164/ajrccm/146.3.722 PMid:1519853

19. Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 2008; 358:1327-1335. https://doi.org/10.1056/NEJMoa070447 PMid:18367735

20. Reynolds SC, Meyyappan R, Thakkar V, et al. Mitigation of ventilator-induced diaphragm atrophy by transvenous phrenic nerve stimulation. Am J Respir Crit Care Med 2017; 195:339-346. https://doi.org/10.1164/rccm.201502-0363OC PMid:27500981

21. Kelsen SG, Criner, G.J. Pump failure: The pathogenesis of hypercapnic respiratory failure in patients with lung and chest wall disease. In: AP Fishman, editor. Fishman’s Pulmonary Disease and Disorders, New York: McGraw-Hill Health Professions Division 1988:2605-2625.

22. Mador JM. Respiratory muscle fatigue and breathing pattern. Chest 1991; 100:1430-1435. https://doi.org/10.1378/chest.100.5.1430 PMid:1935305

23. Bach JR, Saporito LR, Shah HR, et al. Decanulation of patients with severe respiratory muscle insufficiency: Efficacy of mechanical insufflation-exsufflation. J Rehabil Med 2014; 46:1037-1041. https://doi.org/10.2340/16501977-1874 PMid:25096928

24. Eckert DJ, Butler JE. Respiratory Physiology: Understanding the control of Ventilation. In: M. Kryger, T. Roth, WC Dement, editors. Principles and Practice of Sleep Medicine Sixth Edition, Philadelphia: Elsevier 2011:167-173.

25. De Troyer A, Leeper JB, McKenzie DK, et al. Neural drive to the diaphragm in patients with severe COPD. Am J Respir Crit Care Med 1997; 155:1335-1340. https://doi.org/10.1164/ajrccm.155.4.9105076 PMid:9105076

26. McCartney A, Phillips D, James M, et al. Ventilatory neural drive in chronically hypercapnic patients with COPD: Effects of sleep and nocturnal noninvasive ventilation. Eur Respir Rev 2022; 31:220069. https://doi.org/10.1183/16000617.0069-2022 PMid:36130786 PMCid:PMC9724815

27. Bower JS, Sandercock TG, Rothman E, et al. Time domain analysis of diaphragmatic electromyogram during fatigue in men. J Appl Physiol: Respirat Environ Exercise Physiol 1984; 57(3):913-916. https://doi.org/10.1152/jappl.1984.57.3.913 PMid:6490475

28. Nava S, Zanotti E, Ambrosino N, et al. Evidence of acute diaphragmatic fatigue in a “natural” condition; The diaphragm during labor. Am Rev Respir Dis 1992; 146: 1226-1230. https://doi.org/10.1164/ajrccm/146.5_Pt_1.1226 PMid:1443875

29. Laghi F, Cattapan SE, Jubran A, et al. Is weaning failure caused by low-frequency fatigue of the diaphragm. Am J Respir Crit Care Med 2003; 167:120-127. https://doi.org/10.1164/rccm.200210-1246OC PMid:12411288