Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Types of noninvasive nocturnal ventilatory support in neuromuscular and chest wall disease

Nicholas S Hill, MD
Naomi R Kramer, MD
Section Editors
Ronald D Chervin, MD, MS
Polly E Parsons, MD
Deputy Editor
Geraldine Finlay, MD


Noninvasive ventilation refers to mechanical ventilation without the need for an invasive interface (ie, an invasive airway) between the ventilator and the patient. Noninvasive positive pressure ventilation (NPPV) is currently the preferred mode of noninvasive ventilation. Other modes that long antedated NPPV are used occasionally, including negative pressure ventilators and abdominal displacement ventilators. Diaphragm pacers and glossopharyngeal breathing are still used for special applications.

This topic will discuss the different forms of noninvasive ventilation that are used for neuromuscular and chest wall disease, emphasizing the use of NPPV. The types and applications of noninvasive ventilatory support are shown in the table (table 1). Practical aspects of implementing noninvasive nocturnal ventilatory support and daytime noninvasive ventilatory assistance are discussed separately. (See "Practical aspects of nocturnal noninvasive ventilation in neuromuscular and chest wall disease" and "Continuous noninvasive ventilatory support for patients with neuromuscular or chest wall disease".)


Noninvasive positive pressure ventilation (NPPV) is now the most commonly used mode of noninvasive ventilation in most hospitals. This ascendancy has been related to ease of application, portability, demonstrated efficacy, and the ability to eliminate obstructive sleep apneas that may be induced or potentiated by other noninvasive ventilators [1]. NPPV requires an interface (ie, a mask or other device that directs airflow into the upper airway) and a positive pressure ventilator. In contrast to ventilation via an invasive airway, NPPV uses an open breathing circuit, is inherently leaky, and depends upon patient cooperation to achieve ventilatory assistance.

Interfaces — Four types of interfaces are available [2,3]:

Nasal masks (picture 1 and picture 2)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 31, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Hill NS, Redline S, Carskadon MA, et al. Sleep-disordered breathing in patients with Duchenne muscular dystrophy using negative pressure ventilators. Chest 1992; 102:1656.
  2. Hess DR. Noninvasive ventilation in neuromuscular disease: equipment and application. Respir Care 2006; 51:896.
  3. Leger SS, Leger P. The art of interface. Tools for administering noninvasive ventilation. Med Klin (Munich) 1999; 94:35.
  4. Navalesi P, Fanfulla F, Frigerio P, et al. Physiologic evaluation of noninvasive mechanical ventilation delivered with three types of masks in patients with chronic hypercapnic respiratory failure. Crit Care Med 2000; 28:1785.
  5. Bach JR, Alba AS, Saporito LR. Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users. Chest 1993; 103:174.
  6. Antonelli M, Pennisi MA, Pelosi P, et al. Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease: a feasibility study. Anesthesiology 2004; 100:16.
  7. Chiumello D, Pelosi P, Carlesso E, et al. Noninvasive positive pressure ventilation delivered by helmet vs. standard face mask. Intensive Care Med 2003; 29:1671.
  8. Antonelli M, Conti G, Pelosi P, et al. New treatment of acute hypoxemic respiratory failure: noninvasive pressure support ventilation delivered by helmet--a pilot controlled trial. Crit Care Med 2002; 30:602.
  9. Costa R, Navalesi P, Antonelli M, et al. Physiologic evaluation of different levels of assistance during noninvasive ventilation delivered through a helmet. Chest 2005; 128:2984.
  10. Moerer O, Fischer S, Hartelt M, et al. Influence of two different interfaces for noninvasive ventilation compared to invasive ventilation on the mechanical properties and performance of a respiratory system: a lung model study. Chest 2006; 129:1424.
  11. Esquinas Rodriguez AM, Papadakos PJ, Carron M, et al. Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients. Crit Care 2013; 17:223.
  12. Patel BK, Wolfe KS, Pohlman AS, et al. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2016; 315:2435.
  13. Navalesi P, Costa R, Ceriana P, et al. Non-invasive ventilation in chronic obstructive pulmonary disease patients: helmet versus facial mask. Intensive Care Med 2007; 33:74.
  14. Taccone P, Hess D, Caironi P, Bigatello LM. Continuous positive airway pressure delivered with a "helmet": effects on carbon dioxide rebreathing. Crit Care Med 2004; 32:2090.
  15. Mojoli F, Iotti GA, Gerletti M, et al. Carbon dioxide rebreathing during non-invasive ventilation delivered by helmet: a bench study. Intensive Care Med 2008; 34:1454.
  16. Racca F, Appendini L, Gregoretti C, et al. Effectiveness of mask and helmet interfaces to deliver noninvasive ventilation in a human model of resistive breathing. J Appl Physiol (1985) 2005; 99:1262.
  17. Lloyd-Owen SJ, Donaldson GC, Ambrosino N, et al. Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey. Eur Respir J 2005; 25:1025.
  18. Ozsancak Ugurlu A, Sidhom SS, Khodabandeh A, et al. Use and outcomes of noninvasive positive pressure ventilation in acute care hospitals in Massachusetts. Chest 2014; 145:964.
  19. Strumpf, DA, Carlisle, CC, Millman, RP, et al. An evaluation of the Respironics BiPAP bi-level CPAP device for delivery of assisted ventilation. Respir Care 1990; 35:415.
  20. Mehta S, McCool FD, Hill NS. Leak compensation in positive pressure ventilators: a lung model study. Eur Respir J 2001; 17:259.
  21. Ferreira JC, Chipman DW, Hill NS, Kacmarek RM. Bilevel vs ICU ventilators providing noninvasive ventilation: effect of system leaks: a COPD lung model comparison. Chest 2009; 136:448.
  22. Restrick LJ, Fox NC, Braid G, et al. Comparison of nasal pressure support ventilation with nasal intermittent positive pressure ventilation in patients with nocturnal hypoventilation. Eur Respir J 1993; 6:364.
  23. Chadda K, Clair B, Orlikowski D, et al. Pressure support versus assisted controlled noninvasive ventilation in neuromuscular disease. Neurocrit Care 2004; 1:429.
  24. Muñoz X, Crespo A, Marti S, et al. Comparative study of two different modes of noninvasive home mechanical ventilation in chronic respiratory failure. Respir Med 2006; 100:673.
  25. Windisch W, Storre JH, Sorichter S, Virchow JC Jr. Comparison of volume- and pressure-limited NPPV at night: a prospective randomized cross-over trial. Respir Med 2005; 99:52.
  26. Vitacca M, Rubini F, Foglio K, et al. Non-invasive modalities of positive pressure ventilation improve the outcome of acute exacerbations in COLD patients. Intensive Care Med 1993; 19:450.
  27. Gay PC, Hess DR, Hill NS. Noninvasive proportional assist ventilation for acute respiratory insufficiency. Comparison with pressure support ventilation. Am J Respir Crit Care Med 2001; 164:1606.
  28. Hart N, Hunt A, Polkey MI, et al. Comparison of proportional assist ventilation and pressure support ventilation in chronic respiratory failure due to neuromuscular and chest wall deformity. Thorax 2002; 57:979.
  29. Ambrogio C, Lowman X, Kuo M, et al. Sleep and non-invasive ventilation in patients with chronic respiratory insufficiency. Intensive Care Med 2009; 35:306.
  30. Storre JH, Seuthe B, Fiechter R, et al. Average volume-assured pressure support in obesity hypoventilation: A randomized crossover trial. Chest 2006; 130:815.
  31. Abd AG, Braun NM, Baskin MI, et al. Diaphragmatic dysfunction after open heart surgery: treatment with a rocking bed. Ann Intern Med 1989; 111:881.
  32. ADAMSON JP, LEWIS L, STEIN JD. Application of abdominal pressure for artificial respiration. J Am Med Assoc 1959; 169:1613.
  33. DAIL CW, AFFELDT JE, COLLIER CR. Clinical aspects of glossopharyngeal breathing; report of use by one hundred postpoliomyelitic patients. J Am Med Assoc 1955; 158:445.
  34. Bach JR, Bianchi C, Vidigal-Lopes M, et al. Lung inflation by glossopharyngeal breathing and "air stacking" in Duchenne muscular dystrophy. Am J Phys Med Rehabil 2007; 86:295.
  35. Bach JR. Update and perspective on noninvasive respiratory muscle aids. Part 2: The expiratory aids. Chest 1994; 105:1538.
  36. Vianello A, Corrado A, Arcaro G, et al. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil 2005; 84:83.
  37. Fauroux B, Guillemot N, Aubertin G, et al. Physiologic benefits of mechanical insufflation-exsufflation in children with neuromuscular diseases. Chest 2008; 133:161.
  38. Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. Chest 1997; 112:1024.
  39. Lange DJ, Lechtzin N, Davey C, et al. High-frequency chest wall oscillation in ALS: an exploratory randomized, controlled trial. Neurology 2006; 67:991.