Introduction

There are numerous researches pointing out how beneficial Non-invasive ventilation
(NIV) is as a therapeutical method for both chronic and acute respiratory failure. It
increases lung volume and decreases respiratory work and more importantly avoids
complications (such as nosocomial infection, barotrauma, and patient discomfort)
caused by intubation (Garpestad, Brennan, & Hill, 2007). However to obtain
successful NIV therapy, using the most effective NIV mask is a real crucial because it
can cause avoidable side effects such as air leakage, facial skin breakdown, and
discomfort (Keenan, Winston, 2009). These problems can be distressing enough for
the patient to limit the use of therapy. In such individuals, changing mask style might
be effective. However, a variety of NIV masks are commercially available including
the oronasal mask, nasal mask, nasal pillow, helmet, and mouthpiece. Each mask
has different use and without the knowledge regarding its proper use and choice, it
might be difficult to obtain successful NIV therapy and patients’ compliant. As an
acute care nurse I often face with the patients who require long term use of NIV
therapy and the lack of knowledge regarding its different use and management skills
has given rise to the need to gain the knowledge and skills. In this respect, this
annotation of below sources will provide the knowledge related to the differences of
NIV masks and its efficacy and adverse effects that can help nurses choose the most
effective NIV mask for the patient.

Costa, R., Navalesi, P., Antonelli, M., Cavaliere, F., Craba, A., Proietti, R., et al
(2005). Physiologic Evaluation of Different Levels of Assistance During
Noninvasive Ventilation Delivered Through a Helmet. Chest, 128, 2984-2990.

The helmet is one of the newest interfaces that can reduce various side effects of
face mask- skin necrosis, conjunctivitis, eye irritation and gastric distension.
However, with its’ drawbacks such as increased time lag between inspiratory effort
and ventilatory assistance due to its highly compliant soft collar and CO2 rebreathing
due to its large volume, the use of the helmet is still controversial. For this reason,
this physiologic study with 8 healthy volunteers implemented to evaluate the effects
of using Helmet during NIV with different levels of PS and PEEP on inspiratory
efforts, CO2 rebreathing, patient/ventilator interaction, and comfort (using visual
analogue scale). The finding of this article is that the helmet is effective in reducing
the inspiratory effort allowing VT increase and RR reduction and did not change
PiCO2, end-tidal CO2, and VCO2 with the increase of PS level during study.
Moreover it did not affect patient/ventilator interaction. However, not surprisingly, with
high level of PS and PEEP, the volunteers appeared high level of discomfort despite
keeping synchrony with ventilator. Authors hypothesised this is due to increased
respiratory effort of healthy volunteers to maintain synchronise with the NIV, leading
to muscular stress and discomfort. Then does it cause same stress and discomfort to
the patient with respiratory failure? Thus, I think that it is necessary to have further
study with the patients to generalise of this valuable finding.

Glerant, J, C., Rose, D., Oltean, V., Dayen, C., Mayeux, I., Jounieaux. (2007).
Non-invasive Ventilation Using a Mouthpiece in patients with Chronic
Obstructive Pulmonary Disease and Acute Respiratory Failure. Respiration, 74,
632-639.

This is a pair-wise retrospective case-control study performed in the Respiratory

intensive care unit during 14-year period. 29 patients receiving non-invasive positive
pressure ventilation via mouthpiece (mNPPV), 29 patients with nasal or oronasal
mask (Nnppv), and 29 patients with standard medical treatment (SMT) selected
regarding age, SAPSII, admission PaCO2 and pH and criteria of success was
evaluated based on arterial blood gases value and intubation rate. Overall, the result
showed that mNPPV, nNPPV significantly reduces the intubation rate in comparison
with SMT, (93.1%, 86.2% and 44.8%, respectively), and leads to lower PaCO2,
higher pH which is a great value for the patients with hypercapnic respiratory failure.
However, it appeared to be very similar in the respect of the blood gas data
improvement between nNPPV and mNPPV confirming comparable efficacy of these
two modes. Throughout this article, the authors presented information that using a
mouthpiece is as effective as using nasal or oronasal mask in patients with COPD
and ARF, and appears to be alternative method to nNPPV when this technique is
poorly tolerated due to skin necrosis and claustrophobia. However, as mentioned in
this article, mNPPV also has advantages. It requires a higher level of patients’
collaboration and workload for nurses because the patient must keep the mouth
closed to avoid air leakages, and also resulting in a longer learning period for the
patient to understand and cooperate.

Holanda, M, A., Reis, R, C., Winker, G, F, P., Fortalenza, S, C, B., Lima, J, W, O.,
Pereira, E, D, B. (2009). Influence of total face, facial and nasal masks on short-
term adverse effects during non-invasive ventilation. J Bras Pneumol, 35(2),
164-173.

In this article, Holanda et al compared the incidence, type and intensity of adverse
effects as well as the comfort, of total face masks (TFMs), facial masks (FMs), and
nasal masks (NMs) for short-term period of NIV (BiPAP). It is a crossover
randomised study involving 24 healthy volunteers applied two levels of pressure (low
and moderate-to –high) via three types of masks from same manufacturer. Overall,
findings from this study proved that the type and incidence of mask-related short-
term adverse effects are closely related to the mask type, which is core value for my
study. Although there is no significant difference among the masks related to the
comfort score in low NIV pressure, in the mod-high level of pressure setting, NMs
presented the worst comfortable performance than TFMs and FMs. And it also
showed the best performance related to oronasal dryness. Related to TFMs, it had
the best performance concerning pain at the bridge of nose and air leaks, and the
worst result in terms of oronasal dryness and claustrophobia. With FMs, it presented
the worst score in terms of air leaks compared to others. Thus, authors suggested
that TFMs might be reliable option for use in patients who adapt poorly to the NM and
FM due to pain or skin damage, as well as air leaks. This article is surely useful to my
study, nevertheless, it has a number of limitations such as restricted time and devices
(ie ; same mode of NIV and masks from same manufacturer), and also restricted
study subjects (healthy young volunteers). Thus, we need more studies involving
patients, therefore, further, more extensive, research needs to be undertaken to
develop a more in-depth understanding of adverse-effects related to the mask type.

Saatci, E., Miller, D, M., Stell, I, M., Lee, K, C., Moxham, J. (2004). Dynamic dead
space in face masks used with noninvasive ventilators: a lung model study.
Eur Respir J, 23, 129-136.

After completing the review of this article, I was able to determine the influence of
different designs of face masks and different NIV modes on total dynamic dead
space. This laboratory study used modified designed lung model to measure
dynamic dead space/ total tidal volume (VD/VT) of 18 NIV FMs which connected to 4
different NIV modes (CPAP,BiPAP, pressure support, and pressure assist mode). The
finding of this article related to the effects of different types FMs and different
ventilator modes upon VD/VT is significant. However, since the topic of this study is
to find the efficacy of different type of masks, only the influence of different designs of
FMs will be presented here. Throughout this experiment, they found that the face
masks produce the best blood-gas results and there is minor difference on VD
among the masks with different shapes and manufacturers. Moreover, they also
found that FMs with expiratory ports over the nasal bridge is the best in reducing
VD/VT than with ports located in the mask over the cheeks, and at the mask
connector site, if an adequate positive pressure is maintained throughout the
expiratory phase. It means that exhaust ports in the FMs help expired flow to
discharge by a beneficial flow stream and consequently reduce dead apace. This
finding should be a real value when we choose optimal face masks to reduce VD.
However, this article also has limitation which is unavoidable air leaks between
mannequin face and the face mask due to fitting problem. As we know air leaks
decrease the VD and this is a laboratory study which can produce different results
with a small variance. Thus, I thing that to apply face mask firmly in order to reduce
air leaks is as important as to choose proper face masks.

Willson, G, N., Piper, A, J., Norman, M., Chaseling, W, G., Milross, M, A., Collins,
E, R., et al. (2004). Nasal versus full face masks for non-invasive ventilation in
chronic respiratory failure. Eur respire J, 23, 605-609.

This experimental study aimed to determine any differences in terms of sleep quality,
gas exchange and tolerability between using nasal masks (NM) and full face masks
(FFM) in patients with nocturnal hypoventilation due to restrictive or obstructive
disorders and sleep disordered breathing. Participated 16 patients were monitored
under same NIV setting and same oxygen flow rate in the sleep laboratory for
2months. The finding of this study showed that there is no significant difference
between these two masks in terms of gas exchange and arousal indices, however,
given the fact that FFM reduces air leak, there by improving gas exchange and sleep
quality, patients, subjectively, felt less air leakage and more sleep quality in using NM
than FFM. Related to this, the authors raised the possibility that using chinstraps
might have reduced the air leak yielding same efficacy as FFM. After reading this
article, my general impression is that patients feel more comfort when using NM than
using FFM even though FFM weighted more beneficial in reducing air leaks and gas
exchange. It may be explained by adverse effects of FFM which is claustrophobic
causing sleep difficulty. Then if chinstraps can reduce air leaks as much as FFM as
mentioned in the article, it should become ‘standard’ to use chinstraps with NM and
further study should be undertaken to prove the effectiveness of chinstraps.

Conclusion

To conclude, the development of various interfaces have made the delivery of

effective ventilation to patients without intubation possible and it is a real challenge
for nurse to find an optimal interface, which is comfortable and does not cause side
effects because it is one of the crucial issues affecting NIV outcome. Thus, as
advanced practice nurse, we should be aware of the use of different NIV masks and
its advantages and disadvantages to provide the perfect use of NIV masks in
appropriate patient,
References
Garpestad, E., Brennan, J., Hill, N,S. (2007). Noninvasive Ventilation for Critical
Care. Chest, 132, 711-720.

Keenan, S, P., Winston, B. (2009). Interfaces for Noninvasive Ventilation: Does it

MATTER?. J Bras Pneumol, 35(2),103-105.
 ICCN
Annotated Bibliography

Topic: use of different NIV facemasks

Name: Jihea Kim

Date: 22. 06. 2009