Where and how must we perform noninvasive mechanical ventilation?

The classic experience of mechanical ventilation (MV) has recently been integrated with the use of devices providing noninvasive ventilatory assistance in the Intermediate Intensive Care Unit (IICU), to which patients suffering from acute on chronic respiratory insufficiency may be admitted for therapy. Noninvasive mechanical ventilation (NMV) has been demonstrated to be mandatory during severe relapses of chronic obstructive pulmonary disease (COPD). This method of ventilation can reduce mortality, morbidity and time spent in the Intensive Care Unit (ICU) when related to standard medical therapy alone. NMV should be considered for routine care in selected patients after optimization of the delivery system and education of personnel. An ideal monitoring system during MV is important to patient management. It must present interpretable data, high technical accuracy, high sensitivity, good reproducibility, be practical to use, be of low risk to the patient and inexpensive. During acute relapses of COPD in patients who require MV, malnutrition and a multifactorial score (Acute Physiology and Chronic Health Evaluation (Apache) II score) has been shown to be poor and an unfavourable index of outcome. Specific standards for the IICU are necessary, in terms of location, ventilators used, and a training programme in intensive care medicine. Dedicated pulmonary intensivists and nurses should be trained to have a comprehensive theoretical knowledge of the field of intensive respiratory care. COPD patients are the usual candidates for frequent admissions and prolonged stays in the ICU. Advanced COPD may frequently need periods of intensive treatment, monitoring and nursing. These patients may benefit from NMV which provides a specific intermediate treatment. With regard to an optimal cost/benefit ratio, the IICU is a reasonable alternative for COPD patients with less severe acute respiratory failure (ARF), reducing superfluous ICU stays.