Answers to evaluation questions Please find all correct answers in bold below NIV: past, present and future – Prof. Wolfram Windisch 1. Which of the following statements is correct for Non-invasive Positive Pressure Ventilation (NPPV)? a. It exclusively refers to mask ventilation. b. It is provided via tracheostomy. c. It also includes negative pressure ventilation (e.g. iron lung). d. It is the newest mode of ventilatory support. 2. Who was the “driving person” helping victims of the polio epidemic in Denmark in 1952? a. Björn Ibsen. b. Ferdinand Sauerbruch. c. Philip Drinker. d. Colin Sullivan. 3. Which of the following statements on home Non-invasive Positive Pressure Ventilation (NPPV) is correct? a. It is currently only used in chronic obstructive pulmonary disease (COPD) patients. b. It is currently only used in neuromuscular patients. c. Negative pressure ventilation is the current technique of choice. d. It is increasingly being used in acute, chronic and acute on chronic hypercapnic patients worldwide. 4. Which of the following statements is correct for NPPV-modes? a. Target volume ventilation is the best mode. b. Pressure-preset NIV was historically the mode of choice when used for NPPV. c. Across Europe volume-preset NIV is less frequently used than 20 years ago. d. A number of different modes of non-invasive ventilation are available with the advantage of each remaining unproven. 5. Which of the following statements is the best statement to describe the use of NPPV in the acute setting? a. It does not work in COPD-patients. b. Hypoxemic failure is the best indication for acute NPPV. c. It has the potential to avoid intubation. d. Extracorporeal carbon dioxide removal has been shown to be superior.

NIV in acute hypercapnic failure – Prof. Dr. Bernd Schönhofer 1. Regarding NIV in acute hypercapnic failure caused by COPD, which of the following statement is correct? a. Mild hypercapnia is the best predictor of the need for NIV b. pH < 7.2 is an absolute contraindication to NIV c. NIV should never be performed when the patient is comatosed d. NIV is less likely to be tolerated in mild exacerbations of COPD requiring ventilatory support because the patient has less to gain in terms of relief of symptoms e. A very important reason for instituting NIV is to prevent endotracheal intubation 2. Which of the following statements is correct? a. Acute hypercapnic failure results from respiratory muscle insufficiency b. Ventilatory failure typically results in hypocapnia c. Hypercapnic respiratory failure primarily requires oxygen treatment. d. Hypoxemia and hypercapnic always occur simultaneously. 3. The use of non-invasive ventilation in acute hypercapnic failure is... a. contraindicated in patients with obesity-hypoventilation syndrome b. always recommended in patients with kyphoscoliosis to avoid invasive ventilation c. the best indicated in patients with bronchiectasis d. may be indicated as a palliative tool e. indicated when PaCO2 is above 45 mmHg 4. An absolute contraindication for NIV in acute hypercapnic failure is... a. Agitation b. Hypersecretion c. Severe upper gastrointestinal bleeding d. Hypercapnic coma 5. NIV is not indicated as an intervention in acute hypercapnic failure... a. in palliation to improve more rapidly dyspnoea b. in ARDS to open the lung and keep it open c. in obesity hypoventilation to unload respiratory muscles d. in neuromuscular disease in combination with bronchoscopy to remove bronchial secretion

NIV in hypoxemic respiratory failure (excluding acute pulmonary edema) – Dr Raffaele Scala 1. In acute hypoxemic respiratory failure, the rationale for the use of NIV includes... (more than one answer may be correct) a. Unloading of respiratory muscles b. Improving hypoxemia due to V/Q mismatch c. Improving hypoxemia due to shunt d. All of the above 2. What is the strongest predictor of NIV failure in ARDS? a. Multiple organ dysfunction b. PaO2/FiO2 ratio at baseline between 200 and 300 c. Extra-pulmonary etiology d. Cardiopulmonary comorbidities 3. Which of the following situations, in patients with acute hypoxemic respiratory failure, is the level of evidence for use of NIV highest? (more than one answer may be correct) a. ARDS with PaO2/FiO2 ratio between 100 and 200 b. Pulmonary infiltrates in immunocompromised patients c. Severe community acquired pneumonia d. All of the above 4. When can NIV be successfully used in acute hypoxemic respiratory failure? (more than one answer may be correct) a. As prophylaxis of hypoxemia in high-risk patients b. As prevention of endotracheal intubation in patients with established hypoxemia c. As alternative of endotracheal intubation in patients with severe hypoxemia d. Always in pneumonia e. Answers a and b 5. What are the reasons for NIV failure in acute hypoxemic respiratory failure? (more than one answer may be correct) a. Inability to correct hypoxemia b. Intolerance of the mask c. Inability to remove secretions d. All of the above

Indications for long-term NIV in chronic respiratory failure – Prof. Jean-Paul Janssens 1. Among the following disorders, which is not considered as a usual indication for long term NIV: a. COPD b. Duchenne’s Muscular Dystrophy c. Post-polio syndrome d. Obesity hypoventilation e. Idiopathic pulmonary fibrosis 2. The most widely used ventilator mode for long term NIV is presently: a. Negative pressure ventilation b. Volume-cycled controlled ventilation c. Volume-cycled assist-control ventilation d. Pressure support in a spontaneous mode e. Bi-level pressure cycled ventilation 3. Among the following indications for long term NIV, which are supported by randomized controlled studies? (more than one answer may be correct) a. COPD b. Obesity-hypoventilation c. Kyphoscoliosis d. Duchenne’s muscular dystrophy e. Cheyne-Stokes breathing

How do I choose the interface? – Dr J. Escarrabill 1. In relationship with the history of ventilation, which is the correct answer? a. The NIV at home did not exist before 1980. b. Only a small percentage of patients used tracheotomy for long term ventilation before 1980. c. The NIV was first developed in the intensive care unit and then went to home ventilation. d. The development of home ventilation from the 1980’s was based on nasal ventilation. e. None of the above is true. 2. Which of the following statements is false regarding the NIV to treat acute respiratory failure? a. Oro-nasal mask is the first choice. b. In stable patients at 24-48 h of NIV with oro-nasal mask, you can use, in some cases, a nasal mask. c. The ultimate goal is achieve ventilation with no leaks at all. d. Cooperation of the patient is less necessary if you use an oro-facial mask or helmet instead of a nasal mask. e. There are a huge diverse interfaces and it is mandatory for the clinician to find the best alternative for each patient. 3. Sometimes in the long-term ventilation is necessary to change the interface. Which of the following statements is false? a. Daytime pipette mouth ventilation often can avoid tracheotomy (or delay it). b. When skin lesions are not resolved with topical treatments, a temporarily change of the mask model used should be recommended. c. When changes in the model of mask are necessary, visual observation of the leaks is enough. d. By using oro-facial or facial masks is essential to ensure that the patient can remove them in case of coughing, vomiting or choking. e. Face masks often cause less skin lesions, although the patient may have a sensation of claustrophobia. 4. The ideal interface does not exist. Which of the following statements is true, regarding longterm ventilation? a. The only criterion to decide the use of an interface is efficacy in relation to gas exchange. b. In the long term ventilation it doesn't make sense the patient's opinion because he/she doesn't know all existing masks. c. The optimal way to select an interface is the combination between patient preferences and clinical efficacy. d. From a practical standpoint, it is best that the patient select the mask you prefer. e. Only select masks that do not allow any air leak. 5. Respect ideal interface, which of the following statements is false? a. The interfaces must be lightweight, stable and with fixings that interfere little (or nothing) with sleeping. b. Dead space it’s not the same in all interfaces. c. Oro-nasal masks, when used in curcuits without expiratory valve must have holes in the mask to minimize rebreathing. d. The patient's comfort with the mask is crucial in both the acute and long-term ventilation. e. All interfaces are well tested and offer similar benefits.

Air leakage during NIV: how important, how to avoid, how to handle? – Dr P. Wijkstra 1. Leakage during NIV might lead to... (more than one answer may be correct) a. Reduced tidal volume b. Low sleep efficiency c. Patient ventilator asynchrony d. All answers are correct 2. Leak compensation is possible in ventilators with... a. Volume controlled mode b. Pressure controlled mode 3. In case of leakage mouth seal may improve gas exchange because of... (more than one answer may be correct) a. Increased hypopharyngeal pressure b. Maintained EPAP c. Better patient ventilator synchrony d. All answers are correct 4. Humidification can reduce mouth leakage by... a. increasing nasal resistance b. reducing nasal resistance c. better mask fitting

Troubleshooting - what to do when NIV is not going well? – Prof. Jean-Paul Janssens 1. The following events occurring under NIV can be detected using ventilator software reports, except: a. Leaks b. Poor compliance c. Low tidal volume and minute ventilation d. Patient-ventilator asynchrony e. Residual apneas or hypopneas 2. Among the following tools for monitoring NIV, which can be recommended routinely as firstline systematic tests? (more than one answer may be correct) a. Nocturnal pulsoximetry b. Daytime measurement of arterial PCO2 and PO2 (partial pressures of oxygen and carbon dioxide) c. Downloading and analysis of ventilator software d. Polysomnography e. Polygraphy 3. In the presence of residual obstructive events under non-invasive ventilation (bi-level pressure support) for obesity hypoventilation and obstructive sleep apnea-hypopnea syndrome, one should preferably: a. Increase IPAP b. Decrease back-up respiratory rate c. Increase rise time d. Decrease pressure support e. Increase EPAP 4. In the presence of newly detected central events under non-invasive ventilation (bi-level pressure support) for obesity hypoventilation and obstructive sleep apnea-hypopnea syndrome, one should preferably: a. Increase pressure support b. Decrease back-up respiratory rate c. Switch from an assist-control to a spontaneous mode d. Perform a nocturnal recording of transcutaneous PCO2 (partial pressure of carbon dioxyde) under NIV e. Increase EPAP 5. In the presence of patient-ventilator asynchrony under home NIV, one must search for... (more than one answer may be correct) a. Leaks b. Dynamic hyperinflation c. Delayed cycling d. Inappropriate trigger settings e. All of the above

Monitoring of NIV in the acute setting – Dr Raffaele Scala 1. Which are the goals of monitoring NIV in acute setting? (more than one answer may be correct) a. to assess the effectiveness of NIV b. to identify the complications of NIV c. to detect the signs of NIV failure d. all of the above 2. Which are the clinical signs of increased respiratory muscles effort that should be monitored in acute patients receiving NIV? (more than one answer may be correct) a. Paradoxical abdominal breathing b. Rapid shallow breathing c. Answers a and b d. Hypotension and bradycardia 3. Which clinical tools should be used to assess agitation during NIV in acute patients? a. Kelly-Matthay score b. Richmond Scale c. Glasgow Coma Scale d. None of the above 4. The effectiveness of NIV in acute patients should be evaluated with... (more than one answer may be correct) a. SpO2 and Respiratory rate at 1 and 4 hours b. Blood gases and Respiratory rate at 1 and 4 hours c. Transcutaneous PaCO2 and SpO2 at 1 and 4 hours d. All of the above 5. How should be assessed patient-ventilator interaction during NIV? (more than one answer may be correct) a. Looking at respiratory pattern (respiratory rate and tidal volume) b. Looking at the curves of flow and pressure of the ventilator c. Looking at the intentional leaks d. All of the above

Monitoring of NIV in the chronic setting – Dr Peter Wijkstra 1. Oximetry is an excellent tool to monitor ventilation during the night? a. Yes b. No 2. Peak end tidal CO2 (PtCO2) is a better assessment of ventilation than Transcutaneous CO2 (TcCO2)? a. Yes b. No 3. Effectiveness of chronic ventilatory support can be best monitored by... (more than one answer may be correct) a. Oximetry b. PaCO2 c. Clinical improvement d. Combination of a,b,c

How to start NIV in the acute setting - Prof. R. Scala & Prof. Dr B. Schönhofer 1. What is the main reason for a low utilization of NIV in acute respiratory failure? a. lack of equipment b. lack of physician’s knowledge c. inappropriate setting d. insufficient scientific data 2. What are the factors that should be considered in choosing the location where to start NIV in acute respiratory failure? (more than one answer may be correct) a. severity and typology of acute respiratory failure b. level of monitoring of the environment c. nurse-to-patient ratio d. all of the above 3. Which is the most used interface to start NIV in acute respiratory failure? a. helmet b. full-face mask c. nasal mask d. total face mask 4. How should be set the ventilator for starting NIV in acute respiratory failure? a. set immediately high levels of PS and PPEP b. titrate the level of PS and PEEP according to blood gases c. titrate the levels of PS and PEEP according to pt/vent synchrony and pt comfort d. set predefined values of PS and PEEP according to the underlying disease 5. Which points should be carefully assessed when we start NIV in acute setting? (more than one answer may be correct) a. comfort of the patient b. the amount of leaks c. the synchrony between the patient and the ventilator d. all of the above

How to start NIV in the chronic setting - Prof. W. Windisch & Dr P. Wijkstra 1. How is high-intensity NIV started? a. With high inspiratory pressures and controlled ventilation. b. With low inspiratory pressures and controlled ventilation. c. With high inspiratory pressures and assisted ventilation. d. With low inspiratory pressures and assisted ventilation. 2. How is high-intensity NIV defined? a. NIV using inspiratory pressures above 30 cmH2O. b. NIV used for at least 10 hours per night. c. NIV aimed at maximally reducing PaCO2. d. High-intensity NIV does not exist. 3. Which of the following statements on established high-intensity NIV is correct? a. High-intensity NIV typically uses assisted ventilation. b. High-intensity NIV has been primarily established in patients with obesity. c. High-intensity NIV is typically not tolerated by the patient. d. High-intensity NIV is capable of improving quality of life and survival. 4. Which of the following statements is correct for COPD-patients? a. Low-intensity NIV is superior over high-intensity NIV. b. Long-term NIV should only established following exacerbation. c. Quality of life typically deteriorates when long-term NIV is started. d. High-intensity NIV is a beneficial option to treat chronic hypercapnia. 5. What is the physiological aim of high-intensity NIV in COPD-patients? a. To reduce elevated PaCO2-levels. b. To improve inspiratory muscle strength. c. To increase bicarbonate levels. d. To establish REM sleep.

NIV: special considerations – Dr Nicholas Hart 1. A 40 year old with BMI of 41 kg/m2 woman attends clinic complaining of day time somnolence, peripheral oedema and early morning headaches. She has undergone an overnight home oximetry (Figure 1). What is the likely diagnosis?

a. b. c. d. e.

Chronic obstructive pulmonary disease Hypercapnic OSA Eucapnic OSA Lone OHS Combined OSA and OHS

The oximetry demonstrates low baseline SpO2 with prolonged desaturations rather than rapid repetitive desaturations. 2. Regarding lung volumes, which of the following are true in obesity? a. FRC is increased, TLC is increased, RV is increased b. FRC is reduced, ERV is increased, TLC is increased c. FRC is reduced, ERV is reduced, TLC is reduced d. FRC is reduced, RV is increased, TLC is increased e. FRC is increased, ERV is increased, TLC is reduced [Abbreviations: FRC = Functional Residual Capacity; TLC = Total Lung Capacity; RV = Residual Volume; ERV = expiratory reserve volume] The lung volumes are all reduced in obesity; FRC and ERV are inversely correlate with BMI. 3. A patient with a BMI of 47 kg/m2 with a known history of sleep disordered breathing, presents acutely with breathlessness, cyanosis and worsening peripheral oedema. Her arterial blood gas shows a pH 7.22 with a PaO2 6.7kPa and a PaCO2 11.3kPa. The bicarbonate level was 30.3mmol/l. She is diagnosed with an acute decompensation of her sleep disordered breathing. What immediate treatment should be initiated? a. 3L/minute of high flow humidified oxygen therapy b. Continuous positive airway pressure therapy with oxygen therapy c. Nebulised salbutamol and ipratropium bromide driven by oxygen d. Non-invasive bi-level ventilation with oxygen therapy if ongoing hypoxia despite non-invasive bi-level ventilation e. Intubation and mechanical ventilation This patient has acutely decompensated from her sleep disordered breathing and has developed acute on chronic hypercapnic respiratory failure. Non-invasive bi-level ventilation with oxygen is first line treatment, although the patient will also require aggressive diuresis.

4. Which of the following changes does not occur when moving from a seated to a supine posture in simple obesity? a. Increase in tidal volume b. Increase in transdiaphragmatic pressure generation c. Increased neural respiratory d. Increase in intrinsic positive end expiratory pressure e. Reduced respiratory system compliance Tidal volume falls when obese subjects adopt a supine posture. 5. A 50-year-old man was admitted with breathlessness, leg oedema, drowsiness and morning headaches. He was an ex-smoker and he suffered from type 2 diabetes mellitus and hypertension. He was taking metformin and bendroflumethiazide. He was known to snore heavily. On examination, he was morbidly obese (body mass index 43 kg/m2), drowsy, with an elevation of the jugular venous pressure and bilateral leg oedema. Breath sounds were quiet throughout. His respiratory rate was 14bpm with a heart rate of 110 in sinus rhythm. His blood pressure was 155/98. His chest X-ray showed clear lungs but with cardiomegaly and enlarged pulmonary arteries. Arterial blood gases analysis whilst breathing 24% oxygen: PaO2 6.6 kPa (11.3 - 12.6) PaCO2 9.9 kPa (4.7 - 6.0) pH 7.34 (7.35 - 7.45) H+ 46 nmol/L (35 - 45) Bicarbonate 33.1 mmol/L (21 - 29) Haematocrit 0.69 (0.36-0.47) What is the best approach to his management? a. Controlled oxygen therapy b. Controlled oxygen therapy and aggressive diuresis c. Controlled oxygen therapy, aggressive diuresis and non-invasive ventilation d. Controlled oxygen therapy, aggressive diuresis, non-invasive ventilation and therapeutic venesection e. Intubate and ventilate and transfer to the intensive care unit

Specific problems when using NIV in COPD – Prof. Wolfram Windisch 1. Which of the following statements is correct for COPD patients? a. Chronic hypoxemia and chronic hypercapnia always occur simultaneously. b. Long-term NIV is usually applied in chronic hypoxemic respiratory failure. c. Long-term NIV does not improve quality of life in COPD patients. d. COPD can lead to chronic hypercapnic respiratory failure. 2. Which of the following statements on long-term NIV used in COPD is correct? a. It is always superior over long-term oxygen therapy. b. It should be considered in chronic hypercapnic COPD patients. c. It is ineffective in COPD patients. d. It is primarily used following exacerbation. 3. Which of the following statements on high-intensity NPPV is correct? a. High-intensity NPPV typically uses assisted ventilation. b. High-intensity NPPV has been primarily established in restrictive patients. c. High-intensity NPPV typically uses high inspiratory pressures. d. High-intensity NPPV is poorly tolerated by COPD patients. 4. Which of the following statements is correct for COPD-patients? a. High-intensity NIV is superior over low-intensity NPPV. b. Long-term NIV should only established following acute respiratory failure. c. Quality of life typically deteriorates when long-term NIV is started. d. NPPV is useless when used as an adjunct to rehabilitation. 5. Which of the following statements is correct for long-term NIV in COPD-patients? a. It has the potential to improve survival if NIV is capable of reducing PaCO2. b. It is not capable of improving survival. c. It may improve survival at regular cost of reduced quality of life. d. It typically reduces life span.

How to discharge patients with NIV? – Dr J. Escarrabill 1. Regarding the general concept of discharge planning, which answer is false? a. Communication sometimes is inadequate to ensure a good shared decision making process. b. It is difficult to define a "good transition" due to the heterogeneity of the studies and the multiple components of the process. c. There is great variability in clinical practice, even in the same country. d. The relationship with primary care is not essential. e. Local circumstances determine the proposed package of care for each patient. 2. Which of the following statements is true in relation to discharge planning for patients on home mechanical ventilation (HMV)? a. The term "Discharge Planning" only refers to the first time the patient returns to home after the prescription of HMV. b. The term "Discharge Planning" refers to the care of patients with respiratory problems on HMV. c. The opinion of the patient and caregiver are important, but discharge plans only consider the medical point of view. d. In a selected group of patients HMV can be started in outpatient clinics. e. In HMV "discharge planning" is only related to the transfer to another healthcare facility, not at home. 3. Regarding the main characteristics of discharge planning, which of these the following statements is false? a. Discharge plans must be designed through care packages tailored to local circumstances. b. In discharge plans is mandatory the involvement of all stakeholders (integrated care). c. The plans must be highly focused on needs both of the patient and caregivers, meaning information, deliberation and consensus to decide. d. Social needs are common to all patients, so they can be standardized. e. Efforts must be made to ensure the coordination and sometimes must include the figure of a case manager. 4. Regarding education in discharge planning, which of the following statements is false? a. It is mandatory to design education tailored to the needs of the patient and caregiver. b. Key educational points should be verified in each visit. c. Educational needs change over time. d. The performing of procedures that should be done by the patient (and caregiver) should be verified by the health professional to be certain of the proper understanding and implementation. e. Education in HMV is mainly a responsibility of general practitioner. 5. Regarding the assessment of outcomes of home mechanical ventilation (HMV), which of the following statements is false? a. It is mandatory to evaluate the impact of HMV throughout the care cycle. b. In addition to assess the functional impact, changes in patient’s autonomy should be evaluated. c. The study of the reduction or increase of hospital admissions is not useful if it is an isolated analysis. Overall consumption of healthcare resources should be assessed. d. The variability in clinical practice is unavoidable and it must be accepted. e. One of the most important aspects is to assess the caregiver burden.