7 ERS Practical Handbook Noninvasive Ventilation Introduction Implementation of NIV in clinical practice The newer applications discussed above underscore a problem of implementa- tion of “good practice” in NIV, which affects all units to a greater or lesser extent. There is evidence that patients who would benefit from NIV are not receiving it even for gold standard indications, such as acute hypercapnic exacerbation of COPD, for a number of reasons, but mainly because the medical team does not feel skilled enough to deliver it. Of course, the answer to this problem is to pro- vide knowledge and skills to remedy these deficiencies, which is the purpose of this handbook, many NIV courses and the ERS Skills-based Simulator Training in Non-Invasive Ventilation. Intelligent ventilators The question arises, if medical teams are inexperienced, can you make the ventila- tor intelligent? A variety of approaches have been adopted in the past few years to try to combine bilevel pressure support with the delivery of an assured minute ventilation or VT. The underlying aim of these modes is to better adapt to the patient’s own ventilatory requirements, which will vary during different stages of sleep and with different activities during the day. Some devices also have an “intel- ligent” backup rate and a “learn” mode in which the ventilator adapts to patient’s respiratory effort and pattern. AVAPS was one of the first of these new modes. An initial randomised cross­ over trial of AVAPS versus standard pressure support in obesity hypoventilation patients showed a small improvement on nocturnal carbon dioxide tension but no long-term quality of life improvement. Murphy et al. (2012) confirmed there was no long-term advantage of using AVAPS over optimally titrated bilevel pressure support in very obese patients, and results in COPD patients are equivocal. The IVAPS ventilator targets VT rather than minute ventilation and has been shown to produce equivalent control of nocturnal hypoventilation to a group of patients expertly set-up on NIV. In addition, in a group with predominantly restrictive dis- orders starting NIV for the first time, IVAPS resulted in improved adherence over- night and a reduction in stage 1 sleep, suggesting sleep initiation when starting NIV was improved. These results suggest that intelligent modes of ventilation may have a role in certain subgroups but they have not been demonstrated to be supe- rior to conventional pressure support NIV in all patient groups. Other developments Interface development has also advanced very significantly, with better choice and design particularly the use of softer contoured material, rather than rigid plas- tic or vinyl. However, problems with pressure sores and midfacial hypoplasia have not yet been solved and tactics to overcome these issues are discussed in the sec- tion entitled “Choosing the interface”. Organisation and delivery of ventilatory care is likely to evolve too. In acute NIV, there has been a trend to manage sicker patients successfully in high-dependency units. For homecare, greater information from ventilator software enables prob- lems to be solved remotely, and telemonitoring approaches are increasing but need to be validated. There is every hope that the future of NIV will be as exciting as its past!