Non-Invasive Ventilation in Pneumothorax with Chronic Obstructive Pulmonary Disease

Indications and Safety Considerations

The presence of an undrained pneumothorax is considered a relative contraindication to non-invasive ventilation (NIV) and should be excluded as a complication when NIV fails or the patient deteriorates, according to the British Thoracic Society 1
Guidelines recommend considering pneumothorax as a possible complication when a patient on NIV does not improve or worsens, as stated by the British Thoracic Society 1
Before starting or continuing NIV in the presence of a pneumothorax, it is essential to position an adequate chest drain, as recommended by the British Thoracic Society 1

If the patient has an active pneumothorax, an immediate chest drain should be positioned before starting or continuing NIV, as recommended by the British Thoracic Society 1
Radiographic verification of complete lung re-expansion should be performed, as stated by the British Thoracic Society 1
Only after lung re-expansion, NIV can be considered if indicated for hypercapnic respiratory failure (pH <7.35, PaCO₂ >45 mmHg), according to the American Thoracic Society 2

When using NIV in patients at risk of pneumothorax, a pressure difference between IPAP and EPAP of at least 5 cmH₂O should be maintained, but initially avoid excessively high pressures, as recommended by the American Thoracic Society 2
Gradually titrate pressures to normalize PaCO₂, monitoring blood gas analysis after 30-60 minutes, as stated by the American Thoracic Society 2
Blood gas analysis should be checked at 1 hour and certainly at 4-6 hours to evaluate improvement in pH, PaCO₂, and PaO₂, as recommended by the British Thoracic Society 1

NIV should never be started during a hospital admission for acute-on-chronic hypercapnic respiratory failure; the patient should be re-evaluated 2-4 weeks after resolution, as stated by the American Thoracic Society 2
Lack of progression towards correction of blood gas parameters within 4-6 hours is associated with NIV failure, as reported by the British Thoracic Society 1
If NIV is clearly failing and the patient is not a candidate for intubation, NIV should be discontinued and alternative treatments considered, as recommended by the British Thoracic Society 1