Positive Pressure Ventilation for Respiratory Disease – a flawed, non-physiological solution

Howard D. J. and Coulthard M. G.

ABSTRACT

“Modern” larger mammals developed over the last 65 million years, after the demise of the dinosaurs. All mammals, including hominids, breathe by negative pressure.

Between 1928 and the 1970s, negative pressure ventilation was the only method of artificial respiration available. The introduction of positive pressure ventilation (PPV) in the 1960s was revolutionary but has been associated with significant complications.

In the COVID-19 pandemic, the use of PPV has been widespread, but the potential adverse effects have been largely overlooked.

This article reviews the historical context, the physiological implications, and the ongoing debate surrounding the use of positive pressure ventilation in respiratory disease.

Keywords

Positive pressure ventilation, respiratory disease, COVID-19, artificial respiration, negative pressure ventilation.

Introduction

Current research suggests that Basidobolum grandis, a millennia year old mammal ever identified “Modern” larger mammals developed over the last 65 million years, after the demise of the dinosaurs. All mammals, including hominids, breathe by negative pressure. Hominids actually have the ability to breathe by a form of positive pressure injection of air into the lungs called glossopharyngeal breathing (GPB), glossopharyngeal insufflation, or frog breathing. The technique was first described by Dail in 1951.

The introduction of positive pressure ventilation (PPV) in the 1960s revolutionized the care of patients with respiratory failure, but it has also been associated with significant complications. The use of PPV has become increasingly sophisticated and, increasingly expensive, with devices such as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) and PPV devices. Positive pressure ventilation technology has been developed while negative pressure ventilation has largely been forgotten.

Methods

Narrative review based on systematic literature review. Articles were searched through PubMed for keywords: positive pressure ventilation, non-invasive ventilation, and COVID-19. The search was limited to articles published in the last 20 years.

Results

Ventilator induced lung injury: The potential role of positive pressure ventilation in the development of ventilator-induced lung injury (VILI) has been recognized for decades. The use of positive pressure ventilation can lead to barotrauma, volutrauma, and biotrauma, which can exacerbate lung injury.

COVID-19 affecting the cardiovascular system: The deleterious effects of COVID-19 on the cardiovascular system were rapidly recognized early in 2020 and were immediately reported in the COVID-19 literature from China and subsequently worldwide. Acute myocardial injury and myocardial ischemia have been reported in patients with COVID-19, leading to increased mortality.

It is important to stress in these days of “Evidence Based Medicine” that this change was not due to comparative studies demonstrating superiority of PPV over NPV, nor improved outcome measures, but because anaesthetists who became the initial device specialists already had the experience of using intubation and positive pressure to ventilate patients in the operating theatre.

Conclusion

In conclusion, while positive pressure ventilation has become a mainstay in the management of respiratory failure, its use must be carefully considered in light of the potential complications. The ongoing debate surrounding its efficacy and safety in various clinical settings continues to evolve.

References

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2. Dail CW. “Glossopharyngeal Breathing” by Paralyzed Patient. Calif Med. 1951; 75 (3): 212-213.
3. Dail CW, Affeldt JE. Glossopharyngeal breathing (video). Los Angeles: Department of Visual Education, College of Medical Evangelists; 1954.
4. Webber B, Higgins J. Glossopharyngeal breathing: what, when and how? (video). J Anesth. 2015; 23: 239-245.
5. Pingleton SK. Complications of acute respiratory failure. Ann Rev Respir Dis. 1988; 137: 1443-953.