Abstract

OBJECTIVES: High-frequency jet ventilation (HFJV) is a convenient method for providing ventilation during fiberoptic bronchoscopy. We describe an incipient approach of high-frequency jet ventilation via the working channel of a flexible bronchoscope for nonintubated patients who suffer from hypoxemia during bronchoscopy. The aim of this study was to test the efficacy of this incipient approach and determine the possible complications related to it. MATERIALS AND METHODS: Sixteen patients who had oxygen saturation below 70% that did not resolve with nasal oxygen for 20 s during interventional bronchoscopy were included in the study. High-frequency jet ventilation was administrated via the working channel of a bronchoscope for 3 min. Arterial blood gas circumscriptions were compared before and after jet ventilation. RESULTS: Oxygen saturation increased to >90% in all patients 30 s after jet ventilation. Mean arterial oxygen saturation pressure increased from 54.84 to 111.98 mmHg with jet ventilation (p=0.0001). Arterial carbon dioxide tension decreased after jet ventilation. The body mass index had no consequential effect on arterial carbon dioxide pressure after jet ventilation in our patients (p=0.1). Complications such as pneumothorax and working channel damage were not observed. CONCLUSION: High-frequency jet ventilation via the working channel of the bronchoscope is a novel method that can provide optimal ventilation with minimal complications to nonintubated patients suffering from hypoxemia during bronchoscopy. This method also reduces the duration of bronchoscopy procedures. Key Words: High-frequency jet ventilation, bronchoscopy, hypoxemia, ventilation, flexible bronchoscopy Cite this article as: Abedini A, Kiani A, Taghavi K, et al. High-Frequency Jet Ventilation in Nonintubated Patients. Turk Thorac J 2018; 19(3): 127-31. http://www.turkthoracj.org/eng/ozet/978/176/Abstract
Turk Thorac J 2018; 19(3): 127-31
Original Article
High-Frequency Jet Ventilation in Nonintubated Patients
INTRODUCTION
Fiberoptic bronchoscopy has been widely utilized over the last years in pulmonary medicine for diagnosis and treatment
of pulmonary diseases such as pleural tumors, tuberculosis, and lipoid pneumonia [1-3]. Qualified ventilation in sedated
patients during bronchoscopy is an issue of utmost consequentiality. Nasal oxygen supply is adequate for maintaining
conventional oxygen saturation (So2) of over 90% in mildly sedated patients. However, when deeper sedation is needed
during the procedure, dropping oxygen (O2) and elevating carbon dioxide (CO2) pressures as well as acidemia and
arrhythmia are the frequent quandaries faced. Different approaches have been introduced for ventilating deeply sedated
patients [1]. Conventional mechanical ventilation (CMV) conventionally does not ameliorate O2 supplementation during
bronchoscopy in sedated patients. Therefore, providing ventilation in this setting is vital.
High-frequency jet ventilation (HFJV) is an opportune technique that distributes a minuscule tidal volume with a fre-
quency exceeding the physiologic level of the patient [3-5]. HFJV can be applied via supraglottic [such as laryngeal mask
airway (LMA)], transtracheal, or subglottic approaches [6-9]. All of the three methods truncate the expiratory time and
linearly increase the pulmonary capillary wedge pressure and greatest sanctioned working pressure.
The supraglottic HFJV provides the most rapid increase in airway pressure. Transtracheal HFJV approach provides the
most consistent atmospheric pressure of the fraction of inspired oxygen (FiO2). However, both methods increase the peril
DOI: 10.5152/TurkThoracJ.2018.17025
Atefeh Abedini1 , Arda Kiani2 , Kimia Taghavi1 , Ali Khalili3, Alireza Jahangiri Fard4 , Lida Fadaizadeh5 ,
Alireza Salimi1 , Tahereh Parsa6 , Akram Aarabi4 , Behrooz Farzanegan2 ,
Mahsa Pourabdollah Tootkaboni1
1Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid
Beheshti University of Medical Sciences, Tehran, Iran
2Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti
University of Medical Sciences, Tehran, Iran
3Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid
Beheshti University of Medical Sciences, Tehran, Iran
4Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti
University of Medical Sciences, Tehran, Iran
5Telemedicine Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti
University of Medical Sciences, Tehran, Iran
6Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid
Beheshti University of Medical Sciences, Tehran, Iran
Address for Correspondence: Arda Kiani, Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung
Diseases (NRITLD), Massih Daneshvari Hospital, Tehran, Iran
E-mail: ardakiani@sbmu.ac.ir
©Copyright 2018 by Turkish Thoracic Society - Available online at www.turkthoracj.org 127
Cite this article as: Abedini A, Kiani A, Taghavi K, et al. High-Frequency Jet Ventilation in Nonintubated Patients. Turk Thorac J
2018; 19(3): 127-31.
OBJECTIVES: High-frequency jet ventilation (HFJV) is a convenient method for providing ventilation during beroptic bronchoscopy. We
describe an incipient approach of high-frequency jet ventilation via the working channel of a exible bronchoscope for nonintubated
patients who suffer from hypoxemia during bronchoscopy. The aim of this study was to test the efcacy of this incipient approach and
determine the possible complications related to it.
MATERIALS AND METHODS: Sixteen patients who had oxygen saturation below 70% that did not resolve with nasal oxygen for 20 s
during interventional bronchoscopy were included in the study. High-frequency jet ventilation was administrated via the working chan-
nel of a bronchoscope for 3 min. Arterial blood gas circumscriptions were compared before and after jet ventilation.
RESULTS: Oxygen saturation increased to >90% in all patients 30 s after jet ventilation. Mean arterial oxygen saturation pressure in-
creased from 54.84 to 111.98 mmHg with jet ventilation (p=0.0001). Arterial carbon dioxide tension decreased after jet ventilation. The
body mass index had no consequential effect on arterial carbon dioxide pressure after jet ventilation in our patients (p=0.1). Complica-
tions such as pneumothorax and working channel damage were not observed.
CONCLUSION: High-frequency jet ventilation via the working channel of the bronchoscope is a novel method that can provide opti-
mal ventilation with minimal complications to nonintubated patients suffering from hypoxemia during bronchoscopy. This method also
reduces the duration of bronchoscopy procedures.
KEYWORDS: High-frequency jet ventilation, bronchoscopy, hypoxemia, ventilation, arterial oxygen, exible bronchoscopy
Abstract
Received: 18.03.2017 Accepted: 10.04.2018
of blowing debris, barotrauma, and hypercapnia [5,6]. In
comparison with these, complications are minimized with
the subglottic approach. Furthermore, PAWP can be observed,
and the distributed FiO2 can be determined. Recently, sub-
glottic HFJV was utilized broadly via different bronchoscope
channels. However, the working channel of the broncho-
scope (utilized for suction, oxygen distribution, and local
anesthesia administration) has not been applied before in
any study.
We evaluated a novel technique in nonintubated sedated
patients undergoing flexible bronchoscopy (HFJV via the
working channel) in this study.
MATERIALS AND METHODS
Study Design
This randomized clinical tribulation study was designed by
an expert methodologist. The final study population was
estimated to be 10-20 patients. The research project was
approved by the ethics committee and review board of
Shadid Behehti University of Medical Sciences (IR. SBMU.
MSP. REC.1395.218), and ethical clearance conformed to the
Declaration of Helsinki. To comply with health indemnifica-
tion portability, the principle of secrecy of patient informa-
tion was taken into consideration.
Study Population
In total, 150 patients with asthmatic bronchitis and chronic
bronchitis underwent interventional flexible fiberoptic bron-
choscopy for diagnosis or treatment during April-August
2016. Patients signed apprised informed consents after the
study procedure was explained to them. Intervention opera-
tions were routine operative procedures, and none of them
were set for clinical research.
Baseline demographic characteristics including age, gender,
and body mass index (BMI) were recorded for further analy-
sis. Ecumenical guidelines were utilized in determining the
normality of limits [10]. After quantifying the blood pressure
and performing electrocardiogram, patients underwent deep
sedation using a resilient instauration short-half-life drug
(propofol with an infusion rate of 50-75 µg/kg/min; mid-
azolam: 0.02 mg/kg; and fentanyl: 1-2 µg/kg). Sedation status
was monitored using a bispectral index of 60. All bronchos-
copy operations were conducted using a conventional flexi-
ble bronchoscope (BF-1T260, Olympus Tokyo, Japan). The
outer and main diameters of the working channel were 5.9
and 2.8 mm, respectively, which comply with the national
guidelines [10]. Vital signs and So2 were monitored and
CMV approaches were provided during the procedure.
Patients were further monitored using pulse oximetry for O2
saturation during the different prep times of each patient for
approximately 30-60 min. If SpO2 decreased below 70% and
did not resolve within 20 s of nasal oxygenation, the patient
was recommended for study inclusion and HFJV administra-
tion. The inclusion criterion was 70% O2 saturation for 20 s
as the borderline (the greatest time of abiding the least satura-
tion). The omission criteria included rigorous cardiac dis-
eases and unstable hemodynamics. Arterial blood sample
was accumulated to determine the arterial blood gas (ABG).
HFJV (Monsoon, Acutronic Medical Systems AG, Baar,
Switzerland) was applied for 3 min via the working channel
of the bronchoscope. HFJV was performed with the following
parameters: inspiration time of 45%, driving pressure of 3
bar, peak pressure of 80 mbar, FiO2 of 30%-100%, and fre-
quency (ventilator rate) of 250/min. After applying HFJV for
3 min to obtain an incremented SpO2 to 90%, second arte-
rial blood sampling was performed, and the bronchoscopy
procedure was commenced (Figure 1,2). The arterial blood
Figure 1. Non-intubated sedated patient under HFJV during bronchoscopy
with a flexible fiberoptic bronchoscope via the working channel
Figure 2. Jet ventilator catheter
Turk Thorac J 2018; 19(3): 127-31
128
pH was compared in two blood samples. The estimated ven-
tilation efficacy and the availability of oxygen was obtained
by comparing the partial pressure of carbon dioxide (PaCO2)
(mmHg) and the arterial partial pressure of oxygen (PaO2)
(mmHg) in two samples. The design of the current study is
shown on Figure 3.
Statistical Analysis
Data were statistically analyzed using paired t-test and
ANOVA using (SPSS) Statistical Package for Social Sciences
version 22.0 (IBM Corp.; Armonk, NY, USA). Statistical
analyses were conducted following international statistical
standards. The perpetual analysis of variables such as age,
gender, and BMI were presented as frequency and percent-
age and mean (±standard deviation) or median (minimum-
maximum). Categorical variables were expressed as frequen-
cies and percentages. The variables for between-group differ-
ences of the mean were calculated using Student’s t-test with
significance set at p<0.05. Different parameter correlations
were resolved using one-way ANOVA correlation coefficient.
RESULTS
Demographics Analysis
The normality of variables was obtained using Kolmogorov-
Smirnov test. Sixteen patients [10 males (62.5%) and 6
females (37.5%)] met the inclusion criteria. The patients’ age
range was 37-75 years, with a mean age of 56±9.95 years.
BMI of patients was in the range of 20.8-41 kg/m2, with a
mean of 31.6±5.5 kg/m2. Two (12.5%) patients showed mun-
dane BMI; 3 (18.8%) patients were inordinately corpulent
and 11 (68.8%) were exorbitantly corpulent, according to
International World Health Organization (Table 1).
Clinical Analysis
High-frequency jet ventilation increased SpO2 to more than
95% in less than 30 s in all 16 patients. The analysis of two
ABG samples showed that mean PaCO2 decreased from
59.3±6.7 to 52.6±8.09 mmHg after 3 min of jet ventilation.
Paired t-test showed that PaCO2 decreased significantly by
applying HFJV (p=0.001). Arterial pH also increased from
7.29±0.03 to 7.30±0.04 after jet ventilation. However, these
changes were not significant according to the paired t-test
analysis (p=0.08). Mean PaO2 was 54.84 mmHg (PaO2/FiO2
ratio<300) before jet ventilation and increased significantly to
111.98 mmHg (P/F ratio~575) with HFJV. (p=0.0001). Partial
pressure of carbon dioxide (PCO2) was 53.2±0.9 mmHg in
patients with mundane BMI and 52.3±12.1 mmHg in inordi-
nately corpulent patients. Despite our prospects, no significant
differences were observed in PCO2 in individuals with different
BMI status on the basis of one-way ANOVA p=0.1) (Table 2).
Post-procedure Recovery
Leak test was conducted after each procedure to estimate the
possible complications associated with HFJV such as tearing of
the working channel of the fiberoptic bronchoscope. However,
no positive test was reported. To check for pneumothorax as
Table 1. Baseline demographic characteristics and BMI
Parameters Values
Age (year) (mean±SD) 56±9.95
Gender (M/F) 10/6
Body mass index (kg/m2) 31.6±5.5
Cause of intervention procedure
Asthmatic bronchitis, no. (%) 7 (44)
Chronic bronchitis, no. (%) 9 (66)
BMI NL (%) 12.5
Overweight (%) 18.8
Obese (%) 68.8
BMI: body mass index; SD: standard deviation
Figure 4. HFJV connected to the working channel of a flexible fiberoptic
bronchoscope
Figure 3. Design of current randomized clinical tribulation study
150 patients were referred with asthmatic
bronchitis and chronic bronchitis diagnosis
during April-August 2016
3 patients were excluded
from the study due to
rigorous cardiac diseases and
unstable hemodynamics
First arterial blood sample
was accumulated to figure
arterial blood gases (ABG)
Approval diagnostic or treatment
interventional flexible fiber optic
bronchoscopy was operated
HFJV was applied for 3 minutes through the bronchoscope
working channel with Inspiration Time (IT): 45%, Driving
pressure: 3 bar, Peak pressure: 80 mbar, FiO2: 30-100%,
Frequency (Ventilator rate): 250/min
After stabilizing patients SpO2 to 90%, second
arterial blood sampling was performed and the
bronchoscopy procedure was commenced
Sixteen patients
(10 men and 6 women)
consummated the
inclusion criteria
19 patients were recognized as HFJV
necessity case due to SpO2 70% under for
twenty seconds or above
Abedini et al. Bronchoscopy High-Frequency Jet Ventilation
129
another complication of HFJV, we performed chest radiogra-
phy after the procedure and every 2 h twice. No pneumotho-
rax or other complications attributable to HFJV were observed.
DISCUSSION
High-frequency jet ventilation has been applied during
interventional bronchoscopy since 1977. The variable
methods of HFJV and the associated complications have
been studied. Veres et al. [11] studied HFJV via LMA and
achieved qualified ventilation during the procedure.
However, they reported mild hypercapnia due to hypoven-
tilation as the most mundane minor unpropitious effect of
LMA-HFJV. They also reported that the LMA-HFJV tech-
nique resulted in the extension of the bronchoscopy dura-
tion due to removal of the bronchoscope and application of
the ventilation mask when hypoxemia occurred. In an ear-
lier study, Fernandez-Bustamante et al. [12] applied inter-
ventional rigid bronchoscopy connected to a transvector for
ventilation; they reported hypercapnia, hypoxemia, and
transient hemodynamic changes as the most common com-
plications of this HFJV technique. HFJV has been increas-
ingly utilized using nasotracheal or tracheal catheters via
the lateral port of the rigid bronchoscope, via the transtra-
cheal route, or by moving the catheter in the bronchoscope
[13-21]. Hautmann et al. [19] studied HFJV using a tra-
cheal catheter; they achieved adequate gas exchange dur-
ing the bronchoscopy procedure and observed no hypoxia
and hypotension. However, hypercapnia was the most com-
mon complication during their approach.
The current study aimed to introduce a novel HFJV method
to achieve optimal ventilation support and mitigate compli-
cations during bronchoscopy. We delivered HFJV via the
working channel of a flexible fiberoptic bronchoscope to
nonintubated sedated patients who suffer from hypoxemia.
To designate a borderline hypoxemia index, the following
study design was evaluated: SpO2 below 75% is the border-
line of rigorous hypoxemia and SpO2 of 65% and below is
the index value at which the patient will lose consciousness.
Jet ventilation should never be resumed until the airway is
open. Considering that mucus clogged the airway in most of
our patients, conventional ventilations were applied at the
maximum time to open the airway felicitously. Given that
vital organs such as the encephalon have 20 s worth of oxy-
gen storage capacity, 70% O2 saturation for 20 s was desig-
nated as the borderline inclusion criterion (the maximum
time of abiding the minimum saturation).
Considering the lack of access to capnography, we analyzed
ABGs before and after jet ventilation to evaluate ventilation
efficacy and possible ventilator setting adjustment needed.
PaCO2 was found to be significantly reduced in our study
after jet ventilation (p=0.001), whereas PaO2 significantly
increased (p=0.0001). The congruous results favor the effi-
cacy of the current incipient approach, which provides con-
gruous ventilation to patients during bronchoscopy.
A P/F ratio<300 is equivalent to a partial pressure of oxygen
(pO2) <60 mmHg; a P/F ratio<250 is equivalent to a pO2<50
mm Hg; and a P/F ratio<200 is equivalent to a pO2<40 mm
Hg on room air. The P/F ratio significantly increased after
HFJV (p=0.0001). Arterial pH additionally increased after jet
ventilation, but the incrimination was not paramount after 3
min in our patients (p=0.08). However, given that most of our
patients had chronic respiratory acidosis due to asthmatic
bronchitis and chronic bronchitis, the arterial pH results
might have been affected.
Generally, PCO2 reflects the exchange of this gas through the
lungs to the outside air. Some degrees of pulmonary diseases
with hyperventilation cause pH elevation. Pulmonary edema
and acute asthmatic attacks affect lung capacity for freely
exchanging CO2 across the alveolar membrane, thus, leading
to high PCO2 levels.
Additionally, decreased pH is related to ventilation failure
and severe degrees of pulmonary diseases. Overweight indi-
viduals who are hyperventilating will breathe more rapidly
and deeply and will blow off more CO2, thus, leading to low
PCO2 levels. We hypothesized that HFJV will lead to
increased pH in overweight individuals with high BMI.
Despite our prospects, differences in PCO2 value after HFJV
in the three variable BMI groups showed no significant differ-
ences (p=0.1).
Prolonged foreign bodies result in granulation formation in
the field of bronchoscopy. Recently, we utilized HFJV for
clearing the bronchoscopy field when perpetuated peregrine
body predisposed the field to bleeding during procedures.
The current method was used as an auxiliary method in
extracting the peregrine bodies. In pediatric patients, HFJV
was applied with caution and with low jet ventilation pres-
sure.
The issue of retracting the bronchoscope in hypoxemia dura-
tion was resolved by the current approach, and the proce-
dure was diverted. The whole procedure duration was mini-
Table 2. ABG changes after HFJV analysis using paired
t-test
Arterial blood Before jet Post jet
gas levels ventilation ventilation P
pH (mean±SD) 7.29±0.03 7.30±0.04 0.08
PaCO2 mmHg (kPa) 59.3±6.7 52.6±8.1 0.001
(mean±SD)
HCO3 (mmol/L)
PaO2 mmHg (kPa) 54.84 111.98 <0.001
(three digit
enough)
PaO2/FiO2 ratio <300 ~575 <0.001
PaCO2 (kPa/mmHg)
NL 50.9±1.02 53.2±0.0 0.1
(ANOVA)
Overweight 49.1±8.6 52.3±12.1
Obese
ANOVA: analysis of variance; pH: power of hydrogen; PaO2: partial
pressure of oxygen in the alveoli (mmHg); PaCO2: partial pressure of
carbon dioxide in arterial blood (mmHg); Std. Deviation: standard
deviation
Turk Thorac J 2018; 19(3): 127-31
130
mized, and the operator working field was not restricted. Our
procedures were conducted using a flexible bronchoscope
with a working channel diameter of 2.8 mm (Figure 4). We
have applied this method in over 100 recent procedures; the
reports and results of these procedures will be presented
soon. No damages were observed in the bronchoscope with
a working channel diameter of 2.8 mm. We also tried venti-
lation using a bronchoscope with a 2 mm working channel.
However, the use of a smaller working channel diameter
(<2.8 mm) led to high airway pressure and limited the venti-
lation. Thus, we do not recommend using HFJV through a
working channel with <2.8 mm diameter. Jet ventilation was
also ineffective in the working channel when there were too
many secretions because this method blew the secretions
into the airways and disturbed the ventilation method.
Considering that the maximum time of tolerating the mini-
mum saturation of oxygen was selected as the inclusion cri-
teria in the current study, only 16 patients fulfilled the sug-
gested index. A small study group in the current study may
have affected our results. Further studies with higher sample
sizes are required to offer enough data to confirm the effi-
cacy of the current approach.
The use of HFJV in the working channel of a flexible bron-
choscope is suggested to be an effective ventilation tech-
nique. This method delivers an open field for intervention
tools and provides adequate gas exchange without increas-
ing the risk of barotrauma.
Ethics Committee Approval: Ethics committee approval was received
for this study from the Ethics Committee of Shadid Behehti University
of Medical Sciences (IR. SBMU. MSP. REC.1395.218).
Informed Consent: Written informed consent was obtained from all
the patients who participated in this study.
Peer-review: Externally peer-reviewed.
Author contributions: Concept - A.A., A.K.; Design - A.A., A.K., L.F.,
A.S., T.P.; Supervision - A.A., A.K.; Resource - A.A., A.K., M.P.T.;
Materials - A.A., A.K., A.K.; Data Collection and/or Processing -
A.A., A.K., K.T.; Analysis and/or Interpretation - A.A., B.F., M.P.T.;
Literature Search - A.A., A.K., K.T.; Writing - A.A., A.K., K.T.; Critical
Reviews - A.A., A.K., K.T., A.K., A.J.F., L.F., A.S., T.P., A.A., B.F., M.P.T.
Acknowledgements: The authors would like to thank all the hospital
cooperators for their favor in conducting current study.
Conflict of Interest: The authors have no conflicts of interest to
declare.
Financial Disclosure: The authors declared that this study has
received no financial support.
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Abedini et al. Bronchoscopy High-Frequency Jet Ventilation
131
... В исследование A. Abedini и соавт. [40] включено 16 пациентов с исходной выраженной гипоксемией, показатель насыщения кислорода до процедуры не превышал 70%, среднее давление насыщения кислородом 54,8 мм рт. ст. ...
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... Since then, HFJV has become a technique to maintain ventilation. The application of this technique enables rapid pulsation gas to enter the respiratory tract through a narrow jet tube under low pressure [25,26]. HFJV has three characteristics [27][28][29], open system, high-frequency (> 60 bpm) and low tidal volume. ...
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... They showed that the rate of hypoxia (pO 2 < 60 mmHg) was very low (3.7%), though hypercapnia frequently occurred. A study by Abedini and colleagues conducted HFJV via the working channel of the bronchoscope in non-intubated patients with oxygen desaturation that did not resolve with nasal oxygen supplementation [86]. They showed a significant improvement in arterial oxygenation and carbon dioxide tension in a case series including 16 patients. ...
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... IAH links to elevated SOFA scores, high APACHE II, high APACHE III, a further need for mechanical ventilation and insufficient PaO2: FiO2 ratios at admission time. Longer durations of the need for mechanical ventilation and lengths of stay at ICUs in such patients reaffirm the pathophysiological damages of raised ICP [19]. ...
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Conference Paper
Introduction: Myasthenic crisis (MC) is often associated with prolonged intubation and with respiratory complications. This study aims to assess predictors of ventilation duration and to compare the effectiveness of endotracheal intubation and mechanical ventilation (ET-MV) with bilevel positive airway pressure (BiPAP) noninvasive ventilation in MC. Methods: We reviewed consecutive episodes of MC treated at Masih Daneshvari Medical Center. Collected information included patients' demographic data, immunotherapy, medical complications, mechanical ventilation duration, and hospital lengths of stay, as well as baseline and preventilation measurements of forced vital capacity, maximal inspiratory and expiratory pressures, and arterial blood gases. Results: We identified 60 episodes of MC in 52 patients. BiPAP was the initial method of ventilatory support in 24 episodes and ET-MV was performed in 36 episodes. There were no differences in patient demographics or in baseline respiratory variables and arterial gases between the groups of episodes initially treated using Bi- PAP vs ET-MV. In 14 episodes treated using BiPAP, intubation was avoided. The mean duration of BiPAP in these patients was 4.3 days. The only predictor of BiPAP failure (ie, requirement for intubation) was a PCO2 level exceeding 45 mm Hg on BiPAP initiation (P=.04). The mean ventilation duration was 10.4 days. Longer ventilation duration was associated with intubation (P=.02), atelectasis (P_.005), and lowermaximal expiratory pressure on arrival (P=.02). The intensive care unit and hospital lengths of stay statistically significantly increased with ventilation duration (P_.001 for both). The only variable associated with decreased ventilation duration was initial BiPAP treatment (P_.007). Conclusions: BiPAP is effective for the treatment of acute respiratory failure in patients with myasthenia gravis. A BiPAP trial before the development of hypercapnia can prevent intubation and prolonged ventilation, reducing pulmonary complications and lengths of intensive care unit and hospital stay.