NIV Versus NVS: A Review of Respiratory Principles of Physical Medicine After 60 Years of Neglect.

Despite more than 60 years of evidence supporting it, continuous noninvasive ventilatory support (CNVS) via mouth, nasal, oronasal interfaces, and ventilation belts remains underrepresented in physical medicine training, along with the use of mechanical insufflation-exsufflation (MIE) as an alternative for tracheostomy ventilation (TMV) and invasive airway suctioning for patients with ventilatory pump failure. This includes patients with neuromuscular disease (NMD), spinal cord injury (SCI), and morbid obesity. This review summarizes the physiologic rationale of noninvasive ventilation ("NIV") at NVS settings via active and passive ventilator circuits. The limitations of bilevel positive airway pressure (BiPAP) systems in patients with ventilatory pump failure are discussed along with key teaching points for residents and fellows in understanding the difference between traditional NIV and NVS. Integrating these strategies into residency and fellowship curricula can permit patients to avoid tracheotomies, lifetime institutionalization, and over $500,000 in annual nursing charges while advancing the core mission of physiatry, which is to optimize function and quality of life within the limitations of the respiratory muscle impairment.