Historical and Potential Modern Uses of Negative-Pressure Ventilation for Critically Ill Patients

Negative-pressure ventilation (NPV) is a form of noninvasive respiratory support in which an external subatmospheric pressure is applied to the thorax to facilitate lung expansion. Although largely supplanted by positive-pressure ventilation (PPV) in modern-day practice, NPV has garnered renewed interest as a potential noninvasive adjunct or alternative to PPV. Appropriate patient selection would be key, particularly in the ICU setting, where NPV is generally contraindicated in patients with severe upper airway obstruction, high oxygenation requirements, or absent airway reflexes. Clinical studies have investigated the use of NPV in patients with respiratory muscle weakness, acute on chronic respiratory failure, impaired airway clearance, and in the postoperative management of cardiac surgery patients. NPV can be delivered through tank, cuirass, and jacket ventilators, with supplemental oxygen provided as needed via nasal cannula or face mask. Modern negative pressure ventilators can support both spontaneous and controlled modes, including continuous negative extrathoracic pressure, synchronized negative pressure, cyclical negative pressure, high-frequency oscillation, and biphasic ventilation. In addition to providing respiratory support, NPV may also offer hemodynamic benefits in some patients, reduce sedation requirements, and improve patient well-being in the ICU by allowing for oral intake, verbal communication, and increased mobility. Still, the use of NPV has been stymied by challenges around device ergonomics, patient comfort, and clinical familiarity. Further research is needed to better define its role in contemporary medicine in terms of patient selection, equivalency or improvement of outcomes, optimization of interface design and portability, and exploration of applications such as hybrid ventilation strategies and synchronization. This narrative review provides a comprehensive evaluation of NPV in the intensive care unit, including its historical significance, physiologic principles, modern evidence for potential clinical use, modes of delivery, and key opportunities for innovation.