Speech and Mechanical Ventilation

Abstract

We read with interest the recent CHEST article by Garguilo et al1Garguilo M Leroux K Lejaille M et al.Patient-controlled positive end-expiratory pressure with neuromuscular disease: effect on speech in patients with tracheostomy and mechanical ventilation support.Chest. 2013; 143: 1243-1251Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar (May 2013) about speech in patients with tracheostomy and mechanical ventilation (TMV) support being facilitated by simultaneously using two devices to permit essentially continuous speech. In 1990, we reported on 104 users with TMV (82 of whom had neuromuscular diseases [NMDs] and were continuously TMV dependent) who spoke by using cuffless tubes or tubes with deflated cuffs.2Bach JR Alba AS Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes.Chest. 1990; 97: 679-683Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Nineteen had Duchenne muscular dystrophy. Most of them had the exhalation valves of their active ventilator circuits capped for continuous speech; this is a simpler and less expensive method for continuous speech during TMV, without requiring additional devices or causing dyspnea or hypercapnia from slight rebreathing. Indeed, most of the patients were chronically hypocapnic from long-term TMV. Passy-Muir valves also accomplish the same thing and are simpler and cheaper than the proposed positive end expiratory pressure (PEEP),1Garguilo M Leroux K Lejaille M et al.Patient-controlled positive end-expiratory pressure with neuromuscular disease: effect on speech in patients with tracheostomy and mechanical ventilation support.Chest. 2013; 143: 1243-1251Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar but neither these valves nor capping were discussed by Garguilo et al.1Garguilo M Leroux K Lejaille M et al.Patient-controlled positive end-expiratory pressure with neuromuscular disease: effect on speech in patients with tracheostomy and mechanical ventilation support.Chest. 2013; 143: 1243-1251Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Thirty-four of the 104 users with TMV from our study were among the 69 decannulated to continuous noninvasive ventilatory support (CNVS) who preferred it to TMV for convenience, speech, swallowing, appearance, comfort, and safety unanimously overall; none underwent tracheotomy a second time.3Bach JR A comparison of long-term ventilatory support alternatives from the perspective of the patient and care giver.Chest. 1993; 104: 1702-1706Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar After successfully extubating all “unweanable” patients with NMD other than those with amyotrophic lateral sclerosis,4Bach JR Gonçalves MR Hamdani I Winck JC Extubation of patients with neuromuscular weakness: a new management paradigm.Chest. 2010; 137: 1033-1039Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar we no longer consider tracheotomy for any NMDs other than amyotrophic lateral sclerosis. Over 760 further users on CNVS have been reported from 18 centers.5Bach JR Gonçalves MR Hon A et al.Changing trends in the management of end-stage neuromuscular disease respiratory muscle failure: recommendations of an international consensus.Am J Phys Med Rehabil. 2013; 92: 267-277Crossref PubMed Scopus (89) Google Scholar Thus, none of the 12 patients reported by Garguilo et al1Garguilo M Leroux K Lejaille M et al.Patient-controlled positive end-expiratory pressure with neuromuscular disease: effect on speech in patients with tracheostomy and mechanical ventilation support.Chest. 2013; 143: 1243-1251Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar would have undergone tracheotomy by our center, and all would have been able to speak well without PEEP. Indeed, only one-half of their 12 patients were continuously TMV dependent, despite having had tracheostomies for an average of > 13 years. Because long-term survival is possible by both TMV and CNVS (albeit at a mean 10 years longer for Duchenne muscular dystrophy with fewer hospitalizations and pneumonias by CNVS), TMV should be avoided in these conditions, thereby rendering moot any need to consider PEEP for speech.6Ishikawa Y Miura T Ishikawa Y et al.Duchenne muscular dystrophy: survival by cardio-respiratory interventions.Neuromuscul Disord. 2011; 21: 47-51Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar Speech and Mechanical Ventilation: ResponseCHESTVol. 144Issue 5PreviewWe thank Drs Bach and Esquinas for their interest in our study, which aimed to seek alternate ways to improve speech in patients with tracheostomy and mechanical ventilation support.1 The purpose was not to address tracheostomy indications, which remain a controversial subject. As advocates of noninvasive ventilation techniques, Dr Bach and coworkers have largely contributed to their development and encouraged their extensive use; we do not challenge noninvasive ventilation as the first-line treatment of neuromuscular respiratory failure. Full-Text PDF