Mouthpiece Ventilation Research Articles

Palliation of Dyspnea with Mouthpiece Ventilation in Patients with Chronic Obstructive Pulmonary Disease: A Pilot Feasibility Study.

Background: Mouthpiece ventilation (MPV) reduces hypoventilation, but its efficacy in relieving dyspnea in patients with acute chronic obstructive pulmonary disease exacerbation (AECOPD) is unclear. Objective: To assess the feasibility of MPV in relieving dyspnea among patients with AECOPD. Methods: In this prospective single-arm pilot study, the change in dyspnea on numeric rating scale (NRS) after using MPV and side effects of the treatment were studied in 18 patients with AECOPD. Results: The median decrease in dyspnea was 1.5 (95% confidence interval = 0.0-2.5, p = 0.006) on NRS after the intervention lasting a median of 16.9 minutes. Of the patients, 61% found MPV beneficial. The use of MPV did not increase the sense of anxiety or pain. Conclusions: MPV is feasible and may relieve dyspnea in patients with AECOPD, but the intervention needs further evaluation. clinicaltrials.gov study number: NCT03025425.

The feasibility of using mouthpiece ventilation in the intensive care unit for post-extubation breathing support after acute tetraplegia

Study designA prospective cohort of patients with acute tetraplegia.ObjectivesThis study aimed to determine the feasibility of using mouthpiece ventilation (MPV) in the intensive care unit (ICU) for patients who are extubated after suffering an acute cervical spinal cord injury (CSCI).SettingICU, Princess Alexandra Hospital, Brisbane Australia.MethodsNew admissions to ICU in the 14 months between April 2017 and June 2018 with a CSCI who underwent intubation were assessed for inclusion. MPV was provided to consenting participants (who were deemed likely to be able to maintain ventilation on their own) at the time of extubation and was utilised in addition to standard care while participants were awake. MPV settings, usage, and support hours to educate and facilitate MPV were collected. Feedback from participants and clinical staff was gathered throughout the study. Pre- and post-extubation measures of forced vital capacity (FVC), the frequency of endotracheal suction of sputum, and gas exchange using ventilation-perfusion ratios were recorded along with the incidence of reintubation.ResultsFourteen participated in utilising MPV with 16 episodes of extubation. The average time per participant to have MPV titrated and bedside data collected was 178 minutes. Data from 16 episodes of extubation have been included. Three of the 14 participants failed initial extubation. Feedback from participants and clinicians has been positive and constructive, enabling MPV settings to be adapted to the person with acute CSCI during this pilot study.ConclusionMPV is feasible to use post-extubation for people with CSCI in ICU. Pressure control mode MPV was deemed the most suitable for newly extubated acute CSCI patients. Intensive clinical support is required initially to provide education prior to MPV, and at the time of extubation for both patient and treating clinicians. Both report it to be a useful adjunct to ICU treatment.

Daytime alternatives for non-invasive mechanical ventilation in neuromuscular disorders.

Mechanical ventilation in recent years has benefited from the development of new techniques and interfaces. These developments allowed clinicians to offer increasingly personalised therapies with the combination of different complementary techniques for treating respiratory insufficiency in patients with neuromuscular diseases. The mouthpiece ventilation, intermittent abdominal pressure ventilator and the negative pressure ventilation can offer many patients alternative therapy options when ventilation is required for many hours a day. In this non-systematic review, we will highlight the use of alternative methods to non-invasive mechanical ventilation at positive pressure in neuromuscular patients, to ensure the optimal interface for each patient.

Mouthpiece ventilation in neuromuscular disorders: Narrative review of technical issues important for clinical success

In neuromuscular disorders (NMDs), nocturnal non-invasive ventilation (NIV) via a nasal mask is offered when hypercapnic respiratory failure occurs. With disease progression, nocturnal NIV needs to be extended into the daytime. Mouthpiece ventilation (MPV) is an option for daytime NIV. MPV represents a difficult task for home ventilators due to rapidly changing load conditions resulting from intermittent connections and disconnections from MPV circuit. The 252nd ENMC International Expert Workshop, held March 6th to 8th 2020 in Amsterdam, reported general guidelines for management of daytime MPV in NMDs. This report could not present all the detail regarding the technical issues important for clinical success of MPV. Based on the expert workshop discussions and the evidence from existing studies, the current narrative review aims to identify the technical issues of MPV and offers guidance via a decisional algorithm and educational figures providing relevant information that is important for successful implementation of MPV.

252nd ENMC international workshop: Developing best practice guidelines for management of mouthpiece ventilation in neuromuscular disorders. March 6th to 8th 2020, Amsterdam, the Netherlands

The European Neuromuscular Centre (ENMC) has always supported the use of ventilatory support in neuromuscular disorders (NMD's). There is a lack of provision of mouthpiece ventilation (MPV) and a lack of consensus with regard to how/when it can be delivered, The ENMC convened the 252nd ENMC International Workshop: Developing best practice guidelines for management of mouthpiece ventilation in Neuromuscular Disorders in Amsterdam, The Netherlands from the 6th to 8th March 2020. A total of 22 participants, 20 from Europe, one form the USA and one from Canada representing a total of 11 countries.

Mouthpiece ventilation in the management of dyspnea: A single-arm pilot study

Background: Noninvasive ventilation may relieve dyspnea in advanced diseases, but noninvasive ventilation through mouthpiece has not been tested in palliative care. Aim: To assess the feasibility of mouthpiece ventilation in relieving dyspnea among patients with advanced disease. Design: In this prospective single-arm pilot study, the change in dyspnea by mouthpiece ventilation was measured with numeric rating scale (0–10) and 100-mm visual analogue scale. Overall, benefit and adverse events of the therapy were also assessed. Setting/participants: Twenty-two patients with an advanced disease and dyspnea from the Tampere University Hospital or Pirkanmaa Hospice were treated with mouthpiece ventilation. The patients used mouthpiece ventilation as long as they preferred, but for a minimum of 5 min. Results: After the treatment period lasting a median of 13.5 min, mean decrease in dyspnea was −1.1 (95 % confidence interval = −2.2 to −0.1, p = 0.034) on numeric rating scale and −11.8 mm (95 % confidence interval = −19.9 to −3.7, p = 0.006) on visual analogue scale. Nonetheless, there was a high variability in this effect between individual patients. About half of the patients found mouthpiece ventilation beneficial. No serious adverse events occurred, but dry mouth was the most common adverse event. Anxiety did not increase with mouthpiece ventilation. Conclusion: Mouthpiece ventilation is feasible and may relieve dyspnea in some patients with an advanced disease. Further studies are needed, and these might concentrate on stable patients in early palliative care. Before initiation, this study was registered at clinicaltrials.gov (study no. NCT03012737).

Preference of neuromuscular patients regarding equipment for daytime mouthpiece ventilation: A randomized crossover study.

Patients with neuromuscular disorders (NMDs) are likely to develop respiratory failure which requires noninvasive ventilation (NIV). Ventilation via a mouthpiece (MPV) is an option to offer daytime NIV. To determine the preferred equipment for MPV by patients with NMDs. Two MPV equipment sets were compared in 20 patients with NMDs. Set 1, consisted of a non-dedicated ventilator for MPV (PB560, Covidien) with a plastic angled mouthpiece. Set 2, consisted of a dedicated MPV ventilator (Trilogy 100, Philips Respironics) without backup rate and kiss trigger combined with a silicone straw mouthpiece. The Borg dyspnea score, ventilator free time, transcutaneous oxygen saturation (SpO2) and carbon dioxide tension (TcCO2 ) were recorded with and without MPV. Patient perception was assessed by a 17-items list. Carbon dioxide tension measurements and total perception score were not different between the two MPV sets. Dyspnea score was lower with the non-dedicated versus dedicated equipment, 1 (0.5) versus 3 (1-6), P<0.01. All patients with a ventilator free time lower than 6hours preferred a set backup rate rather than a kiss trigger. Sixty five percent of patients preferred the commercial arm support and 55% preferred the plastic angled mouthpiece. Dedicated and non-dedicated MPV equipment are deemed effective and comfortable. Individualization of arm support and mouthpiece is advised to ensure success of MPV. A ventilator free time lower than 6hours seems to be a useful indicator to a priori set a backup rate rather than a rate at zero associated to the kiss trigger.

Increased exercise tolerance using daytime mouthpiece ventilation for patients with diaphragm paralysis

Mouthpiece ventilation can improve exercise tolerance in patients with unilateral or bilateral diaphragm paralysis http://ow.ly/X2Pd30dCT7n

Mouthpiece ventilation and complementary techniques in patients with neuromuscular disease: A brief clinical review and update.

Noninvasive ventilatory support (NVS) is sometimes reported as suboptimal in patients with neuromuscular disease (NMD). The reasons for this include inadequate ventilator settings and/or lack of interface tolerance. NVS has been used for many years in patients with NMD disorders as a viable alternative to continuous ventilatory support via a tracheostomy tube. The mouthpiece ventilation (MPV) is a ventilatory mode that is used as daytime ventilatory support in combination with other ventilatory modalities and interfaces for nocturnal NVS. However, there is still a poor understanding of this method's benefits compared with other modalities. This review aims to highlight the indications and advantages along with the disadvantages of MPV.

Diurnal Mouthpiece Ventilation and Nocturnal Noninvasive Ventilation vs Invasive Mechanical Ventilation in Patients With Amyotrophic Lateral Sclerosis

Diurnal Mouthpiece Ventilation and Nocturnal Noninvasive Ventilation vs Invasive Mechanical Ventilation in Patients With Amyotrophic Lateral Sclerosis

Accuracy of tidal volume delivered by home mechanical ventilation during mouthpiece ventilation: A bench evaluation.

The aim of our study was to evaluate efficacy and reliability of currently available ventilators for mouthpiece ventilation (MPV). Five life-support home ventilators were assessed in a bench test using different settings simulating the specificities of MPV, such as intermittent circuit disconnection and presence of continuous leaks. The intermittent disconnection of the circuit caused relevant swings in the delivered tidal volume ( VT), showing a VT overshoot during the disconnection periods and a VT decrease when the interface was reconnected to the test lung. The five ventilators showed substantial differences in the number of respiratory cycles necessary to reach a stable VT in the volume-controlled setting, ranging from 1.3 ± 0.6 to 7.3 ± 1.2 cycles. These differences were less accentuated in the volume-assisted setting (MPV-dedicated mode, when available). Our data show large differences in the capacity of the different ventilators to deal with the rapidly changing respiratory load features that characterize MPV, which can be further accentuated according to the used ventilator setting. The dedicated MPV modes allow improvement in the performance of ventilators only in some defined situations. This has practical consequences for the choice of the ventilator to be used for MPV in a specific patient.

Effectiveness and safety of mouthpiece ventilation and nocturnal non-invasive ventilation in patients with kyphoscoliosis: Short and long-term outcomes after an episode of acute respiratory failure

BackgroundKyphoscoliosis is a skeletal condition involving the hyperflexion of the thoracic spine. It is characterized by reduced chest wall compliance and impaired respiratory mechanisms leading to progressive hypo-ventilation. We evaluated the effectiveness and the safety of non-invasive ventilation (NIV) in patients after an episode of acute respiratory failure (ARF). MethodsEighteen patients with severe kyphoscoliosis who had been hospitalized for an episode of ARF were followed for 4 years. NIV was applied via mouthpiece (MPV) during the daytime and via mask during the night. The primary outcomes were changes in physiological and functional parameters as well as quality of life. Secondary outcomes were considered re-hospitalization and mortality rate after discharge. A set of control subjects was used for comparison. ResultsAll patients showed a significant improvement in several clinical, physiological, functional and quality of life parameters. Four of them (22.2%) died during the four year follow-up period. In the uni-variate analysis patients who died had higher cardiac co-morbidity, lower MIP and SNIP, higher paCO2, and oxygen desaturation index at initial admission. ConclusionsDiurnal MPV associated with nocturnal NIV had significantly improved lung function, clinical outcomes and quality of life. It should be considered as a safe alternative to traditional administering of NIV.

Home monitoring of daytime mouthpiece ventilation effectiveness in patients with neuromuscular disease.

Mouthpiece ventilation (MPV) allows patients with neuromuscular disease to receive daytime support from a portable ventilator, which they can disconnect at will, for example, for speaking, eating, swallowing, and coughing. However, MPV carries a risk of underventilation. Our purpose here was to evaluate the effectiveness of daytime MPV under real-life conditions. Eight wheelchair-bound patients who used MPV underwent daytime polygraphy at home with recordings of airflow, mouthpiece pressure, thoracic and abdominal movements, peripheral capillary oxygen saturation (SpO2), and transcutaneous partial pressure of carbon dioxide (PtcCO2). Times and durations of tasks and activities were recorded. The Apnea-Hypopnea Index (AHI) was computed. Patient-ventilator disconnections ≥3 minutes and episodes of hypoventilation defined as PtcCO2>45 mmHg were counted. Patient-ventilator asynchrony events were analyzed. The AHI was >5 hour(-1) in two patients. Another patient experienced unexplained 3% drops in arterial oxygen saturations at a frequency of 70 hour(-1). Patient-ventilator disconnections ≥3 minutes occurred in seven of eight patients and were consistently associated with decreases in SpO2 and ≥5-mmHg increases in PtcCO2; PtcCO2 rose above 45 mmHg in two patients during these disconnections. The most common type of patient-ventilator asynchrony was ineffective effort. This study confirms that MPV can be effective as long as the patient remains connected to the mouthpiece. However, transient arterial oxygen desaturation and hypercapnia due to disconnection from the ventilator may occur, without inducing unpleasant sensations in the patients. Therefore, an external warning system based on a minimal acceptable value of minute ventilation would probably be useful.

Open-Mouthpiece Ventilation Versus Nasal Mask Ventilation in Subjects With COPD Exacerbation and Mild to Moderate Acidosis: A Randomized Trial

Open mouthpiece ventilation is efficacious in patients with neuromuscular disease. We used this ventilation technique in patients with exacerbations of COPD with mild to moderate acidosis. The study was performed in 2 respiratory monitoring care units. Fifty subjects with exacerbations of COPD, breathing frequency > 25, PaCO2 > 45, and pH between 7.25 and 7.30, as well as Kelly scale ≤ 2 were enrolled. Subjects were randomly assigned to receive noninvasive ventilation (NIV) via nasal mask or mouthpiece ventilation. The primary outcome was improvement in arterial blood gases. Arterial blood gases and breathing frequency were recorded 2 h after the start of the enrollment and then after 12, 24, and 48 h. The duration of NIV, hospital stay, and acceptability of the interface (mouthpiece or nasal mask) using a Likert scale were assessed. No subjects had deterioration of gas exchange. The 2 groups had similar trends in arterial blood gases and breathing frequency. No differences in duration of NIV or hospital stay were noted. However, a significant difference in acceptability was found: subjects preferred mouthpiece ventilation (P < .01). Open mouthpiece ventilation is a useful technique and may prevent further deterioration of gas exchange in COPD patients with mild to moderate acidosis (similar to traditional NIV delivered by a nasal mask). www.chictr.org registration ChiCTR-TRC-12002672.

Chest Wall and Neuromuscular Disease

Chest wall and neuromuscular diseases encompass a broad spectrum of illnesses that affect the mechanics of breathing. This chapter reviews the physiology of the respiratory system and the impact of these diseases. A brief discussion of various chest wall and neuromuscular diseases is included. The approach to the evaluation of a patient with suspected chest wall or neuromuscular disease, including key aspects of the history, physical examination, and diagnostic testing, is discussed. Respiratory care, including ventilation, cough, swallowing, and sleep, is described. Tables outline neuromuscular diseases affecting the respiratory system, causes of diaphragm weakness and paralysis, and a comprehensive approach to respiratory care in chest wall and neuromuscular disease. Figures include illustrations of the anatomy of the respiratory system and contraction of the diaphragm, pressure measures above and below the diaphragm, radiographic images of chest wall diseases and measurement of the Cobb angle, a computed tomographic scan of a patient with pectus excavatum, a graph showing patterns of pulmonary function testing in chest wall and neuromuscular disease, and photos of mouthpiece ventilation and a mechanical insufflator-exsufflator device. Videos show a fluoroscopic sniff test demonstrating unilateral diaphragm paralysis and the use of a mechanical insufflator-exsufflator device. This review contains 9 highly rendered figures, 2 videos, 3 tables, and 40 references.

Open circuit mouthpiece ventilation: Concise clinical review

In 2013 new “mouthpiece ventilation” modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via “mask” interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used.NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates “air-stacking” to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.

Open circuit mouthpiece ventilation: Concise clinical review

In 2013 new “mouthpiece ventilation” modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via “mask” interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used.NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates “air-stacking” to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.

Twenty-Four Hour Noninvasive Ventilation in Duchenne Muscular Dystrophy: A Safe Alternative to Tracheostomy

Almost all patients with Duchenne muscular dystrophy (DMD) eventually develop respiratory failure. Once 24 h ventilation is required, either due to incomplete effectiveness of nocturnal noninvasive ventilation (NIV) or bulbar weakness, it is common practice to recommend invasive tracheostomy ventilation; however, noninvasive daytime mouthpiece ventilation (MPV) as an addition to nocturnal mask ventilation is also an alternative. The authors' experience with 12 DMD patients who used 24 h NIV with mask NIV at night and MPV during daytime hours is reported. The mean (± SD) age and vital capacity (VC) at initiation of nocturnal (only) NIV subjects were 17.8±3.5 years and 0.90±0.40 L (21% predicted), respectively; and, at the time of MPV, 19.8±3.4 years and 0.57 L (13.2% predicted), respectively. In clinical practice, carbon dioxide (CO2) levels were measured using different methods: arterial blood gas analysis, transcutaneous partial pressure of CO2 and, predominantly, by end-tidal CO2. While the results suggested improved CO2 levels, these were not frequently confirmed by arterial blood gas measurement. The mean survival on 24 h NIV has been 5.7 years (range 0.17 to 12 years). Of the 12 patients, two deaths occurred after 3.75 and four years, respectively, on MPV; the remaining patients continue on 24 h NIV (range two months to 12 years; mean 5.3 years; median 3.5 years). Twenty-four hour NIV should be considered a safe alternative for patients with DMD because its use may obviate the need for tracheostomy in patients with chronic respiratory failure requiring more than nocturnal ventilation alone.

Nocturnal mouthpiece ventilation and medical hypnosis to treat severe obstructive sleep apnea in a child with cherubism

A 4-year old boy presented severe obstructive sleep apnoea due to complete nasal obstruction secondary to cherubism. Because of anticipatory anxiety due to numerous surgical interventions, medical hypnosis was proposed to facilitate non-invasive continuous positive pressure ventilation (CPAP) acceptance. CPAP by means of an oral interface was completely accepted after three hypnosis sessions and resulted in the correction of his obstructive sleep apnea (OSA) syndrome. This report highlights the benefit of medical hypnosis in facilitating CPAP acceptance as well as the efficacy of mouthpiece ventilation in a severe form of cherubism with complete nasal obstruction.

24-HOUR NONINVASIVE VENTILATION IN DUCHENNE MUSCULAR DYSTROPHY

PURPOSE: Duchenne patients eventually require 24 hour ventilatory support. Many centers recommend tracheostomy rather than noninvasive ventilation (NIV). We report the outcome of 19/23 adult DMD patients on nocturnal NIV plus daytime mouthpiece ventilation (MPV).