Tracheostomy Intermittent Positive Pressure Ventilation Research Articles

Prolonging Survival in Amyotrophic Lateral Sclerosis

To assess the efficacy of noninvasive ventilatory support and intermittent positive pressure ventilation via uncuffed tracheostomy tubes (uTIPPV) to prolong survival in amyotrophic lateral sclerosis. Survival was prolonged by continuous noninvasive ventilatory support or TIPPV dependence. Once noninvasive ventilatory support was no longer adequate for six noninvasive ventilatory support users, they and 22 others underwent tracheotomy within 1 mo of measurement of spirometry (forced vital capacity and forced volume expired in 1 sec), peak cough flows, maximum insufflation capacity, manually assisted peak cough flows, and mechanically assisted peak cough flows. Glottic function was estimated by maximum insufflation capacity, FVC difference, and bulbar-innervated muscle function by Norris scale bulbar-innervated muscle subscore. Cuffless tubes were replaced by cuffed ones when hypoventilation developed despite increasing uTIPPV volumes. The survival of 22 patients was prolonged by continuous noninvasive ventilatory support dependence for 7.8 +/- 8.1 mos (range, 1-36 mos; median, 5 mos) after 13.9 +/- 11.2 mos (range, 2-36 mos) of part-time noninvasive ventilatory support. Six of these and 22 others underwent tracheotomy and initially used uTIPPV effectively. For ten of the 28 (35.7%) patients, the tubes had to be replaced by cuffed ones after 5.7 +/- 7.8 mos with the other 18 still using tracheostomy intermittent positive pressure ventilation volumes via uncuffed tubes for 20.2 +/- 17.6 mos at data collection. Pretracheotomy FVC was significantly lower in the ten patients who eventually required cuffed tubes (0.70 +/- 0.44 vs. 1.06 +/- 0.43 L, P < 0.05). The bulbar-innervated muscle was significantly lower when the uTIPPV users required cuffed TIPPV than when beginning uTIPPV (Norris scale bulbar-innervated muscle subscore, 3.20 +/- 1.30 vs. 8.00 +/- 3.20, P < 0.05), respectively. Noninvasive and tracheostomy IPPV via cuffless tubes can prolong survival for patients with amyotrophic lateral sclerosis until excessive air leak and hypoventilation necessitate a cuffed tube.

Predictive equations over-estimate the resting energy expenditure in amyotrophic lateral sclerosis patients who are dependent on invasive ventilation support.

BackgroundAmyotrophic lateral sclerosis (ALS) is a form of degenerative motor neuron disease. At the end stage of the disease artificial feeding is often required. Nevertheless, very little is known about the energy demand of those ALS patients who are chronically dependent on tracheostomy intermittent positive pressure ventilation. The objective of our study was to clarify the resting energy expenditure (REE) in mechanically ventilated ALS patients.MethodsWe measured the REE of five ALS patients (four men, one female) twice during a 12 month-period using indirect calorimetry with two sampling flow settings (40 L/min and 80 L/min). The measured REEs (mREE) were compared with values calculated using five different predictive equations.ResultsThe mean (± SD) of all mREEs was 1130 ± 170 kcal/d. The measurements with different flow settings and at different time instances provided similar results. The mean of mREEs was 33.6% lower, as compared to the mean calculated with five different predictive equations REE (p < 0.001). Each of the predictive equations over-estimated the REE.ConclusionsThe mREE values were significantly lower for every patient than all the predicted ones. Determination of daily nutrition with predictive equations may therefore lead in mis-estimation of energy requirements. Because ALS patients may live years with artificial ventilation their nutritional support should be based on individual measurements. However, further study is needed due to the small number of subjects.

Outcome and attitudes toward home tracheostomy ventilation of consecutive patients: A 10-year experience

To describe survival, predictors of long-term outcome and attitudes in patients treated at home by tracheostomy-intermittent positive-pressure ventilation (TIPPV) for respiratory failure during a 10-year period (1995-2004). Seventy-seven consecutive patients were treated by TIPPV at home. Patients were divided into three groups: neuromuscular, pulmonary, and non-pulmonary patients. Effects of TIPPV on survival, factors influencing outcome after TIPPV, and attitudes of patients and caregivers regarding mechanical ventilation were studied. Forty-one patients (53%) were neuromuscular, 19 (25%) were affected by pulmonary diseases, and 17 (22%) by non-pulmonary diseases. The median survival time after TIPPV in the group was 49 months (range 3-149 months). There was statistically significant longer survival in neuromuscular compared to pulmonary patients (p=0.006), and a trend toward longer survival for non-pulmonary when compared to pulmonary patients (p=0.048). Chronic obstructive pulmonary disease (COPD) patients (n=14) showed the poorest outlook (median survival 26 months, range 3-45 months) and the highest number of emergency readmissions to hospital. The median survival in amyotrophic lateral sclerosis (ALS) patients was 49 months (range 30-61), lower than the whole group of neuromuscular patients. Major tracheostomy complications were low: 2.6%. Multivariate analysis showed that COPD and ALS patients had a three-fold higher risk of death than patients with other diagnoses. Lastly, 64 patients (83%) were pleased they had chosen TIPPV and 69 (90%) would choose it again. Forty-two caregivers (55%) were pleased the patients had chosen home ventilation, but 29 (38%) reported major burdens. TIPPV is well-received by the patients, is safe, and provides survival for long periods of time. Underlying conditions (COPD and ALS) might represent important prognostic factors for survival.

The Amyotrophic Lateral Sclerosis Functional Rating Scale Predicts Survival Time in Amyotrophic Lateral Sclerosis Patients on Invasive Mechanical Ventilation

To determine whether the amyotrophic lateral sclerosis functional rating scale (ALSFRS), which is a validated instrument that assesses the functional status and the disease progression in patients with amyotrophic lateral sclerosis (ALS), predicts hospital length of stay and survival time in ALS patients treated with tracheostomy-intermittent positive-pressure ventilation (TIPPV). Thirty-three consecutive ALS patients with acute respiratory failure who received therapy with TIPPV were prospectively followed up from their admission to the hospital until death. The association of ALSFRS score at hospital admission with length of hospital stay and survival after TIPPV were examined using Cox proportional hazard models, adjusting for age at baseline, sex, and symptom duration. The median ALSFRS score of the ALS patients at hospital admission was 11 (range, 4 to 22). The median length of hospital stay was 55 days (range, 7 to 124 days), with a hospital mortality rate of 9%. For the 30 patients (91%) discharged from the hospital, the median survival time was 37 months (range, 2 to 64 months). The total ALSFRS score (above or below the median score) was a significant predictor of length of hospital stay (hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.2 to 6.5; p = 0.003) and survival after TIPPV (HR, 3.76; 95% CI, 1.4 to 9.7; p = 0.002). The total ALSFRS score at hospital admission was also associated with length of hospital stay (HR, 2.1; 95% CI, 1.1 to 5.1; p = 0.005) and survival (HR, 0.52; 95% CI, 0.1 to 0.8; p = 0.002) when included in a Cox multivariable model together with the other demographic and clinical variables. In ALS patients with acute respiratory failure who have been treated with TIPPV, the total ALSFRS score may predict length of hospital stay and long-term survival after invasive mechanical ventilation.

Continuous Noninvasive Ventilation for Patients with Neuromuscular Disease and Spinal Cord Injury

Patients with a variety of neuromuscular diseases including quadraplegia due to high spinal cord lesions can be managed with full-time noninvasive ventilation instead of intermittent positive pressure ventilation (IPPV) via a tracheostomy. This approach is not suitable for patients with severe bulbar involvement. To be successful with full-time noninvasive IPPV, the ventilator user must realize three goals. First, respiratory system compliance should be optimized and maintained by frequent full inflations delivered by stacking breaths from a volume-cycled ventilator or by insufflating air at adequate pressures using a mechanical insufflator-exsufflator. Second, normal levels of alveolar ventilation are sustained using a variety of noninvasive approaches, including nasal, oronasal, or mouthpiece interfaces. Third, patients must be taught to use techniques and devices to enhance cough, particularly the mechanical insufflator-exsufflator. When these goals are met, noninvasive NPPV can offer patients greater comfort, simpler and more convenient ventilator use, and reduced rates of infections, complications, and hospitalizations as compared with tracheostomy IPPV.

Neuromuscular ventilatory insufficiency: effect of home mechanical ventilator use v oxygen therapy on pneumonia and hospitalization rates.

The purpose of this study was to determine rates of pneumonia and hospitalization for patients receiving oxygen therapy, patients having indwelling tracheostomy tubes, and those using tracheostomy or noninvasive methods of home mechanical ventilation. Six hundred eighty-four users of assisted ventilation for 13,751 patient-years or 19.8 years per patient were surveyed by mail and twice by telephone over a span of four years. Pneumonia and hospitalization rates were significantly higher for ventilator users with chronic obstructive pulmonary disease or with neuromuscular ventilatory insufficiency and gastrostomy tubes than for ventilator users with neuromuscular ventilatory insufficiency without gastrostomy tubes. Of the latter group, more than 90% of the pneumonias and hospitalizations were triggered by otherwise benign intercurrent upper respiratory tract infections. Oxygen therapy was associated with a significantly (P < 0.001) higher rate of pneumonias and hospitalizations than that seen for untreated patients after initial episodes of respiratory distress or during the use of either tracheostomy intermittent positive pressure ventilation or noninvasive ventilatory assistance methods. The lowest pneumonia and hospitalization rates (P < 0.001) were by full-time, noninvasive intermittent positive pressure ventilation users. We conclude that oxygen therapy is not an effective substitute for assisted ventilation for patients with primarily ventilatory insufficiency. Noninvasive ventilatory aids can be used effectively for up to full-time ventilatory support for patients with neuromuscular conditions whose bulbar muscle function is adequate to avert the need for gastrostomy tube placement.

Prevention of Pulmonary Morbidity for Patients With Duchenne Muscular Dystrophy

To evaluate the effects of a new respiratory management protocol on respiratory morbidity and hospitalization rates for patients with Duchenne muscular dystrophy (DMD). A retrospective cohort study. Using a protocol in which oxyhemoglobin desaturation was prevented or reversed by the use of noninvasive intermittent positive pressure ventilation (IPPV) and assisted coughing as needed, the hospitalization rates and days for 24 protocol DMD ventilator users were compared with those of 22 nonprotocol DMD tracheostomy IPPV users. The 22 conventionally managed patients were hospitalized a mean of 72.2+/-112 days when undergoing tracheostomy. This included a 16.1+/-5.4-day period of translaryngeal intubation. The 24 protocol patients were hospitalized a mean of 6.0+/-2.4 days (p<0.005) when beginning ventilator use. Over their next 126.2 patient-years of ventilator use, the 24 protocol patients had significantly lower rates of hospitalization (p<0.008) and hospitalization days (p<0.005) than had the tracheostomy IPPV users over a 167.2 patient-year period. This is true although 14 of the 24 protocol patients went on to require 24-h noninvasive IPPV for 4.5+/-3.6 years. Five of the 14 have yet to be hospitalized. The use of inspiratory and expiratory aids can prolong survival while significantly decreasing the pulmonary morbidity and hospitalization rates associated with conventional resort to tracheostomy IPPV.

Normalization of blood carbon dioxide levels by transition from conventional ventilatory support to noninvasive inspiratory aids

Chronic hypocapnia seems to be common in long-term ventilator assisted individuals (VAIs) with paralytic/restrictive respiratory conditions. It has predominantly been reported for VAIs using intermittent positive pressure ventilation (IPPV) delivered via tracheostomy tubes. Chronic hypocapnia decreases ventilator-free breathing time (VFBT) and may be associated with increased bone resorption. Attempts to reverse chronic hypocapnia by decreasing minute ventilation and providing supplemental carbon dioxide have failed because of air hunger and patient resistance. We maintained normocapnia in 22 24-hour-a-day VAIs by using noninvasive IPPV. Chronic hypocapnia was corrected in three VAIs and hypercapnia in two VAIs by switching from conventional ventilatory support to the use of noninvasive inspiratory muscle aids. The other 17 VAIs remained normocapneic by being managed by noninvasive ventilatory support from onset of ventilatory failure. Eleven of these VAIs had been intubated or tracheostomized for brief periods but were successfully returned to noninvasive support. We conclude that alveolar ventilation can be maintained within normal range for VAIs who use noninvasive IPPV and can be normalized by transition from conventional tracheostomy IPPV to noninvasive IPPV.

A Comparison of Long-term Ventilatory Support Alternatives From the Perspective of the Patient and Care Giver

Tracheostomy, noninvasive intermittent positive pressure ventilation (IPPV) methods, and body ventilators can be used for ventilatory support. These methods vary with respect to safety, convenience, effect on speech, sleep, swallowing, appearance, comfort, and general patient acceptability. The purpose of this study was to determine patient and care giver ventilatory support preferences concerning these quality of life issues. One hundred sixty-eight predominantly neuromuscular patients with greater than 1 month of experience in the use of both tracheostomy and noninvasive methods were surveyed. At the time of the study they had a mean age of 54.7 +/- 11.4 years, were using ventilatory aids a mean of 17.1 +/- 6.5 h/d, and had been doing so for 22.7 +/- 13.1 consecutive years. The 59 respondents who switched from tracheostomy to noninvasive aids significantly preferred the latter for every item and unanimously preferred them over all. The 76 respondents switched from body ventilator use to tracheostomy IPPV significantly preferred use of the former for appearance and speech and the latter for sleep and security and had no other significant preferences. However, the 35 respondents switched from a regimen of noninvasive aids including noninvasive IPPV to tracheostomy IPPV significantly preferred the noninvasive aids for each item except for sleep, swallowing, and security for which there were no significant preferences. We conclude that whether patients switched to or from noninvasive ventilatory support regimens which include noninvasive IPPV, noninvasive methods are considered by patients to be more convenient, to have less untoward effects on speech, appearance and comfort, and are preferred overall to tracheostomy IPPV.

Noninvasive Options for Ventilatory Support of the Traumatic High Level Quadriplegic Patient

The ventilation of 25 ventilator-dependent traumatic quadriplegic patients was supported by noninvasive means of ventilatory assistance. Twenty-four of the 25 were initially managed by endotracheal intubation, and 23 of these went on to tracheostomy intermittent positive pressure ventilation before being converted to NVA. Seventeen of the 23 patients had their tracheostomies closed. This included three patients with no significant free time except with the use of glossopharyngeal breathing. Seven of the 25 patients who used NVA for at least one year with no significant free time have employed NVA for a mean of 7.4 +/- 7.4 years (1 to 22 years). Mouth IPPV was the most common form of NVA used both during the daytime and overnight. The wrap ventilators, intermittent abdominal pressure ventilator, and GPB were also employed for long-term respiratory support. It was concluded that, in general, because of their youth, intact mental status and bulbar musculature, and absence of obstructive lung disease, patients with traumatic high level spinal cord injury are candidates to benefit from these techniques.

Tracheostomy Ventilation: A Study of Efficacy with Deflated Cuffs and Cuffless Tubes

The purpose of this study was to evaluate the effectiveness of long-term tracheostomy intermittent positive pressure ventilation (TIPPV) with deflated cuffs or cuffless tracheostomy tubes for patients with neuromuscular ventilatory failure. One hundred four unweanable ventilator-dependent patients with neuromuscular ventilatory insufficiency were referred for pulmonary rehabilitation. Ninety-one of the 104 patients converted from TIPPV with an inflated cuff to either a deflated cuff (28 patients) or no cuff (63 patients). Arterial blood gas (ABG) and routine daytime monitoring of end-tidal PCo2 were performed on all patients during this transition. In addition, periodic daytime and continuous overnight oximetry were performed on 21 of these patients receiving TIPPV with deflated cuffs or cuffless tubes. Thirteen of the 21 patients also had continuous overnight end-tidal PCo2 monitoring. Despite a mean vital capacity of 17 +/- 12.3 percent and the fact that 16 of the 21 patients could tolerate only 60 minutes or less of autonomous respiration (free time), ABG, daytime SaO2 and end-tidal PCo2 were within normal limits for all 21 patients and mean overnight SaO2 was 94 percent or greater for all except one patient who used a cuffless tracheostomy tube. Six patients experienced very transient desaturations below 90 percent but no one had a maximum end-tidal PCo2 greater than 47 mm Hg. Patients with adequate pulmonary compliance and sufficient oropharyngeal muscle strength for functional swallowing and articulation are candidates for conversion to TIPPV with deflated cuffs or cuffless tracheostomy tubes despite little or no autonomous respiration.

Management of Chronic Alveolar Hypoventilation by Nasal Ventilation

This is a study of the effect of nocturnal nasal intermittent positive pressure ventilation (NIPPV) on symptoms of chronic alveolar hypoventilation (CAH), sleep oxygen saturation (SaO2), and frequency of hospitalization of patients with progressive neuromuscular respiratory insufficiency or restrictive lung disease from thoracic wall deformity. The nocturnal use of NIPPV is explored in combination with other noninvasive methods of supported ventilation for daytime support as alternatives to tracheostomy and long-term tracheostomy intermittent positive pressure ventilation (TIPPV). Sixteen patients with less than 400 ml of vital capacity (VC) supine and less than 15 minutes of autonomous respiration (free time) maintained a mean SaO2 of 95.9 +/- 2.6 percent (SD) during sleep on NIPPV without added oxygen. Seventeen other patients with adequate free time for a sleep trial unaided had an average SaO2 of 81.8 +/- 11.0 percent which improved to 94.1 +/- 3.4 percent on NIPPV alone. The average length of use of NIPPV by the 42 patients who have used it for one month or more is 21 (3-67) months. All 34 patients who were not dependent on ventilatory support 24 hours a day demonstrated significant improvement and in most cases normalization of ABG when off aid. Thirteen patients were converted from IPPV via an endotracheal tube or TIPPV to NIPPV. Long-term use of a custom molded thermoplastic nasal interface for the delivery of NIPPV is reported for 17 patients. Unnecessary morbidity and hospitalizations can be avoided by early awareness and appropriate management of CAH. NIPPV can be an effective alternative to TIPPV, body ventilators, or oxygen therapy.

Management alternatives for post-polio respiratory insufficiency. Assisted ventilation by nasal or oral-nasal interface.

Post-poliomyelitis patients may develop insidious respiratory failure. Chronic alveolar hypoventilation symptoms are often misdiagnosed and the condition is frequently treated inappropriately by oxygen therapy. Physicians are often at a loss to offer assisted ventilation by noninvasive methods and tracheostomy and long-term tracheostomy intermittent positive pressure ventilation is often refused. We studied the use of two noninvasive positive airway pressure alternatives for the nocturnal ventilatory support of 31 post-poliomyelitis patients. These methods were intermittent positive pressure ventilation via nasal access (NIPPV) and via a strapless oral-nasal interface (SONI IPPV). The use of custom fabricated interfaces was also evaluated. Practical alternatives for assisted daytime ventilation included glossopharyngeal breathing, the pneumobelt ventilator and mouth intermittent positive pressure ventilation. Overnight sleep monitoring was performed on 10 patients breathing autonomously or with body ventilators then repeated on NIPPV and/or SONI IPPV. The mean sleep oxygen saturation (SaO2) increased from 87.5 +/- 9.1% on unassisted breathing or body ventilators to 96.2 +/- 2.0% (P less than 0.01) on NIPPV or SONI IPPV. Of 12 other patients with a mean vital capacity of 472 +/- 480 ml and no significant free time supine, 11 patients also maintained SaO2 greater than 94% during sleep supine on NIPPV and/or SONI IPPV. Twenty-one patients have been on nocturnal NIPPV for an average of 23 (3-70) months. Six have been on nocturnal SONI IPPV for an average of 35 (5-66) months. All patients' hypoventilation symptoms were relieved. In conclusion, NIPPV and SONI IPPV can improve the nocturnal ventilation of post-poliomyelitis patients with chronic alveolar hypoventilation.(ABSTRACT TRUNCATED AT 250 WORDS)