Tracheostomy Mechanical Ventilation Research Articles

Mechanical insufflation–exsufflation to facilitate ventilator weaning and possible decannulation for patients with encephalopathic conditions

BackgroundClinicians are often faced with apparently tracheostomy mechanical ventilation dependent (TMV), patients who are ventilator unweanable due to encephalopathic/upper motor neuron conditions, that hamper return to the community. ObjectivesA protocol is suggested to wean these patients from mechanical ventilation and criteria offered for possible decannulation. MethodsAfter excluding patients with severe muscle weakness due to neuromuscular diseases and high level spinal cord disorders, consecutive, apparently unweanable and unresponsive encephalopathic patients were to be weaned by a protocol that first normalized CO2 levels at full ventilatory support settings. Then, supplemental oxygen was discontinued so that ambient air baseline oxyhemoglobin saturation (O2 Sat) could be determined and subsequently be normalized by using mechanical insufflation–exsufflation (MIE), at 60–70 cmH2O pressures, via the tubes every 2 hours, with the tube cuffs inflated. Once ambient air O2 Sat levels remained normal, ambient air spontaneous, unassisted autonomous breathing “sprints” were initiated and continued until O2 Sat decreased below 95% with respiratory distress. Patients spontaneously moving over 300 mL of air into their lungs without pressure support had very good prognoses for rapid ventilator weaning. Patients were not returned to TMV irrespective of tachypnea. After the “sprint”, they were rested by using 1–3 hours of full ventilatory support before the next sprint. Sprints lengthened until being fully weaned. After weaning, potential decannulation was evaluated using MIE expiratory flows (MIE-EF) and O2 Sat. ResultsO2 Sat normalized from the initial use of MIE via the tube for 7 of 13 patients then 4 weaned from the initial ambient air sprint. Weaning occurred in 4 days or less for 11 of 13. Despite continuous TMV dependence for 31 days to 15 months before the intervention, 7 weaned patients were successfully decannulated, 6 of the 7 with MIE-EF ≥ 190 L/m. All but 2 remained unresponsive, but 6 were discharged home to their families once decannulated. ConclusionOnce primary ventilatory pump failure is excluded and lung disease improved to the extent that the ambient air O2 Sat can be normalized by using MIE via invasive airway tubes to clear airway secretions, encephalopathic patients can have sufficient muscle strength to wean from ventilatory support and possibly be decannulated if mechanically augmented cough flows exceed 190 L/m.

Amyotrophic Lateral Sclerosis and Noninvasive Positive Pressure Ventilatory Support: "Nasal Noninvasive Ventilation" or "Noninvasive Ventilatory Support"?

Many studies suggest a brief statistical benefit on survival and quality of life by using nasal noninvasive ventilation for patients with amyotrophic lateral sclerosis and other neuromuscular conditions. Indeed, nasal noninvasive ventilation has become synonymous with continuous positive airway pressure and lo-span bilevel positive airway pressure. Nasal noninvasive ventilation, however, may not normalize CO2 levels and continuous positive airway pressure and O2 exacerbate hypercapnia and often lead to CO2 narcosis, intubation, and ultimately tracheostomy or palliative care death. However, a third option can be to offer up to continuous noninvasive ventilatory support and extubation to it. Noninvasive ventilatory support can be effective for full, definitive ventilatory support, even for people with no measurable vital capacity, and has maintained classic amyotrophic lateral sclerosis patients for up to 12 yrs without resort to tracheotomies. Nineteen centers have reported 335 amyotrophic lateral sclerosis patients using continuous noninvasive ventilatory support instead of tracheostomy mechanical ventilation for an average of 14 mos (6 mos to 14 yrs). The noninvasive ventilatory support must also be used in conjunction with mechanical insufflation-exsufflation to clear airway debris and normalize or renormalize ambient air oxyhemoglobin saturation, both to avoid intubation and to facilitate extubation. People with amyotrophic lateral sclerosis satisfying specific criteria, even when continuously dependent on tracheostomy mechanical ventilation, can be decannulated and placed on continuous noninvasive ventilatory support with mechanical insufflation-exsufflation.

Continuous noninvasive ventilatory support outcomes for patients with neuromuscular disease: a multicenter data collaboration

BackgroundTypically, patients with progressive neuromuscular disorders (NMDs) develop acute respiratory failure (ARF), are intubated, and when failing spontaneous breathing trials (SBTs) undergo a tracheotomy and receive tracheostomy mechanical ventilation (TMV). However, increasing numbers of patients use nasal noninvasive ventilation (NIV), initially for sleep and this is extended to continuous dependence (CNVS). This can be used as a strategy to assist in successful extubation . We retrospectively reviewed 19 centers offering CNVS and mechanical insufflation-exsufflation (MI-E) as an alternative to TMV. MethodsCenters with publications or presentations concerning CNVS outcomes data were pooled for amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and spinal muscular atrophy type 1 (SMA1). Progression to CNVS dependence without hospitalization, duration of dependence, and extubations and decannulations to CNVS were recorded. Prolongation of life was defined by duration of CNVS dependence without ventilator free breathing ability (VFBA). ResultsThere were 1623 part time (<23 h/day) NVS users with ALS, DMD, and SMA1 from 19 centers in 16 countries of whom 761 (47%) were CNVS dependent for 2218 patient-years. This included: 335 ALS patients for a mean 1.2 ± 1.0 (range to 8) years each; 385 DMD patients for 5.4 ± 1.6 (range to 29) years; and 41 SMA1 patients for 5.9 ± 1.8 (range to 20) years. Thirty-five DMD and ALS TMV users were decannulated to CNVS and MI-E. At data collection 494 (65%) patients were CNVS dependent but 110 (74 of whom with bulbar ALS), had undergone tracheotomies. ConclusionsALS, DMD, and SMA1 patients can become CNVS dependent without requiring hospitalization but CNVS cannot be used indefinitely for many patients with advanced upper motor neuron diseases.

An Overview of Tracheostomy Tubes and Mechanical Ventilation Management for the Speech-Language Pathologist

PurposeThe speech-language pathologist (SLP) plays an integral role when working with patients who have tracheostomy tubes and are on mechanical ventilation. The patients and the clinical team depend on our expertise to make critical decisions on speaking valve use, introduction of food by mouth (per os), weaning off of the ventilator, weaning from the feeding tube, and tracheostomy tube decannulation.ConclusionsWhile not expected to be experts on the cardiopulmonary function of patients, SLPs must have a solid foundation of knowledge when it comes to patients with highly complex disease processes and care plans. This clinical focus article is meant to serve as an overview for the SLP working with tracheostomy tubes and ventilators and for those SLPs interested in entering this area of practice.

The Intermittent Abdominal Pressure Ventilator as an Alternative Modality of Noninvasive Ventilatory Support: A Narrative Review.

Noninvasive ventilation has become the initial treatment for symptomatic ventilatory pump failure but, when used at ventilatory support settings, can be an alternative to tracheostomy mechanical ventilation. The intermittent abdominal pressure ventilator, a corset with an internal air sack inflated by a ventilator, allows to increase tidal volumes through the raising of the diaphragm and its consequent passive descent. It has been used for daytime support for more than 70 yrs, but its knowledge among clinicians is scarce. A narrative review was performed by searching PubMed, Medline, and the Cochrane Database of Systematic Reviews using the terms "IAPV" or "pneumobelt." One hundred forty patients were cited using the intermittent abdominal pressure ventilator from 1946 until it went off the market in the 1970s, although many continued to use it. There was only one publication on its use from 2003 to 2017, but three publications from 2017 through 2021. It has been used for full diurnal ventilatory support by some patients for more than 50 yrs and has even been used throughout the labor of a mother with no ventilator-free breathing ability. The intermittent abdominal pressure ventilator is a ventilatory support alternative for patients with ventilatory pump failure. It can be effective and well tolerated and maintain quality of life without facial interfaces. More widespread application is warranted.

A pilot study on efficacy and tolerability of diaphragm pacing for amyotrophic lateral sclerosis

AbstractBackgroundThe efficacy and safety of diaphragm pacing (DP) for amyotrophic lateral sclerosis (ALS) patients has not been elucidated.AimTo investigate the efficacy and safety of DP for ALS in Japan.Materials and MethodsWe implanted the NeuRx RA/4 Diaphragm Pacing SystemR (NeuRx) in 5 ALS patients without tracheostomy mechanical ventilation and conditioned subsequently. Participants could combine NeuRx with non‐invasive ventilation such as biphasic positive airway pressure (BIPAP). The primary endpoint was overall survival, defined as the period from implantation to the administration of mechanical ventilation with tracheostomy or death.ResultsThree men and 2 women (59.6 ± 9.6 years old, 44 to 70 years old) underwent laparoscopic implantation of NeuRx. The survival differed considerably among individuals (20.7 ± 18.6 months, 5.0‐48.7 months). However, 2 patients with BIPAP showed longer survival. Breakage of the external cord connector occurred in 3 patients and focal epidermal infection occurred in two patients: however, these complications did not lead to serious conditions. An autopsy of one patient revealed no severe damage to the adjacent diaphragm tissue.ConclusionThe efficacy of NeuRx varied between individuals. The combination use of NeuRx with BIPAP might lead to longer survival than NeuRx alone. No serious safety issues were observed.

Daytime noninvasive ventilatory support for patients with ventilatory pump failure: a narrative review

Over the past three decades, the use of noninvasive ventilation or “NIV” to assuage symptoms of hypoventilation for patients with early onset or mild ventilatory pump failure has been extended to up to the use of continuous noninvasive ventilatory support (CNVS) at full ventilatory support settings as a definitive alternative to tracheostomy mechanical ventilation. NVS, along with mechanical insufflation-exsufflation, now provides a noninvasive option for the management of both chronic and acute respiratory failure for these patients. The most common diagnoses for which these methods are useful include chest wall deformities, neuromuscular diseases, morbid obesity, high level spinal cord injury and idiopathic, primary or secondary disorders of the ventilatory control. Thus, NVS is being used in diverse settings: critical care units, medical wards, at home, and in extended care. The aim of this review is to examine the techniques used for daytime support.

Anesthetic Care During Lateral Thoracic Expansion for Asphyxiating Thoracic Dystrophy

Jeune syndrome or asphyxiating thoracic dystrophy (JATD) is a rare autosomal recessive disorder with an estimated incidence of 1 in 100,000 to 130,000 live births. The typical phenotype of JATD is osteochondrodysplasia (narrow thorax and shorted ribs) in association with short limb dwarfism. The thoracic dysplasia results in respiratory insufficiency, usually requiring tracheostomy and chronic mechanical ventilation beginning in infancy and childhood. Lateral thoracic expansion is one surgical procedure that has been described in an attempt to enlarge the thoracic cage and alleviate the progressive respiratory failure. In addition to respiratory involvement, patients with JATD may have other co-morbid conditions involving the kidneys, pancreas, liver, and eyes. Given the underlying thoracic dysplasia and other associated comorbid conditions, the intraoperative care of such patients can be challenging. We present two patients with JATD who presented for lateral thoracic expansion. Previous reports of the intraoperative care of such patients are reviewed and options for anesthetic care are discussed. J Med Cases. 2016;7(7):294-298 doi: http://dx.doi.org/10.14740/jmc2549w

Abstract 18891: Racial Differences in End-of-life Care Associated With Heart Failure Hospitalizations in the United States: A Population-based Analysis From 2011-2012

Background and objectives: Racial disparities in healthcare delivery constitute a major public health problem in the US. There are few studies evaluating the effect of race on utilization of end-of-life (EOL) procedures in HF hospitalizations in the US. Hypothesis: Utilization of EOL procedures differs significantly between racial-ethnic groups independent of socioeconomic status (SES) or probability of in-hospital death. Methods: We used the 2011-2012 Nationwide/National Inpatient Sample to identify primary HF hospitalizations. EOL procedures of interest were intubation, tracheostomy and prolonged mechanical ventilation, hemodialysis, cardiopulmonary resuscitation, gastrostomy, enteral or parenteral nutrition. Relevant ICD-9 codes were used. We used residential ZIP code as a proxy for SES. Multivariate logistic models were used to evaluate racial differences in EOL care while adjusting for SES and probability of in-hospital mortality. Results: 375,740 hospitalizations representing 1.8 million hospitalizations nationwide were included in the study. Mean age was 72.6 (SD 14.6) years and 50.1% were women. Overall 7.81% were intubated, 0.69% underwent tracheostomy, and 6.55% underwent hemodialysis, 0.55% underwent CPR, 0.22% had a gastrostomy and 0.45% received enteral or parenteral nutrition. Blacks, Hispanics, Asians or Pacific Islanders and Other races were more likely to receive EOL procedures compared to Whites after adjusting for SES and probability of in-hospital death. (Fig) Use of any EOL procedure was associated with higher age and sex adjusted odds of in-hospital mortality (OR 6.54, 6.09 - 7.04; p&lt;0.001) and average charges ($76,917 vs. 35,841, p&lt;0.001). Conclusions: Racial-ethnic minorities hospitalized for HF are significantly more likely to receive aggressive EOL care compared to Whites. The reasons for racial differences in utilization of EOL care in HF should be investigated in future studies.

Parameters affecting the tidal volume during expiratory abdominal compression in patients with prolonged tracheostomy mechanical ventilation.

[Purpose] The aim of this study was to clarify physical parameters affecting the tidal volume during expiratory abdominal compression in patients with prolonged tracheostomy mechanical ventilation. [Methods] Eighteen patients with prolonged mechanical ventilation were included in this study. Expiratory abdominal compression was performed on patients lying in a supine position. The abdomen above the navel was vertically compressed in synchronization with expiration and released with inspiration. We measured the tidal volume during expiratory abdominal compression. [Results] The mean tidal volume during expiratory abdominal compression was higher than that at rest (430.6 ± 127.1 mL vs. 344.0 ± 94.3 mL). The tidal volume during expiratory abdominal compression was correlated with weight, days of ventilator support, dynamic compliance and abdominal expansion. Stepwise multiple regression analysis revealed that weight (β = 0.499), dynamic compliance (β = 0.387), and abdominal expansion (β = 0.365) were factors contributing to the tidal volume during expiratory abdominal compression. [Conclusion] Expiratory abdominal compression increased the tidal volume in patients with prolonged tracheostomy mechanical ventilation. The tidal volume during expiratory abdominal compression was influenced by each of the pulmonary conditions and the physical characteristics.

Duchenne muscular dystrophy: life prolongation by noninvasive ventilatory support.

American, Japanese, and Canadian centers have demonstrated that noninvasive intermittent positive pressure ventilatory support (NVS) can be used continuously and in the long-term by people with Duchenne muscular dystrophy as a definitive alternative to tracheostomy mechanical ventilation. The aim of this study was to report this for the first time in Europe. In this study, more than 300 patients with Duchenne muscular dystrophy were followed. End-tidal carbon dioxide, oxyhemoglobin saturation, and vital capacity were measured at each visit. Of the 300 patients, 79 used NVS for 8 hrs or more per day and 20 of these became continuously dependent on NVS. A total of 20 patients have continuously depended on NVS for survival, for a total of 336 patient-years, up to 16 yrs in one case. Nocturnal NVS was begun for symptomatic hypoventilation when the vital capacity had decreased to a mean of 831 ± 173 ml, and continuous dependence on NVS was necessary when the vital capacity had decreased below 297 ± 113 ml. Noninvasive respiratory management can prolong survival without resorting to tracheotomy and without hospitalization.

Home mechanical ventilation in South Korea.

PurposeTo survey the use of invasive and noninvasive home mechanical ventilation (HMV) methods in South Korea from the perspective of physical medicine and rehabilitation (PM&R).Materials and MethodsFor 413 users of HMV, retrospective reviews of PM&R interventions and survey of HMV methods employed from Mar 2000 to Dec 2009.ResultsOf the 413 users, the majority of whom with progressive neuromuscular disorders (NMDs) (n=358), 284 patients initially used noninvasive mechanical ventilation (NIV), while 63 others who were using tracheostomy mechanical ventilation switched to NIV as part of their rehabilitation. The NMD patients began HMV at an earlier age (34.9±20.3 yrs), and used for longer (14.7±7.5) hours than patients with non-neuromuscular causes of respiratory impairment.ConclusionNoninvasive management was preferred over invasive ones, and transition to the former was a result of PM&R interventions.

Lung Transplantation for Diffuse Panbronchiolitis

Purpose Diffuse panbronchiolitis (DPB) is characterized by chronic sinobronchial infection and diffuse bilateral micronodular pulmonary lesions consisting of peribronchial infiltration of inflammatory cells. Although the use of long-term therapy with macrolide antibiotics significantly improved the survival of DPB patients, some DPB patients deteriorate despite the macrolide therapy, requiring lung transplantation (LTx). LTx for DPB patients has been rarely reported and the outcome after LTx remains unknown because DPB is a rare complex genetic disease affecting East Asians. We describe our experience of LTx for DPB. Methods and Materials We retrospectively analyzed 5 LTx for DPB of 100 LTx at our institution between October 1998 and November 2012. Results The male-to-female ratio was 1:4, and median age at LTx was 37 years (27-40 years). Bilateral cadaveric LTx and living donor lobar LTx were performed for 4 and 1 DPB patients, respectively. Three of 5 patients had undergone the radical operation for chronic paranasal sinusitis before transplantation. All patients received long-term macrolide therapy for DPB, and as a result Pseudomonas aeruginosa was preoperatively isolated in the sputum of all patients. After LTx, 4 of 5 recipients required tracheostomy and prolonged mechanical ventilation for a median time of 21 days (2-26 days). While one patient had severe acute rejection episode (A3), no recipient developed severe pneumonia or fatal infectious disease. Histological examination revealed chronic inflammation localized mainly in the respiratory bronchioles with characteristic interstitial accumulation of foamy histiocytes, neutrophils and lymphocyte infiltration, suggesting DPB. All 5 patients have survived and have not encountered bronchiolitis obliterans syndrome or DPB recurrence at a median follow-up of 2 years (0.8-9.4 years). Conclusions Lung transplantation is a viable option for the treatment of progressive DPB in the long term.

Tracheostomy mechanical ventilation in patients with amyotrophic lateral sclerosis: Clinical features and survival analysis

BackgroundTracheostomy mechanical ventilation (TMV) is performed in amyotrophic lateral sclerosis (ALS) patients with a respiratory failure or when the non-invasive ventilation (NIV) is no longer effective. We evaluated the clinical characteristics and survival of a cohort of tracheostomized ALS patients, followed in a single ALS Clinical Center. MethodsBetween 2001 and 2010, 87 out of 279 ALS patients were submitted to TMV. Onset was spinal in 62 and bulbar in 25. After tracheostomy, most patients were followed up through telephone interviews to caregivers. A complete survival analysis could be performed in fifty-two TMV patients. Results31.3% ALS patients underwent tracheostomy, with a male prevalence (M/F=1.69) and a median age of 61years (interquartile range=47–66). After tracheostomy, nearly all patients were under home care. TMV ALS patients were more likely than non-tracheostomized (NT) patients to be implanted with a PEG device, although the bulbar-/spinal-onset ratio did not differ between the two groups. Kaplan–Meyer analysis showed that tracheostomy increases median survival (TMV, 47months vs NT, 31months, p=0.008), with the greatest effect in patients younger than 60 at onset (TMV≤60years, 57.5months vs NT≤60years, 38.5months, p=0.002). ConclusionsTMV is increasingly performed in ALS patients. Nearly all TMV patients live at home and most of them are fed through a PEG device. Survival after tracheostomy is generally increased, with the stronger effect in patients younger than 60. This survival advantage is apparently lost when TMV is performed in patients older than 60. The results of this study might be useful for the decision-making process of patients and their families about this advanced palliative care.

A home respiratory support programme for children by parents and layperson carers

To describe a respiratory support programme for children at home by parents and layperson carers. Analysis of records of children with long-term mechanical respiratory support at home. From 1979 to 2008 the programme managed 168 children (median age 7 years, range 3 weeks-19 years) with obstructive sleep apnoea (55, 32%), neuromuscular conditions (42, 25%), tracheo-bronchomalacia (23, 14%), kyphoscoliosis-cerebral palsy (20, 12%), acquired central hypoventilation (8, 5%), congenital central hypoventilation (7, 4%), chronic lung disease or pulmonary hypoplasia (8, 5%), traumatic quadriplegia (3, 2%) and tumour-related quadriplegia (2, 1%). One hundred and sixty-one (96%) were discharged: 73 (46%) remain in the programme; 27 (16%) transferred to adult services, 25 (15%) recovered and 36 (23%) died. Principal modes of therapy were mask continuous positive airway pressure (CPAP) 35%, mask bilevel positive airway pressure 30%, tracheostomy CPAP 20%, tracheostomy mechanical ventilation 8%, phrenic nerve pacing 3%, negative pressure chamber ventilation 2% and nasal tube CPAP 2%. Two unexpected deaths occurred at home: one from accidental tracheostomy decannulation and another unrelated to respiratory support. Average time in the programme was 3.3 years. Parents of 69 children were provided with trained carers. Successful discharge resulted from early recognition of potential to discharge, parental training, recruitment and training of carers, purchase of equipment and secure funding. Seven children were not discharged, two of whom died in the hospital and five are subject to discharge planning. Respiratory support of children at home by trained parents and layperson carers is safe and efficient. All modes of respiratory support may be used.

Sleep in Restrictive and Neuromuscular Respiratory Disorders

Thoracic restrictive disorders (i.e., chest wall deformities or neuromuscular diseases), may predispose to sleep-disordered breathing, poor sleep quality, and nocturnal hypoventilation. These disorders intensify the effects of reductions in both respiratory center output and central chemosensitivity and increases in upper airway resistance that occur with the onset of sleep. Normally, rapid eye movement (REM) sleep suppresses the activity of nondiaphragmatic breathing muscles, further reducing ventilation. Diaphragmatic or upper airway muscle weakness and reduced chest wall compliance in patients with thoracic restrictive disorders enhance the severity of sleep-disordered breathing during REM sleep, worsening gas exchange abnormalities and sleep fragmentation and impairing daytime functioning. Although daytime respiratory function and nocturnal oxygen saturation are not well correlated, some markers may be useful for identifying patients with thoracic restriction at risk for sleep-disordered breathing. Although some patients may respond to continuous positive airway pressure (CPAP) alone, noninvasive positive pressure ventilation (NPPV) is a more important part of disease management for patients with restrictive thoracic disorders. This technique improves nocturnal ventilation and sleep quality but may also contribute to sleep fragmentation in some patients. If the patient is an unsuitable candidate for or fails NPPV, tracheostomy mechanical ventilation should be considered.

The decision-making process on tracheostomy mechanical ventilation in patient with non-invasive positive pressure ventilation

The decision-making process on tracheostomy mechanical ventilation in patient with non-invasive positive pressure ventilation

The problems of home care management for patient with tracheostomy mechanical ventilation

The problems of home care management for patient with tracheostomy mechanical ventilation

Tracheal Stenosis: Conservative Surgery as a Primary Mode of Management

Tracheal and laryngeal stenosis has become increasingly common following prolonged intubation or tracheostomy for mechanical ventilation and is directly related to trauma. Tracheal resection up to 4 to 5 cm. with an end to end anastomosis is the generally accepted treatment. However, tracheal resection carries the danger of mortality and considerable morbidity. From 1974 to 1979 all patients in our series with tracheal stenosis, even with laryngeal involvement, regardless of etiology and age were intiially treated by conservative surgical management consisting of dilation, severance of the stenotic ring, intralesional injection of triamcinolone acetonide, and stenting with a silicone T tube for 90 days. Sixteen of 19 patients obtained good results and enjoy an adequate airway without a tracheostomy tube. The longest follow-up period was five years and the shortest, six months. Intralesional injection of triamcinolone acetonide is essential for successful treatment. No mortality or serious complications resulted from this treatment. Our experience indicates that patients with tracheal and laryngeal stenosis should undergo a primarily conservative surgical management. This technique appears worthy of trial prior to contemplating a more extensive procedure.