Noninvasive options for ventilatory support of the traumatic high level quadriplegic patient
Bach JR, Alba AS. Noninvasive options for ventilatory support of the traumatic high level quadriplegic patient. Chest 1990; 98; 613-619
“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.”
- Article 1 and Evidence
- Baydur, Ahmet, et al. Long Term Non-Invasive Ventilation in the Community for Patients with Musculoskeletal Disorders: 46 Year Experience and Review. Thorax 2000; 51 (1); 4-11
- This study assesses the long term outcomes in 79 patients with musculoskeletal disorders who received non-invasive ventilation for chronic respiratory failure.
- Results measured retrospectively included vital capacity and carbon dioxide tension before and after initiation of ventilation, type and duration of ventilator assistance, the need for a tracheostomy, and mortality.
- 29 of the 79 subjects eventually required tracheostomies.
- The study deducts that non-invasive ventilation for long-term treatment is feasible but that tolerance can vary among the population.
- The conclusion states that “despite a number of discomforts associated with M/NIPPV, a larger proportion of patients experienced improved wellbeing, independence, and ability to perform daily activities.
- Overall, this article supports the use of NVA in patients that need ventilation, similar to the original article, but also points out that NVA is suitable only for patients that fit certain criteria, and it is not the best solution for all cases with similar diagnoses.
- 31 patients regained independent respiration, and did so for a mean of 2.4 +/- 2.2 years.
- 25 patients were able to use NVA completely, of which 20 were able to return to private residences
- The time needed to convert from tracheostomy IPPV to NVA spanned from 2 weeks to 3 months
- 7 patients combined use of NVA and tracheostomyIPPV
- 7 patients were able to use NVA for 24 hr support long-term
- “Body ventilators and noninvasive direct airway pressure methods, including mouth IPPV and possibly nasal IPPV, can maintain adequate alveolar ventilation in high level quadriplegic patients.”
- Patients with little to no vital capacity or free time can still be successful candidates for NVA.
- Patients who had the most motivation to keep their tracheostomy tubes plugged during daytime hours and attempted mouth IPPV and worked on their GPB skills converted to full time NVA more successfully.
- Management Stages from table described:
- Patients medically stabilized, supplemental oxygen use discontinued, and aggressive manual or mechanical assisted coughing used.
- Cuff was completed deflated for increasing amounts of time until it could be tolerated for all daytime hours, partial cuff inflation was used at night.
- 24-h tracheostomy IPPV with a deflated cuff was introduced, for some subjects an iron lung or chest shell was used.
- Patients were trained to use mouth IPPV during the day with the tracheostomy tube unplugged, body ventilators were used at night, and patients were switched to a fenestrated tracheostomy tube.
- Cufflesstracheostomy tubes were introduced, each patient attempted to use an IAPV unless they had a contraindication.
- Mouth IPPV was used to wean patients from the ventilators and GPB was taught to motivated subjects.
- The tracheostomy tubes were replaced with a tracheostomy button.
- Patients were able to pick the forms of NVA that they preferred and create their own plan of care.
- Not every patient was able to progress through the management steps to step 8.
- Options most commonly used for ventilation of high level quadriplegic patients include electrophrenic nerve stimulation and/or tracheostomy IPPV.
- EPR is expensive and has not be found to be an effective long-term option for a majority of patients for which it has been tried.
- Tracheostomy IPPV has many potential complications including accidental disconnection, mucous plugging of the tube with acute airway obstruction, tracheomalacia, tracheal stenosis, hemorrhage, granuloma and crusting with difficult tube changes, and cronic gram-negative colonization with purulent bronchitis.
- Interest in NVA as an alternative to tracheostomy IPPV is increasing, but the use of these techniques had not yet at this time been described in the management of traumatic high level spinal cord injury.
- Clinical Significance
- Who is this study relevant to in physical therapy?
- Physical therapists that could potentially work with patients that have high level traumatic spinal cord injuries
- Physical therapists that work with patients that need outside ventilation due to other reasons
- What do physical therapists need to know about the topic of mechanical ventilation and why?
- The mechanics behind all forms of ventilator support, including how each type works:
- This way a therapist could recognize if something was not working correctly or could notice signs of infection, or a complication the patient might be having.
- The pros and cons of each type of ventilator support:
- Physical therapists need to know this because patients might ask the therapist for advice about their options. We need to be able to talk through the positive and negative factors of NVA and tracheostomies with our patients if they come to us with questions.
- How each form of ventilation will affect our treatments:
- When we treat patients that need ventilation assistance we need to understand the way the patient’s respiratory system will react. Even if the reason we are treating the patient is orthopedic based and has nothing to do with the cardiopulmonary system, we have to know the way different forms of ventilation will change the patient’s response to exercise and the risks there are with each version of assistance.
- Article 2 and Evidence
- Hill NS. Complications of Noninvasive Positive Pressure Ventilation. Respiratory Care 1997; 42 (4); 432-442
- The purpose of this article is to “discuss complications and limitations occurring with the use of NPPV, beginning with those associated with the mask and positive pressure ventilation, those interfering with patient acceptance and adaptation, and those inherent to noninvasive techniques.”
- Complications related to interface include discomfort, sores, and rash at the point of contact with the skin, impeded speech and eating, claustrophobia, aspiration, interference with swallowing and salivary retention, pressure on lips and cheeks, dental deformity, aerophagia, allergic reactions, nasal air leaking, and accidental disconnection.
- Complications related to air pressure and flow include noise, nasal, sinus, or ear pain, nasal dryness, coldness, burning, or epistaxis, nasal congestion, oral dryness, gastric insufflation, eye irritation, barotrauma, pneumothorax, poor synchrony, and autocycling.
- The biggest threats to NPPV continuation include intolerance and a failure to ventilate adequately.
- The study also presents possible solutions to many of the complications mentioned and concludes by stating that “Noninvasive positive pressure ventilation is safe and has few major complications when used in appropriately selected patients.”
- The following chart shows the results of the 25 subjects that were able to transition to NVA and the length of time they were able to stay at each level of ventilatory support.
- To present guidelines and a step by step process for transitioning patients from tracheostomy IPPV with full cuff inflation to noninvasive ventilator assistance.
- To present data on 80 ventilator-dependent traumatic quadriplegic patients that were taken through the transition process towards noninvasive ventilator assistance.
- 80 patients were included in this study. These patients were admitted for pulmonary rehabilitation and management of ventilator dependence.
- The patients went through a specific protocol included in Table 1 below that outlines the steps taken from a 24 hr tracheostomy where each patient began to the optimal outcome of NVA on a prn basis.
- Subjects for this article came for treatment from the year 1965 up until the article was published in 1990.
This presentation and the articles it references provide an in-depth look at the use of noninvasive ventilation and research that presents the positive outcomes and complications that can arise. Physical therapists that work with patients that need ventilation assistance should be knowledgeable about the discussion between invasive and noninvasive ventilation. PTs can use the information presented in this project to better understand the ways NVA can benefit or inhibit a person so they can discuss with patients the options available if asked, they can understand the mechanics of all forms of ventilator support, and they can apply this information to better understand how each form of ventilation will affect our plan of care.
- Long-term NVA for patients with traumatic high level quadriplegia can be a safe and effective alternative to tracheostomy IPPV or EPR.
- Tracheostomy site closure and mastery of GPB can allow patients freedom from the fear of tube disconnection and can provide more hours of free time for patients.
- NVA deserves more study with this particular patient population.
- Of 74 tracheostomy IPPV patients, 73 were successfully converted to fenestrating tubes and used mouth IPPV with tubes unplugged for an increasing amount of time during the day.
- 70 of 74 patients were able to be converted to up to 24 hr tracheostomy IPPV with completely deflated cuffs and were able to produce effective speech
- 18 patients were supported entirely by NVA at discharge, 15 who originally had 24 hr tracheostomyIPPV
Poster By: Lauren Cotton, Student PT