Title : Tracheostomy-free total ventilatory support
Abstract:
Introduction: Home mechanical ventilation became possible once electricity became widely available. From 1930 through 1952, it was via negative pressure body ventilators. Subsequently, it became possible via tracheostomy (TVS) or up to continuous noninvasive ventilatory support (CNVS) for those offered it and who refused tracheotomies.
Methods: Candidates for definitive noninvasive management of ventilatory pump failure (VPF) have very involved families and absence of severe upper motor neuron disease that tends to close the upper airway and render mechanically assisted cough flows ineffective. Interventions for definitive, up to continuous noninvasive positive pressure ventilatory support (CNVS), include NVS via oral, nasal, and oronasal interfaces up to 24 hours a day, and intermittent abdominal pressure ventilator. These permit extubation and trach tube decannulations of ventilator unweanable (vital capacity as low as 0 ml) patients who satisfy specific criteria. An oximetry, NVS, mechanical in-exsufflation (MIE) protocol is used to clear the airways (essentially noninvasive airway suctioning) to avoid intubations and for successful extubations and decannulations of even ventilatory unweanable patients. NVS settings are about 20 cm H2O pressure support (PS) by bi-level or pressure assist ventilation, by volume targeted bi-level, or preferably by volume preset ventilation over a range of 650 to 1500 ml. This range permits optimal rest, support, lung expansion, and tidal volume variation.
Results: In 1993 257 VPF patients were published who left Iron Lungs in 1954 in favor of up to CNVS via mouthpiece,??? None were known to have died from respiratory causes. Several continue to use mouthpiece CNVS today, now for 70 years. The same center has 20 patients with spinal muscular atrophy type 1 (SMA1), nasal CNVS dependent from as young as 3 months of age, with only trace residual ocular movements, now between 20 and 30 years of age, all with 0 ml of VC. Over 270 consecutive intubated, ventilator unweanable VPF patients, including with SMA1, satisfying specific criteria were extubated, and over 100 decannulated of trach tubes, despite having no ventilator free breathing ability.
Conclusion: Considering that tracheotomy tubes increase ventilator dependence and hinder weaning, cause morbidity and mortality, enormous expense for nursing care, and are not desired by patients who can use NVS and MIE in the community, it because evident that no one needs a trach tube for only being too weak to breathe.
