Management of Chronic Alveolar Hypoventilation by Nasal Ventilation: DISCUSSION
Nocturnal NIPPV can normalize Sa02 for many patients with САН without oxygen therapy. It can provide adequate ventilation for some patients with little or no free time or VC and can reverse signs and symptoms of САН. It can decrease the number of hospitalizations for respiratory insufficiency for patients with САН. It can, thus, be an alternative to IPPV via intubation, tracheostomy or phrenic nerve pacing for some patients when:
Excessive oral leak rendering NIPPV entirely ineffective was surprisingly uncommon. The greatest difficulties encountered were from the discomfort of CPAP mask pressure and leak into the eyes. Although this was largely corrected by the fabrication and use of a custom nasal interface, its use, too, was not without difficulty. The gasket material for the nasal seal needed to be repaired or replaced every two to six months and two patients were more comfortable with the CPAP mask.
The VC and free time can be significantly less supine than in the sitting position. Supine VC may be a better indicator of sleep hypoventilation for patients with paralytic/restrictive respiratory insufficiency and should, thus, be made part of routine pulmonary function monitoring. Total weaning from a ventilator should not be expected when the supine VC is <30 percent of predicted. The Sa02 monitoring should be performed. Aggressive weaning efforts can lead to multiple ^hospitalizations and reintubations.
The indication of one method of assisted ventilation over another depends on the clinical situation, home environment and personal choice. For the patients who required 24-h aid, GPB, MIPPV and the Pneu- mobelt were the preferred methods for daytime aid. Most of these patients also preferred MIPPV for nocturnal support as well. When nocturnal support alone was indicated, the method preferred by six of the nine patients introduced to both NIPPV and MIPPV was NIPPV This was because of better natural humidification and greater facility with speech with NIPPV. A custom molded interface may be considered to improve comfort. We recommend the use of negative pressure body ventilators only for transition from tracheostomy ventilation to noninvasive positive airway pressure alternatives or occasionally for ventilatory assistance during URIs. eriacta 100 mg
During URIs, flexibility between noninvasive systems is important. The daily regimen of assisted ventilation invariably needs to be extended and frequent sighs may be necessary for assisted coughing. A mechanical forced exsufflation device is an extremely effective manner in which to provide effective pulmonary toilet for patients with little or no expiratory reserve. Intubation is, therefore, not necessarily required for pulmonary toilet during these episodes.
Most of these 52 patients had been pressured repeatedly by their physicians to undergo tracheostomy. In several cases, living wills were drawn up and the patients were forced to refuse tracheostomy against medical advice. All previously tracheostomized patients emphatically prefer ventilatory support by NIPPV and other noninvasive aids. Eight of these patients have now survived over 30 years on noninvasive assistance. Thus, noninvasive positive airway pressure methods, including NIPPV, can be safely used by many patients up to 24 h a day.
