Management of Chronic Alveolar Hypoventilation by Nasal Ventilation: PATIENTS AND METHODS
Fifty-two patients with the diagnoses and average VC values listed in Table 1 were referred because of symptomatic САН, poorly tolerated and/or ineffective assisted ventilation on body ventilators, or desire to remove or avoid tracheostomy. All were alert and cooperative with functional oropharyngeal muscles and no acute pulmonary disease. All had primarily paralytic/restrictive respiratory insufficiency due to neuromuscular disorders or severe kyphoscoliosis diagnosed by pulmonary function testing prior to referral. No patient had substance abuse problems.
The patient evaluation included an investigation for symptoms and complications related to САН. Many of the reported symptoms are commonly seen in patients with obstructive sleep apnea. Of the 32 patients dependent on nocturnal body ventilator use, six were symptomatic for САН (rocking bed, two patients; chest shell, two patients; and iron lung, two patients). The other 20 were questioned regarding the symptoms they may have experienced prior to the introduction of assisted ventilation. In all, 45 of the 572 patients have had signs and symptoms of САН including 17 patients on oxygen therapy flable 2). The seven patients who were never symptomatic for САН had received 24-h ventilatory support since onset of their primary disorder (six, post-polio; one, spinal cord injury) but were seeking a more convenient method of nocturnal support.
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Table 1 — Summary ofVC Values Related to Diagnosis and Ventilatory AID
|
|
|
|
Mean VCf |
|
Mean Time on |
Patients on |
Mean Time on |
|
|
|
No. |
|
|
|
|
Ventilatory |
NIPPV |
NIPPV in |
|
Diagnosis* |
Patients |
Sitting |
% Predicted |
‘ Supine |
% Predicted |
Aid, Months |
>1 Month |
Months^ |
|
Polio |
25 |
998 ±605 |
24 ±14 |
756 ±486 |
17 ±12 |
223.0±177.4 |
22 |
27.1 ±13.5 |
|
Myopathy |
7 |
1,083 ±593 |
26± 17 |
693 ±322 |
17 it 11 |
55.0 ±22.9 |
5 |
14.6 ±5.8 |
|
Duchenne |
5 |
316 ±69 |
7±3 |
312 ±100 |
7±4 |
69.8 ±15.7 |
5 |
25.6± 16.9 |
|
Kyphoscoliosis |
5 |
841 ±318 |
23±6 |
825 ±339 |
23±7 |
47.0 ±15.5 |
1 |
27.0 |
|
SCI |
4 |
268 ±204 |
7±6 |
290 ±207 |
8±6 |
46.4 ±38.7 |
5 |
15.0 ±5.7 |
|
MND |
3 |
1,231 ±723 |
31 ±18 |
824 ±381 |
21 ±11 |
22.6 ±8.5 |
3 |
7.0±4.8 |
|
KYPHO-COPD |
1 |
1,700 |
51 |
1,700 |
51 |
31.0 |
1 |
16.0 |
|
MS |
1 |
100 |
3 |
80 |
2 |
0.2 |
0 |
|
|
SPINA BIF |
1 |
1,310 |
26 |
1,300 |
26 |
71.0 |
1 |
9.0 |
|
Total |
52 |
906 ±662 |
23± 16 |
677 ±462 |
17 ±13 |
129.8 ±72 |
43 |
19.8 ±12.1 |
A medical summary was obtained from the referring physician which included the longitudinal results of the pulmonary function studies, ABG, and a detailed history of previous hospitalizations for respiratory insufficiency. This information was corroborated with review of the hospital charts of 36 of the 52 patients and with the past medical history for respiratory hospitalizations, intubations, and pneumonias obtained from each patient.
Prior to the institution of daily nocturnal noninvasive aids, 17 of the 52 patients had been intubated, then tracheostomized a total of 26 times. Thirteen were intubated on multiple occasions following unsuccessful “weaning” attempts before converting to noninvasive support. The majority of the patients who were never tracheostomized reported that they had rejected this option on at least one occasion. Apcalis Oral Jelly
Oxygen therapy was associated with exacerbation of COs retention and worsening symptoms in 15 of the 17 patients so treated. It contributed to hypercapnic coma in three patients and to respiratory arrest in two others. Respiratory stimulants and CPAP did not improve respiratory function for nine and three patients, respectively. In all, four patients lapsed into hypercapnic coma and four others had respiratory arrests prior to management by noninvasive aids.
