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John Bach, MD
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From the Department of Physical Medicine and Rehabilitation, New Jersey Medical School, University of Medicine and Dentistry of New Jersey.

Correspondence to: John Bach, MD, University Hospital B-261, 150 Bergen St, Newark, NJ 07103; email: bachjr@umdnj.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(4):1026-1027. doi:10.1378/chest.10-1218
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To the Editor:

I appreciate the letter from Dr Vianello et al about difficulties when extubating patients who are unweanable. Airway protection is, indeed, critical. However, as reported in 1994,1 if the glottis is sufficient to permit assisted cough peak flows (CPFs) of 160 L/min, then aspiration of saliva does not decrease baseline pulse oxyhemoglobin saturation (Spo2) <95% (the only indication for tracheotomy in amyotrophic lateral sclerosis),2 and 98 of 98 such extubations were successful.3 Since this does not occur in other neuromuscular disorders (NMDs) (eg, Duchenne muscular dystrophy [DMD]), tracheotomies are not needed for those patients.2 Oral intake is less of a concern since following extubation a percutaneous gastrostomy under local anesthesia (modified Stamm or radiographically inserted) can be done as the patient uses continuous noninvasive ventilation (NIV) with little risk of respiratory complications.4 The Gilardeau Deglutition Index is a subjective indication of the ability to safely swallow, not a quantifiable indication of glottic integrity or the risk of aspiration to decrease Spo2. The maximum insufflation capacity (MIC), vital capacity (VC), their difference (MIC-VC), and the assisted and unassisted CPF difference are quantifiable and reproducible measures of glottic integrity. When patients are capable of air stacking (MIC-VC >0), their assisted CPFs are almost always >160 L/min, and extubation to NIV/mechanically assisted coughing (MAC) should be successful close to 100% of the time, even in the absence of respiratory muscle function.

From a diagnostic perspective, almost all patients with DMD can air stack and generate sufficient assisted CPFs for successful extubation, even with VCs close to 0 mL. Not only has secretion aspiration not caused a baseline Spo2 to decrease to <95% in the DMD population, it specifically also has not for our 75 patients with severe spinal muscular atrophy type 1, many of whom have been continuously NIV-supported for over 15 years. Thus, aspiration that decreases the Spo2 baseline to <95% should be the only indication for tracheotomy in patients with NMDs. None of 397 patients with DMD who were continuous NIV users in a recent consensus from four centers (in Bologna, Italy; Hokkaido, Japan; Newark, New Jersey; and Porto, Portugal) that extubated 37 patients with DMD who were unweanable had unsuccessful procedures or required tracheotomy.

Vianello and colleagues note that “tachypnea, dyspnea, and continuous NIV after extubation may hamper swallowing efforts.” This can only be because they do not use volume-cycled mouthpiece NIV at 1 to 1.5 1 volumes to permit 6 L of minute ventilation by four insufflations for 15 s between swallows. Tachypnea-caused weight loss can be corrected by using 1 to 1.5 1 volumes delivered by mouthpiece.

Vianello and colleagues recognize the importance of family and caregiver involvement for MAC postextubation and postdecannulation as well as at home as needed. Indeed, if home care providers are not available or willing to provide this for 24 to 48 h postextubation to maintain ambient air Spo2 ≥95%, extubation is likely to fail, and tracheotomy warranted. If care providers are not adept at providing this care postextubation, they will not do it to prevent future hospitalizations either.

In conclusion, it is not possible to obtain our outcomes without using our methods. These include mouthpiece and volume-cycling NIV, air stacking, MAC, measurement of assisted CPFs, and the training of patient and family in all of this. Whereas the upfront work is considerable, the fewer subsequent hospitalizations,5 lesser need for institutional management, and better quality of quality of life it affords warrant it.

Bach JR, Saporito LR. Indications and criteria for decannulation and transition from invasive to noninvasive long-term ventilatory support. Respir Care. 1994;395:515-528. [PubMed]
 
Bach JR, Bianchi C, Aufiero E. Oximetry and indications for tracheotomy for amyotrophic lateral sclerosis. Chest. 2004;1265:1502-1507. [CrossRef] [PubMed]
 
Bach JR, Gonçalves MR, Hamdani I, Winck JC. Extubation of patients with neuromuscular weakness: a new management paradigm. Chest. 2010;1375:1033-1039. [CrossRef] [PubMed]
 
Bach JR, Gonzalez M, Sharma A, Swan K, Patel A. Open gastrostomy for noninvasive ventilation users with neuromuscular disease. Am J Phys Med Rehabil. 2010;891:1-6. [CrossRef] [PubMed]
 
Bach JR, Rajaraman R, Ballanger F, et al. Neuromuscular ventilatory insufficiency: effect of home mechanical ventilator use v oxygen therapy on pneumonia and hospitalization rates. Am J Phys Med Rehabil. 1998;771:8-19. [CrossRef] [PubMed]
 

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References

Bach JR, Saporito LR. Indications and criteria for decannulation and transition from invasive to noninvasive long-term ventilatory support. Respir Care. 1994;395:515-528. [PubMed]
 
Bach JR, Bianchi C, Aufiero E. Oximetry and indications for tracheotomy for amyotrophic lateral sclerosis. Chest. 2004;1265:1502-1507. [CrossRef] [PubMed]
 
Bach JR, Gonçalves MR, Hamdani I, Winck JC. Extubation of patients with neuromuscular weakness: a new management paradigm. Chest. 2010;1375:1033-1039. [CrossRef] [PubMed]
 
Bach JR, Gonzalez M, Sharma A, Swan K, Patel A. Open gastrostomy for noninvasive ventilation users with neuromuscular disease. Am J Phys Med Rehabil. 2010;891:1-6. [CrossRef] [PubMed]
 
Bach JR, Rajaraman R, Ballanger F, et al. Neuromuscular ventilatory insufficiency: effect of home mechanical ventilator use v oxygen therapy on pneumonia and hospitalization rates. Am J Phys Med Rehabil. 1998;771:8-19. [CrossRef] [PubMed]
 
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