0
Correspondence |

Continuous Critical Care and Long-Term Noninvasive Ventilatory Support for Patients With Neuromuscular Disease FREE TO VIEW

Glen Cheng, BS; John R. Bach, MD
Author and Funding Information

University of Medicine and Dentistry of New Jersey New Jersey Medical School Newark, NJ

Correspondence to: Glen Cheng, BS, UMDNJ-New Jersey Medical School, 150 Bergen St, University Hospital B261, Newark, NJ 07101; e-mail: chenggl@umdnj.edu

The authors have reported to the ACCP that no significant 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 (www.chestjournal.org/misc/reprints.shtml).


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The authors have reported to the ACCP that no significant 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 (www.chestjournal.org/misc/reprints.shtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(1):246-247. doi:10.1378/chest.08-1895
Text Size: A A A
Published online

To the Editor:

A recent article in CHEST (May 2008) by Ozsancak et al1 provided an in-depth review of randomized studies on the use of nocturnal noninvasive ventilation (NIV) for patients with chronic symptomatic ventilatory insufficiency. Whereas nonrandomized studies have demonstrated that continuous ventilatory support can also be provided noninvasively in both the short-term and long-term settings,27 unlike in randomized trials on the treatment of symptoms, ethical concerns preclude the enrollment of patients with continuous ventilator dependence using noninvasive interfaces into randomized clinical trials on the efficacy of ventilator use. Although the authors have reviewed the use of continuous NIV elsewhere,8 because its use as an alternative to ventilatory support via tracheostomy has rarely been reported9 and the article by Ozsancak et al1 does not mention it, this may cause readers to overlook the potential of NIV for ventilatory support.

While Ozsancak et al1 reviewed the numerous benefits of nocturnal NIV compared to invasive mechanical ventilation, they did not discuss the practical NIV interfaces that facilitate daytime ventilatory support by noninvasive means, that is, NIV administered via 15-mm angled mouthpieces that have been used by hundreds of patients in both the community setting9 and the critical care setting.6,10 Whereas NIV can be provided via nasal, oronasal, and mouthpiece interfaces, only the latter eliminates continuous connection to the ventilator and facilitates speech, swallowing, air stacking, and cosmesis.

It is also important to note that NIV cannot be used indefinitely either for nocturnal-only or full-time support if chest colds result in respiratory failure because of ineffective coughing. Thus, NIV can only be successful indefinitely if mechanically assisted coughing (MAC) is used by the patient with neuromuscular weakness who needs to cough out airway secretions.46 Failure to recognize the need for supporting the expiratory muscles via MAC as well as the inspiratory muscles by NIV at full ventilatory support settings can result in what is termed NIV failure, when in fact the failure is often due to the omission of optimal NIV interfaces, full ventilatory support settings, and the omission of MAC to prevent airway congestion and pneumonia.46,10 Our center routinely extubates patients with neuromuscular diseases who have failed multiple spontaneous breathing trials, to the use of NIV and MAC, rather than resort to tracheotomy.4,6,7

Ozsancak A, D'Ambrosio C, Hill NS. Nocturnal noninvasive ventilation. Chest. 2008;133:1275-1286. [PubMed] [CrossRef]
 
Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163:540-577. [PubMed]
 
Deis JN, Abramo TJ, Crawley L. Noninvasive respiratory support. Pediatr Emerg Care. 2008;24:331-338. [PubMed] [CrossRef]
 
Bach JR, Baird JS, Plosky D, et al. Spinal muscular atrophy type 1: management and outcomes. Pediatr Pulmonol. 2002;34:16-22. [PubMed] [CrossRef]
 
Bach JR. Amyotrophic lateral sclerosis: prolongation of life by noninvasive respiratory aids. Chest. 2002;122:92-98. [PubMed] [CrossRef]
 
Gomez-Merino E, Bach JR. Duchenne muscular dystrophy: prolongation of life by noninvasive respiratory muscle aids. Am J Phys Med Rehabil. 2002;81:411-415. [PubMed] [CrossRef]
 
Bach JR, Saltstein K, Sinquee D, et al. Long-term survival in Werdnig-Hoffman disease. Am J Phys Med Rehabil. 2007;86:339-345. [PubMed] [CrossRef]
 
Bach JR. Noninvasive mechanical ventilation. 2002; Philadelphia, PA Hanley & Belfus
 
Bach JR, Alba AS, Saporito LR. Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users. Chest. 1993;103:174-182. [PubMed] [CrossRef]
 
Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. Chest. 1997;112:1024-1028. [PubMed] [CrossRef]
 

Figures

Tables

References

Ozsancak A, D'Ambrosio C, Hill NS. Nocturnal noninvasive ventilation. Chest. 2008;133:1275-1286. [PubMed] [CrossRef]
 
Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163:540-577. [PubMed]
 
Deis JN, Abramo TJ, Crawley L. Noninvasive respiratory support. Pediatr Emerg Care. 2008;24:331-338. [PubMed] [CrossRef]
 
Bach JR, Baird JS, Plosky D, et al. Spinal muscular atrophy type 1: management and outcomes. Pediatr Pulmonol. 2002;34:16-22. [PubMed] [CrossRef]
 
Bach JR. Amyotrophic lateral sclerosis: prolongation of life by noninvasive respiratory aids. Chest. 2002;122:92-98. [PubMed] [CrossRef]
 
Gomez-Merino E, Bach JR. Duchenne muscular dystrophy: prolongation of life by noninvasive respiratory muscle aids. Am J Phys Med Rehabil. 2002;81:411-415. [PubMed] [CrossRef]
 
Bach JR, Saltstein K, Sinquee D, et al. Long-term survival in Werdnig-Hoffman disease. Am J Phys Med Rehabil. 2007;86:339-345. [PubMed] [CrossRef]
 
Bach JR. Noninvasive mechanical ventilation. 2002; Philadelphia, PA Hanley & Belfus
 
Bach JR, Alba AS, Saporito LR. Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users. Chest. 1993;103:174-182. [PubMed] [CrossRef]
 
Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. Chest. 1997;112:1024-1028. [PubMed] [CrossRef]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543