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Correspondence |

Speech and Mechanical VentilationSpeech and Mechanical Ventilation FREE TO VIEW

John R. Bach, MD; Antonio M. Esquinas, MD, PhD, FCCP
Author and Funding Information

From the Department of Physical Medicine and Rehabilitation (Dr Bach), University Hospital; and Intensive Care Unit (Dr Esquinas), Hospital General Universitario Morales Meseguer.

Correspondence to: John R. Bach, MD, Department of Physical Medicine and Rehabilitation, University Hospital B-403, 150 Bergen St, Newark, NJ 07103; e-mail:bachjr@umdnj.edu.


Financial/nonfinancial disclosures: The authors have 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. See online for more details.


Chest. 2013;144(5):1739-1740. doi:10.1378/chest.13-1506
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To the Editor:

We read with interest the recent CHEST article by Garguilo et al1 (May 2013) about speech in patients with tracheostomy and mechanical ventilation (TMV) support being facilitated by simultaneously using two devices to permit essentially continuous speech. In 1990, we reported on 104 users with TMV (82 of whom had neuromuscular diseases [NMDs] and were continuously TMV dependent) who spoke by using cuffless tubes or tubes with deflated cuffs.2 Nineteen had Duchenne muscular dystrophy. Most of them had the exhalation valves of their active ventilator circuits capped for continuous speech; this is a simpler and less expensive method for continuous speech during TMV, without requiring additional devices or causing dyspnea or hypercapnia from slight rebreathing. Indeed, most of the patients were chronically hypocapnic from long-term TMV. Passy-Muir valves also accomplish the same thing and are simpler and cheaper than the proposed positive end expiratory pressure (PEEP),1 but neither these valves nor capping were discussed by Garguilo et al.1

Thirty-four of the 104 users with TMV from our study were among the 69 decannulated to continuous noninvasive ventilatory support (CNVS) who preferred it to TMV for convenience, speech, swallowing, appearance, comfort, and safety unanimously overall; none underwent tracheotomy a second time.3 After successfully extubating all “unweanable” patients with NMD other than those with amyotrophic lateral sclerosis,4 we no longer consider tracheotomy for any NMDs other than amyotrophic lateral sclerosis. Over 760 further users on CNVS have been reported from 18 centers.5 Thus, none of the 12 patients reported by Garguilo et al1 would have undergone tracheotomy by our center, and all would have been able to speak well without PEEP. Indeed, only one-half of their 12 patients were continuously TMV dependent, despite having had tracheostomies for an average of > 13 years. Because long-term survival is possible by both TMV and CNVS (albeit at a mean 10 years longer for Duchenne muscular dystrophy with fewer hospitalizations and pneumonias by CNVS), TMV should be avoided in these conditions, thereby rendering moot any need to consider PEEP for speech.6

References

Garguilo M, Leroux K, Lejaille M, et al. Patient-controlled positive end-expiratory pressure with neuromuscular disease: effect on speech in patients with tracheostomy and mechanical ventilation support. Chest. 2013;143(5):1243-1251. [CrossRef] [PubMed]
 
Bach JR, Alba AS. Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest. 1990;97(3):679-683. [CrossRef] [PubMed]
 
Bach JR. A comparison of long-term ventilatory support alternatives from the perspective of the patient and care giver. Chest. 1993;104(6):1702-1706. [CrossRef] [PubMed]
 
Bach JR, Gonçalves MR, Hamdani I, Winck JC. Extubation of patients with neuromuscular weakness: a new management paradigm. Chest. 2010;137(5):1033-1039. [CrossRef] [PubMed]
 
Bach JR, Gonçalves MR, Hon A, et al. Changing trends in the management of end-stage neuromuscular disease respiratory muscle failure: recommendations of an international consensus. Am J Phys Med Rehabil. 2013;92(3):267-277. [CrossRef] [PubMed]
 
Ishikawa Y, Miura T, Ishikawa Y, et al. Duchenne muscular dystrophy: survival by cardio-respiratory interventions. Neuromuscul Disord. 2011;21(1):47-51. [CrossRef] [PubMed]
 

Figures

Tables

References

Garguilo M, Leroux K, Lejaille M, et al. Patient-controlled positive end-expiratory pressure with neuromuscular disease: effect on speech in patients with tracheostomy and mechanical ventilation support. Chest. 2013;143(5):1243-1251. [CrossRef] [PubMed]
 
Bach JR, Alba AS. Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest. 1990;97(3):679-683. [CrossRef] [PubMed]
 
Bach JR. A comparison of long-term ventilatory support alternatives from the perspective of the patient and care giver. Chest. 1993;104(6):1702-1706. [CrossRef] [PubMed]
 
Bach JR, Gonçalves MR, Hamdani I, Winck JC. Extubation of patients with neuromuscular weakness: a new management paradigm. Chest. 2010;137(5):1033-1039. [CrossRef] [PubMed]
 
Bach JR, Gonçalves MR, Hon A, et al. Changing trends in the management of end-stage neuromuscular disease respiratory muscle failure: recommendations of an international consensus. Am J Phys Med Rehabil. 2013;92(3):267-277. [CrossRef] [PubMed]
 
Ishikawa Y, Miura T, Ishikawa Y, et al. Duchenne muscular dystrophy: survival by cardio-respiratory interventions. Neuromuscul Disord. 2011;21(1):47-51. [CrossRef] [PubMed]
 
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