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Helene Prigent, MD, PhD; Marine Garguilo, SP; David Orlikowski, MD, PhD; Frédéric Lofaso, MD, PhD
Author and Funding Information

From Service de Physiologie (Dr Prigent and Prof Lofaso), Centre d’Investigation Clinique et d’Innovation Technologique (Ms Garguilo), and Unité de Ventilation à Domicile - Service de Réanimation (Prof Orlikowski), Raymond-Poincaré, Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Garches, France; and EA4497, Université de Versailles Saint-Quentin-en-Yvelines (Dr Prigent, Ms Garguilo, and Profs Orlikowski and Lofaso).

Correspondence to: Helene Prigent, MD, PhD, Service de Physiologie, Raymond-Poincaré Hôpitaux, Universitaires Paris Ile de France Ouest, Garches, 92380, France; email: helene.prigent@rpc.aphp.fr


Financial/nonfinancial disclosures: Drs Orlikowski, Lofaso, and Prigent are part of the EA 4497 Research Laboratory of the University of Versailles Saint-Quentin-en-Yvelines, which has received some equipment from ResMed for research projects independent from the present study. Ms Garguilo has reported 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):1740-1741. doi:10.1378/chest.13-1858
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To the Editor:

We thank Drs Bach and Esquinas for their interest in our study, which aimed to seek alternate ways to improve speech in patients with tracheostomy and mechanical ventilation support.1 The purpose was not to address tracheostomy indications, which remain a controversial subject. As advocates of noninvasive ventilation techniques, Dr Bach and coworkers have largely contributed to their development and encouraged their extensive use; we do not challenge noninvasive ventilation as the first-line treatment of neuromuscular respiratory failure. However, the choice of ventilation modalities is not a simple one and depends on many factors, such as efficiency, patient’s tolerance, teams’ experience in the different ventilation techniques, patients’ environment, health-care systems, and also, above all, each patient’s opinion. Invasive ventilation through tracheostomy may be required during a patient’s history either transitorily or permanently, depending on these many factors, and its use remains widely different among countries.2-4 Providing the best care for all patients also includes seeking to improve the management of patients with tracheostomy, which, therefore, remains an important topic.

As tracheostomy remains a treatment option in our country (France), our experience has allowed us to reassess the effects of tracheostomy and, contrary to Dr Bach’s 20-year-old experience on the long-term effects of tracheostomy,5 we have shown that, thanks to the improvement of medical-care techniques, sleep6 and swallowing7 performances improve with the use of invasive ventilation. Likewise, speech and communication may be improved by appropriate adjustment of ventilator settings.8,9

We did not discuss the occlusion of the ventilator expiratory circuit (whether through the use of a one-way phonation valve or the capping of the expiratory line) as we have previously compared the use of a phonation valve vs positive end-expiratory pressure as techniques to improve speech in patients with tracheostomy and mechanical ventilation support.10 We showed that they provided equivalent efficiency in improving phonation while presenting different inconveniences. For instance, phonation valve use in a patient with tracheostomy and mechanical ventilation support, as well as capping the expiratory line of the ventilator, imposes a complete expiration through the upper airways that some patients do not tolerate over time. Interestingly, when given the choice, only two among the 10 patients studied preferred the use of a speaking valve over positive end-expiratory pressure. It is, therefore, important to remain interested in alternative methods to improve patients under mechanical ventilation as experience shows that one solution rarely fits them all.

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]
 
Divo MJ, Murray S, Cortopassi F, Celli BR. Prolonged mechanical ventilation in Massachusetts: the 2006 prevalence survey. Respir Care. 2010;55(12):1693-1698. [PubMed]
 
Garner DJ, Berlowitz DJ, Douglas J, et al. Home mechanical ventilation in Australia and New Zealand. Eur Respir J. 2013;41(1):39-45. [CrossRef] [PubMed]
 
Lloyd-Owen SJ, Donaldson GC, Ambrosino N, et al. Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey. Eur Respir J. 2005;25(6):1025-1031. [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]
 
Nardi J, Prigent H, Garnier B, et al. Efficiency of invasive mechanical ventilation during sleep in Duchenne muscular dystrophy. Sleep Med. 2012;13(8):1056-1065. [CrossRef] [PubMed]
 
Terzi N, Prigent H, Lejaille M, et al. Impact of tracheostomy on swallowing performance in Duchenne muscular dystrophy. Neuromuscul Disord. 2010;20(8):493-498. [CrossRef] [PubMed]
 
Hoit JD, Banzett RB, Lohmeier HL, Hixon TJ, Brown R. Clinical ventilator adjustments that improve speech. Chest. 2003;124(4):1512-1521. [CrossRef] [PubMed]
 
Prigent H, Samuel C, Louis B, et al. Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. Am J Respir Crit Care Med. 2003;167(2):114-119. [CrossRef] [PubMed]
 
Prigent H, Garguilo M, Pascal S, et al. Speech effects of a speaking valve versus external PEEP in tracheostomized ventilator-dependent neuromuscular patients. Intensive Care Med. 2010;36(10):1681-1687. [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]
 
Divo MJ, Murray S, Cortopassi F, Celli BR. Prolonged mechanical ventilation in Massachusetts: the 2006 prevalence survey. Respir Care. 2010;55(12):1693-1698. [PubMed]
 
Garner DJ, Berlowitz DJ, Douglas J, et al. Home mechanical ventilation in Australia and New Zealand. Eur Respir J. 2013;41(1):39-45. [CrossRef] [PubMed]
 
Lloyd-Owen SJ, Donaldson GC, Ambrosino N, et al. Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey. Eur Respir J. 2005;25(6):1025-1031. [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]
 
Nardi J, Prigent H, Garnier B, et al. Efficiency of invasive mechanical ventilation during sleep in Duchenne muscular dystrophy. Sleep Med. 2012;13(8):1056-1065. [CrossRef] [PubMed]
 
Terzi N, Prigent H, Lejaille M, et al. Impact of tracheostomy on swallowing performance in Duchenne muscular dystrophy. Neuromuscul Disord. 2010;20(8):493-498. [CrossRef] [PubMed]
 
Hoit JD, Banzett RB, Lohmeier HL, Hixon TJ, Brown R. Clinical ventilator adjustments that improve speech. Chest. 2003;124(4):1512-1521. [CrossRef] [PubMed]
 
Prigent H, Samuel C, Louis B, et al. Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. Am J Respir Crit Care Med. 2003;167(2):114-119. [CrossRef] [PubMed]
 
Prigent H, Garguilo M, Pascal S, et al. Speech effects of a speaking valve versus external PEEP in tracheostomized ventilator-dependent neuromuscular patients. Intensive Care Med. 2010;36(10):1681-1687. [CrossRef] [PubMed]
 
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