Invasive positive pressure ventilation

Sleeplessness in ALS has numerous causes. Respiratory insufficiency, difficulty repositioning in bed, anxiety and depression can all contribute to poor sleep. Treatment of depression with sedating antidepressants such as mirtazapine, tricyclic antidepressants, or trazadone can help promote sleep. Zolpidem, a non benzodiazepine sleep aid, is effective and carries a low risk of respiratory depression. Other medications that can be helpful include anithistamines, chloral hydrate and selective use of benzodiazepines (Gordon and Mitsumoto, 2006). Non-invasive positive pressure ventilation can help relieve orthopnea in those with respiratory muscle weakness, and special equipment, such as a hospital bed, can reduce nighttime discomfort. 

Wijkstra P, Guyatt GH, Lacasse Y, Casanova D, Gay T, Goldstein RS. A meta analysis of nocturnal non-invasive positive pressure ventilation in patients with COPD. Chest 2003 124 (1) ... 

Abbreviations NIPPV, noninvasive positive pressure ventilation TIPPV, tracheotomy invasive positive pressure ventilation RT, respiratory thaapist PT, physiotherapist MD, medical doctor. 

Sivak ED, Shefner JM, Mitsumoto H, et al. The use of non-invasive positive pressure ventilation (NIPPV) in ALS patients. A need for improved determination of intervention timing. Amyotroph Lateral Scler Other Motor Neuron Disord 2001 2 139-145. 

Wijkstra PJ. Non-invasive positive pressure ventilation (NIPPY) in stable patients with chronic obstructive pulmonary disease (COPD). Respir Med 2003 97 1086-1093. 

Wijkstra PJ, Lacasse Y, Guyatt GH, et al. Nocturnal non-invasive positive pressure ventilation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2002 (3) CD002878. 

Windisch W, Freidel K, Schucher B, et al. Evaluation of health related quality of life using the MOS 36 short form health status survey in patients receiving non-invasive positive pressure ventilation. Intensive Care Med 2003 29(4) 615-621. 

In contrast to some countries, the polio epidemics of the 1950s did not trigger the initiation of long-term ventilation (LTV) in Japan (1). The first patient to receive LTV at home was in Tokyo in 1975, when an adult with neuromuscular disease (NMD) received tracheal invasive positive pressure ventilation (TIPPV) (2). Despite the introduction of public assistance for costs associated with home mechanical ventilation (HMV), fewer than 200 patients were receiving HMV between 1990 and 1993 (Fig. 1) (2). 

Figure 1 Transition of the number of patients with HMV. Abbreviations HMV, home mechanical ventilation NPPV, nasal positive pressure ventilation TIPPV, tracheal invasive positive pressure ventilation.

Abbreviations. TIPPV, tracheal invasive positive pressure ventilation NIPPV, noninvasive positive pressure ventilation ALS, amyotrophic lateral sclerosis NMD, neuromuscular diseases LTV, long-term ventilation. 

Noninvasive positive-pressure ventilation (NPPV) provides ventilatory support with oxygen and pressurized airflow using a face or nasal mask with a tight seal but without endotracheal intubation. In patients with acute respiratory failure due to COPD exacerbations, NPPV was associated with lower mortality, lower intubation rates, shorter hospital stays, and greater improvements in serum pH in 1 hour compared with usual care. Use of NPPV reduces the complications that often arise with invasive mechanical ventilation. NPPV is not appropriate for patients with altered mental status, severe acidosis, respiratory arrest, or cardiovascular instability. 

In May 2002, Vianna et al. (9) evaluated LTV in patients with a stay >30 days, in 77 ICUs in Rio de Janeiro, noting by telephone interview that 26 were publicly funded and 51 were in the private system. There were 645 patients of whom 62 (9.6%) met the criteria for prolonged stay. The main causes were pulmonary and neurological illness. Invasive ventilation was used in 93% of public and 79% of private units. Noninvasive ventilation was not registered in public units, but used in 12% of private patients. The authors noted that noninvasive positive pressure ventilation (NIPPV) in specialized respiratory units would reduce costs as well as length of stay in the ICU. A study conducted by nurses (10) in the ventilator-dependent pediatric population improved the process of family care during their ICU stay and when at home. 

Montiel GC, Roncoroni AJ, Quadrelli SA, et al. Central alveolar hypoventilation with cor pulmonale successful treatment by non-invasive intermittent positive pressure ventilation. Medicina (B Aires) 1994 54 343-348. 

---