Ventilation mouthpiece

Nebulizers Traditionally used for the acute care of nonambulatory, hospitalized patients, particularly with coordination or dexterity difficulties. Solutions or suspensions can be nebulized by ultrasonics or an air jet and administered via a mouthpiece, ventilation mask, or tracheostomy. 

Boitano LJ, Benditt JO. An evaluation of home volume ventilators that support open-circuit mouthpiece ventilation. Respir Care 2005 50 1457-1461. 

McKim DA, LeBlanc C. Maintaining an Oral Tradition specific equipment requirements for mouthpiece ventilation instead of tracheostomy for Neuromuscular Disease. Respir Care 2(X)6 51 297-298. 

Figure 6 Post-polio patient with severe scoliosis using mouthpiece ventilation during activities of daily living.

Figure 7 Duchenne muscular dystrophy patient, dependent on noninvasive ventilation using daytime mouthpiece ventilation mounted on his electric wheelchair.

Despite commencing elective bi-level positive airway pressure ventilatory support, he was unable to sustain adequate gas exchange. The reduced tone of his facial muscles was addressed with the use of a chinstrap. However, an anatomical jaw malocclusion could not be remedied and he declined ventilation via a mouthpiece. He sustained marked air leakage at the mouth, such that many ventilator delivered breaths did not result in adequate ventilatory support, as seen by limited chest and abdominal excursion (Fig. 9). He was advised to consider an elective tracheostomy, but relocated and was lost to follow-up. Ultimately he agreed, at his new location, to have mouthpiece ventilation and he has remained stable. 

Most children are managed with NPPV (1,50). However, some require invasive ventilation through a tracheostomy. The main indications for a tracheostomy in children are airway abnormalities such as tracheobronchomalacia or tracheal stenosis, chronic disease of prematurity, and NMD (1,51,52). The indications for a tracheostomy are comparable to those of the adult population. They include the persistence of hypercapnia despite NPPV and additional measures such as daytime mouthpiece ventilation, aspiration, and bulbar dysfunction (53). In children, NPPV is more difficult to perform in those who might be 24-hour dependent, than in adults. Infants with primaiy alveolar hypoventilation (Ondine s curse) are preferentially ventilated by means of a tracheostomy (18). Tracheostomy ventilation favors airway inflammation (54) and may affect speech and language development (55). In children with progressive NMD, the decision of a tracheostomy has to be discussed on an individual basis, taking into account the familial environment and the parent s and child s perspective (52,56). In any case, sending children home with invasive ventilation is more difficult than when noninvasive ventilation is used (52). 

The 1960s witnessed the continued support of some polio patients at home, as well as the introduction of mouthpiece ventilation for long term, even continuous, support at some specialized rehabilitation hospitals (4). The 1960s also ushered in intensive care units (ICUs) that served as specialized centers to treat patients with acute respiratory failure. Sophisticated mechanical ventilators were developed to treat these patients. Some of whom failed to wean and often spent weeks or months in these units because no other facilities were available to adequately care for them. 

Take care when handling sharps. When practical, use a mouthpiece or other ventilation device as an alternative to mouth-to-mouth resuscitation. 

Toussaint M, Steens M, Wasteels G, et al. Diurnal ventilation via mouthpiece survival in end-stage Duchenne patients. Eur Respir J 2006 28 549-555. 

Bach JR, Alba AS. Sleep and nocturnal mouthpiece IPPV efficiency in postpoliomyelitis ventilator users. Chest 1994 106 1705-1710. 

Volume ventilation is often used for patients with a tracheostomy, but can also be very effective for daytime ventilation when using NIV with a mouthpiece (see Figs. 6 and 7). Volume ventilation when used during the day can allow patients to air stack and thus vary... 

Ventilatory support can be provided with NIPPV from volume-cycled ventilators via an angled mouthpiece, lipseal, nasal, or oral-nasal interface. Simple 15- or 22-mm-angled mouthpieces are most convenient for daytime ventilatory support (Fig. 3). To use mouthpiece IPPV, adequate neck rotation and oral motor function are necessary to prevent leakage from the mouth or nose. In addition, the patient must open the glottis and vocal cords, dilate the hypopharynx, and maintain airway patency to receive the air. 

Figure 3 A 51-year-old man with ALS and no ventilator-free breathing ability using daytime mouthpiece IPPV. Abbreviations ALS, amyotrophic lateral scoliosis IPPV, intermittent positive pressure ventilation.

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