Tracheostomy positive pressure ventilation

Cazzolli PA, Oppenheimer EA. Use of nasal and tracheostomy positive pressure ventilation in patients with amyotrophic lateral sclerosis (ALS). Abstracts of Papers, 7th International Conference on Noninvasive Ventilation Across the Spectrum from Critical Care to Home Care, Orlando, Florida, March 14-17, 1999. 

Cazzolli PA, Oppenheimer EA. Home mechanical ventilation for amyotrophic lateral sclerosis nasal compared to tracheostomy-intermittent positive pressure ventilation. J Neurol Sci 1996 139(suppl) 123-128. 

Wood DE, Mathisen DJ. Late complications of tracheotomy. Clin Chest Med 1991 12 597-609. 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. 

Harley HR. Ulcerative tracheo-oesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation. Thorax 1972 27 338-352. 

Goodenberger DM, Couser JI Jr., May JJ. Successful discontinuation of ventilation via tracheostomy by substitution of nasal positive pressure ventilation. Chest 1992 102(4) 1277-1279. 

Cazzolli PA, Oppenheimer EA. Home mechanical ventilation for motor neuron disease (MND/ ALS) nasal compared to tracheostomy intermittent positive pressure ventilation (IPPV). Abstracts of Papers, 6th Intemational Symposium on ALS/MND, Dublin, Ireland, November 17-19, 1995. Moss AH, Oppenheimer EA, Casey P, et al. Patients with amyotrophic lateral sclerosis receiving long-term mechanical ventilation advance care planning and outcomes. Chest 1996 110 249-255. 

The most common causes of failure to wean include chronic obstructive pulmonary disease (COPD) exacerbations, neuromuscular diseases, h) oxic respiratory failure, post surgical complications (2), and heart failure. Weaning from the tracheostomy must consider the balance of respiratory muscle function and work of breathing. The work of breathing is determined by ventilatory demand, compliance of the lungs and chest wall, airway resistance, and intrinsic positive end-expiratory pressure (PEEPi). Adequacy of ventilatory drive and neuromechanical output can be assessed from the respiratory rate, airway occlusion pressure at 100 milliseconds (Po.i), maximum inspiratory pressure (MIP), and maximum voluntary ventilation (MW). 

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. 

---