Mouth Intermittent Positive Pressure Ventilation in the Management of Postpolio Respiratory Insufficiency

doi:10.1378/chest.91.6.859

Chest

Volume 91, Issue 6, June 1987, Pages 859-864

https://doi.org/10.1378/chest.91.6.859 Get rights and content

The use of mouth intermittent positive pressure ventilation alone or in combination with other noninvasive respiratory techniques as an alternative to tracheostomy in the home management of respirator-dependent postpolio persons was studied in 75 patients. The onset of polio was at an average age of 15 years. At that time, all were dependent on some form of respiratory assistance, most frequently, the iron lung. Fifty-nine percent of them remained respirator-dependent from the onset. Forty-one percent became respirator-dependent at an average of 18 years after onset of polio. Overall, they lost an average of 1.9 percent of vital capacity per year. All used mouth intermittent positive pressure ventilation as their predominant mode of respiratory assistance for an average of 14.5 years. Four of them who had no measurable vital capacity used only mouth intermittent positive pressure ventilation 24 hours per day. Of the 66 who had no significant tolerance off 24 hours per day respiratory assistance, only six had tracheostomies. Despite severe physical disability and dependence on artificial ventilation, the majority of these persons have married, have been gainfully employed, and lead useful lives in society.

Section snippets

METHOD

Seventy-five postpolio persons on MIPPV were studied. Seventy were managed in the home, five in chronic care institutions. Eight had complete quadriplegia, while 67 had varying degrees of quadriparesis. None had severe bulbar involvement. All were wheelchair dependent. The majority were mobile only in motorized wheelchairs. Twenty-seven had significant scoliosis. Sixty-six were ventilator dependent 24 hours a day and could tolerate only seconds of time free of assisted ventilation unless

RESULTS

Seventy-five respirator dependent postpolio persons were separated into three categories as a function of the amount and method of respiratory assistance. Table 1 represents those persons with no tolerance off mechanical aid who used only MIPPV 24 hours per day. Twenty-three of these persons had been dependent on aid since the onset of polio. Twenty returned to at least overnight respiratory aid an average of 18.1 years (one to 37) postpolio and subsequently progressed to full-time respirator

DISCUSSION

Respiratory insufficiency in the majority of postpolio patients is due primarily to respiratory muscle weakness. Most of our patients requiring full time aid have VCs below 1 L. In others requiring full time aid, VCs as high as 1,700 ml have been noted. These patients may have intrinsic lung disease, central hypoventilation, or a pattern of upper airway collapse and sleep apnea episodes as well as thoracic deformity. Symptoms of hypoventilation are insidious in onset but lead to cor pulmonale

ACKNOWLEDGMENTS

The authors wish to thank Marie Schultheiss, B.A.C. C.P.T., Craig Senna, C.R.T.T., Enrique Gonzalez, C.R.T.T., and Joan Adler, M.A., for their technical assistance. We also wish to thank Ms. Diane Perlman for her help in preparing this paper.

REFERENCES (20)

GaraySM et al.
Sustained reversal of chronic hypercapnia in patients with alveolar hypoventilation syndromes
Am J Med
(1981)
RochesterDF et al.
Diaphragmatic energy expenditure in chronic respiratory failure
Am J Med
(1977)
BergofskyEH
Cor pulmonale in the syndrome of alveolar hypoventilation
Prog Cardiovasc Dis
(1967)
LibbyDM et al.
Acute respiratory failure in scoliosis or kyphosis: prolonged survival and treatment
Am J Med
(1982)
Paralytic poliomyelitis—UnitedStates
1982 and 1983
Current Trends. MMWR
(1984)
LassenHCA
Traitement des troubles respiratoires et de la paralysie bulbaire dans la poliomyelite
J Med Lyon
(1956)
FischerAD
Poliomyelitis: late respiratory complications and management
Orthopedics
(1985)
GuillenminaultC et al.
Sleep apnea syndrome as a long-term sequela of poliomyelitis
Froc Foundation Series
(1978)
AlbaA et al.
Management of respiratory insufficiency in spinal cord lesions
BachJR et al.
Glossopharyngeal breathing and non-invasive aids in the management of post-polio respiratory insufficiency

There are more references available in the full text version of this article.

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Although in 1987 we first published CNVS via a nasal interface for a multiple sclerosis patient with no VFBA and 100 ml of VC,2 with the release of a bi-level pressure cycled mode (BiPAP™, Respironics Inc., Murrysville, Pa) devices in 1990, NMD patients are being placed on BiPAP at less than NVS and full respiratory muscle rest settings. With advancing disease, some have had their sleep bi-level mode settings increased and were commenced on daytime mouthpiece NVS with a volume-cycled mode, however, once intubated for any reason they received a tracheotomy rather than continue CNVS.3-7 Typically, most clinicians still do not offer diurnal mouthpiece (Fig. 1) and nasal NVS, when mask NIV use exceeds 15–20 h and tracheostomy is therefore recommended.
Typically, patients with progressive neuromuscular disorders (NMDs) develop acute respiratory failure (ARF), are intubated, and when failing spontaneous breathing trials (SBTs) undergo a tracheotomy and receive tracheostomy mechanical ventilation (TMV). However, increasing numbers of patients use nasal noninvasive ventilation (NIV), initially for sleep and this is extended to continuous dependence (CNVS). This can be used as a strategy to assist in successful extubation . We retrospectively reviewed 19 centers offering CNVS and mechanical insufflation-exsufflation (MI-E) as an alternative to TMV.
Centers with publications or presentations concerning CNVS outcomes data were pooled for amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and spinal muscular atrophy type 1 (SMA1). Progression to CNVS dependence without hospitalization, duration of dependence, and extubations and decannulations to CNVS were recorded. Prolongation of life was defined by duration of CNVS dependence without ventilator free breathing ability (VFBA).
There were 1623 part time (<23 h/day) NVS users with ALS, DMD, and SMA1 from 19 centers in 16 countries of whom 761 (47%) were CNVS dependent for 2218 patient-years. This included: 335 ALS patients for a mean 1.2 ± 1.0 (range to 8) years each; 385 DMD patients for 5.4 ± 1.6 (range to 29) years; and 41 SMA1 patients for 5.9 ± 1.8 (range to 20) years. Thirty-five DMD and ALS TMV users were decannulated to CNVS and MI-E. At data collection 494 (65%) patients were CNVS dependent but 110 (74 of whom with bulbar ALS), had undergone tracheotomies.
ALS, DMD, and SMA1 patients can become CNVS dependent without requiring hospitalization but CNVS cannot be used indefinitely for many patients with advanced upper motor neuron diseases.
Respiratory Complications of Pediatric Neuromuscular Diseases
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In general, the objectives of NVS in patients with NMD are to normalize gas exchange, relieve dyspnea, correct sleep-disordered breathing and abnormal sleep architecture, prevent or reverse cor pulmonale, improve daytime function, promote and sustain growth and development, improve quality of life, and prolong survival. The addition of NVS in this patient population has changed the natural history of their diseases.26–32 NVS is applied with a variety of interfaces and ventilators, at full ventilator support settings to optimally rest respiratory muscles, which low-span bilevel positive airway pressure and continuous positive airway pressure do not achieve.
Noninvasive Ventilator Devices and Modes
2020, Sleep Medicine Clinics
Sleep disorders in aging polio survivors: A systematic review
2020, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
Invasive ventilation by tracheotomy seems more effective than BiPAP for improving sleep quality [32]. However, BiPAP has been shown to improve alveolar gas exchange (decreasing PCO2, increasing nocturnal PO2) and symptoms among polio survivors [33–35] but has not been compared to invasive pressure support. Indeed, patients often favour BiPAP instead of tracheotomy [31].
Sleep disturbances, especially sleep disordered breathing and sleep movement disorders, seem to be highly prevalent among aging polio survivors. They could contribute to late functional deterioration, fatigue, poor quality of life and negative health outcomes, thereby increasing cardiovascular risk.
This review focused on current knowledge of the prevalence of sleep disorders in polio survivors, their features, predictive factors and management.
Articles were searched in PubMed and the Cochrane Library up to March 2018.
Articles needed to 1) be written in English; 2) include only participants with previous poliomyelitis or post-polio syndrome diagnosis; and 3) involve any form of sleep disorders. Articles about isolated fatigue or non-specific sleep complaints as well as non-polio specific articles (neuromuscular disorders) were not included in the qualitative analysis.
Among 166 studies identified, 41 were included in this review. The prevalence of sleep apnea syndrome, nocturnal alveolar hypoventilation and restless legs syndrome seemed higher than in the general population (from 7.3% to 65%, 15% to 20% and 28% to 63%, respectively). This review highlights the lack of randomised studies assessing sleep disorder management in this specific population.
Because of the small number of eligible publications, none was excluded for methodological limitations, and only a qualitative analysis was provided.
Follow-up of polio survivors should include systematic screening for sleep disorders because they are associated with adverse consequences. Sleep disorder evaluation and management should improve the long-term survival and quality of life of polio survivors. Methodologically robust clinical trials are needed, but the decreasing prevalence and large clinical spectrum of the disease may complicate the creation of comparable groups.
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2020, Respiratory Medicine
Home mechanical ventilation (HMV) is used in heterogeneous conditions underlying chronic hypercapnic respiratory failure, but there are sparse data on long-term clinical outcomes. The aim was to systematically analyse the time and the circumstances of death on HMV.
All-cause mortality data of HMV patients were prospectively collected between 2008 and 2018 in a large tertiary centre. Data were categorised into diagnostic groups including neuromuscular disease (NMD), chest wall disease (CWD), chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), overlap syndrome of COPD and OSA (overlap) and other group. The primary outcome was time-to-death from initiation of HMV.
1210 deaths were recorded over a 10-year period. Median time-to-death was 19.5 [6–55] months and differed between groups (Kruskal Wallis p < 0.001). CWD (98.5 [23.5–120] months) and slowly progressive NMD (64.5 [28–120] months) had the longest time-to-death on HMV, while OHS (33 [13–75] months) and overlap syndrome (30.5 [14.5–68.5] months) had a longer median time-to-death than COPD (19.5 [7–42.5] months) and motor neurone disease (7 [3–14] months). Daily adherence to HMV of greater than 4 h/night was associated with better outcomes (10 [3–24] vs. 30 [10–76] months; p < 0.001). 43% with confirmed location of death died outside the hospital.
The time-to-death on home mechanical ventilation varies widely across disease groups with chronic respiratory failure and seems to be associated with daily usage time.
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2014, Revista Portuguesa de Pneumologia
Citation Excerpt :
Pressure cycling in assist control mode, also using active ventilator circuits, can be used as well but does not permit air stacking. Since the patient can take as much of the delivered air as wanted for speech, shouting, eating, coughing, etc., volumes are set from 700 to 1500 mL for adult patients.50,51 The mouthpiece can be mounted close to the head so that the patient can grab it as desired.47–49
In 2013 new “mouthpiece ventilation” modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.
Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via “mask” interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22 mm angled mouthpieces and straw-type mouthpieces are the most commonly used.
NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates “air-stacking” to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.
Em 2013, foram introduzidos novos modos de «ventilação por peça bucal», para ventiladores portáteis disponíveis comercialmente. Apesar disto, há pouco conhecimento sobre como usar a ventilação não invasiva por pressão positiva intermitente (NIV) em oposição à pressão positiva bi-nível (PAP) e ambas têm sido referidas, quase exclusivamente, como sendo utilizadas através de interfaces nasais ou oro-nasais, em vez de através de uma simples peça bucal.
É referido com frequência a falência da ventilação não invasiva, devido à acumulação de secreções nas vias respiratórias, devido à hipercapnia por deficiente ajuste dos parâmetros da PAP ou devido a uma reduzida tolerância à interface. Esta última pode ser causada por fatores como pressão excessiva na face devido a um ajuste defeituoso, fuga excessiva de ar pela boca, ansiedade, claustrofobia e falta de sincronia entre o doente e o ventilador. Deste modo, a interface tem um papel crucial na tolerância e eficácia. Interfaces que cobrem o nariz e/ou a boca (oro-nasal) são as mais habitualmente usadas, mas são as que apresentam maior propensão a provocarem lesões na pele e claustrofobia. A maioria dos inconvenientes associados pode ser evitada usando VNI por bocal. A VNI de circuito aberto por peça bucal está a ser usada por um número significativo de doentes em alguns centros, na assistência ventilatória diurna e como complemento da VNI noturna através de «máscara». A VNI por peça bucal é igualmente utilizada durante o sono com o bucal fixo na posição, através de uma orla de cobertura do lábio. As peças bucais mais utilizadas são as pequenas anguladas de 15 e 22 mm e as de tipo «palhinha».
A VNI através de de peça bucal é usada por um número significativo de doentes como uma alternativa eficaz à ventilação assistida através de tubo de traqueostomia (VTM) e está associada à redução do risco de pneumonias e outras complicações respiratórias. A sua utilização facilita a «acumulação de ar» que aumenta a eficácia da tosse, o discurso e a compliance pulmonar, melhorando a qualidade de vida dos doentes com doenças neuromusculares (DNM) em comparação as alternativas invasivas. Considerando estes benefícios e a disponibilização de modos ventilatórios NIV por peça bucal, é agora garantido um maior conhecimento desta técnica. Esta revisão destaca as indicações, técnicas, vantagens e desvantagens do VNI por peça bucal.

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: Manuscript received July 25; revision accepted October 30.

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Chest

Clinical InvestigationsMouth Intermittent Positive Pressure Ventilation in the Management of Postpolio Respiratory Insufficiency

Section snippets

METHOD

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

Am J Med

Am J Med

Prog Cardiovasc Dis

Am J Med

1982 and 1983

Current Trends. MMWR

Traitement des troubles respiratoires et de la paralysie bulbaire dans la poliomyelite

J Med Lyon

Poliomyelitis: late respiratory complications and management

Orthopedics

Sleep apnea syndrome as a long-term sequela of poliomyelitis

Froc Foundation Series

Management of respiratory insufficiency in spinal cord lesions

Glossopharyngeal breathing and non-invasive aids in the management of post-polio respiratory insufficiency

Clinical Investigations
Mouth Intermittent Positive Pressure Ventilation in the Management of Postpolio Respiratory Insufficiency