Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis

Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report

BACKGROUND

Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations.

STUDY DESIGN AND METHODS

An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations.

RESULTS

Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement.

INTERPRETATION

Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making.

Effect of Noninvasive Positive Pressure Ventilation on Prognosis and Blood Gas Level in COPD Patients Complicated with Respiratory Failure

Chronic obstructive pulmonary disease (COPD) is a respiratory disease caused by chronic bronchitis, which seriously threatens the life safety of patients. Noninvasive positive pressure ventilation (NIPPV) has great advantages in its treatment. Here, we explore the effect of NIPPV on prognosis and blood gas level in COPD patients complicated with respiratory failure (RF). A case control study was retrospectively analyzed, where 36 COPD patients with RF were regarded as the regular group to carry on the routine treatment, and 42 patients were assigned to the research group to carry out the routine treatment plus NIPPV. The monofactorial analysis showed that the overall response rate, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC in the research group were higher than those in the regular group, while partial pressure of arterial carbondioxide (PaCO₂), posttreatment endotracheal intubation (EI), length of stay (LOS), tumor necrosis factor (TNF-α), interleukin (IL)-6, IL-1β, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and modified Medical Research Council (mMRC) scores in the research group were lower than those in the regular group. These results indicated that NIPPV can improve the curative effect of emergency medicine patients with RF, improve BG level and PF, reduce inflammation, and facilitate patient's recovery.

How to eat, drink and speak on non-invasive ventilation

We report our observations on six individuals with non-bulbar neuromuscular disorders using non-invasive ventilation (NIV), who were able to maintain adequate hydration and nutrition orally despite being ventilator-dependant. All had severe respiratory muscle weakness, with a vital capacity less than 500 mL and cough peak flow rate less than 250 L/min. Their median (range) age was 49 (23–64) years; they had been on NIV for 8 (2–24) years. We compared them with an age- and sex-matched normal control. Individuals with neuromuscular disorders needed to chew each mouthful of food significantly more times (median 44, range 18–120 chews) than normal controls (median 15, range 10–20 chews). They took longer to completely swallow a mouthful of food (median 37, range 24–100 s) compared to normal controls (median 14.5, range 10–21 s). Multiple swallows for each mouthful were seen in all neuromuscular individuals, but in only one normal control. Two individuals coughed after swallowing; both these subjects were clinically stable at the time of the study. The median number of NIV breaths associated with chest expansion for each mouthful was 11 (range 5–49). All subjects blocked some NIV breaths whilst eating. Before swallowing, they always waited until the expiratory phase of the NIV breath was complete; no post-swallow expiration was seen, whereas normal subjects invariably exhibited post-swallow expiration. All individuals were able to block several ventilator breaths whilst swallowing un-thickened liquids. The median (range) number of words between breaths was 5 (4–7) for the neuromuscular individuals on NIV, significantly fewer than 11 (8–13) for the matched controls. Eating, drinking and speaking are possible whilst on NIV. Use of cough-assist after eating is recommended, given the likelihood of silent aspiration.

[Mouthpiece ventilation in neuromuscular diseases]

Le document qui suit est la traduction intégrale du compte rendu établi à l’occasion du 252e atelier international ENMC consacré, du 6 ou 8 mars 2020, au « Développement de recommandations pour l’utilisation de la ventilation par embout buccal dans les maladies neuromusculaires », et publié très récemment dans la revue Neuromuscular Disorders (M. Chatwin, M. Gonçalves, J. Gonzalez-Bermejo, M. Toussaint, et al. 252nd ENMC international workshop: Developing best practice guidelines for management of mouthpiece ventilation in neuromuscular disorders. March 6th to 8th 2020, Amsterdam, the Netherlands. Neuromuscular Disorders 2020 ; 30 : 772–81. https://doi.org/10.1016/j.nmd.2020.07.008).

Long-Term Non-invasive Ventilation in Children: Current Use, Indications, and Contraindications

This review focuses on the delivery of non-invasive ventilation-i.e., intermittent positive-pressure ventilation-in children lasting more than 3 months. Several recent reviews have brought to light a dramatic escalation in the use of long-term non-invasive ventilation in children over the last 30 years. This is due both to the growing number of children receiving care for complex and severe diseases necessitating respiratory support and to the availability of LT-NIV equipment that can be used at home. While significant gaps in availability persist for smaller children and especially infants, home LT-NIV for children with chronic respiratory insufficiency has improved their quality of life and decreased the overall cost of care. While long-term NIV is usually delivered during sleep, it can also be delivered 24 h a day in selected patients. Close collaboration between the hospital complex-care team, the home LT-NIV program, and family caregivers is of the utmost importance for successful home LT-NIV. Long-term NIV is indicated for respiratory disorders responsible for chronic alveolar hypoventilation, with the aim to increase life expectancy and maximize quality of life. LT-NIV is considered for conditions that affect respiratory-muscle performance (alterations in central respiratory drive or neuromuscular function) and/or impose an excessive respiratory load (airway obstruction, lung disease, or chest-wall anomalies). Relative contraindications for LT-NIV include the inability of the local medical infrastructure to support home LT-NIV and poor motivation or inability of the patient/caregivers to cooperate or understand recommendations. Anatomic abnormalities that interfere with interface fitting, inability to protect the lower airways due to excessive airway secretions and/or severely impaired swallowing, or failure of LT-NIV to support respiration can lead to considering invasive ventilation via tracheostomy. Of note, providing home LT-NIV during the COVID 19 pandemic has become more challenging. This is due both to the disruption of medical systems and the fear of contaminating care providers and family with aerosols generated by a patient positive for SARS-CoV-2 during NIV. Delay in initiating LT-NIV, decreased frequency of home visits by the home ventilation program, and decreased availability of polysomnography and oximetry/transcutaneous PCO2 monitoring are observed. Teleconsultations and telemonitoring are being developed to mitigate these challenges.

Experiences of Speaking With Noninvasive Positive Pressure Ventilation: A Qualitative Investigation

Purpose The aim of this study was to describe experiences of speaking with 2 forms of noninvasive positive pressure ventilation (NPPV)-mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP)-in people with neuromuscular disorders who depend on NPPV for survival. Method Twelve participants (ages 22-68 years; 10 men, 2 women) with neuromuscular disorders (9 Duchenne muscular dystrophy, 1 Becker muscular dystrophy, 1 postpolio syndrome, and 1 spinal cord injury) took part in semistructured interviews about their speech. All subjects used M-NPPV during the day, and all but 1 used BPAP at night for their ventilation needs. Interviews were audio-recorded, transcribed, and verified. A qualitative descriptive phenomenological approach was used to code and develop themes. Results Three major themes emerged from the interview data: (a) M-NPPV aids speaking (by increasing loudness, utterance duration, clarity, and speaking endurance), (b) M-NPPV interferes with the flow of speaking (due to the need to pause to take a breath, problems with mouthpiece placement, and difficulty in using speech recognition software), and (c) nasal BPAP interferes with speaking (by causing abnormal nasal resonance, muffled speech, mask discomfort, and difficulty in coordinating speaking with ventilator-delivered inspirations). Conclusion These qualitative data from chronic NPPV users suggest that both M-NPPV and nasal BPAP may interfere with speaking but that speech is usually better and speaking is usually easier with M-NPPV. These findings can be explained primarily by the nature of the 2 ventilator delivery systems and their interfaces.