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Britton D, Hoit JD, Pullen E, Benditt JO, Baylor CR, Yorkston KM. Experiences of Speaking With Noninvasive Positive Pressure Ventilation: A Qualitative Investigation. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:784-792. [PMID: 31306604 DOI: 10.1044/2019_ajslp-msc18-18-0101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Deanna Britton
- Department of Speech and Hearing Sciences, Portland State University, OR
- Northwest Center for Voice and Swallowing, Oregon Health & Sciences University, Portland
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Jeannette D Hoit
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson
| | - Elizabeth Pullen
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson
| | - Joshua O Benditt
- Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, Seattle
| | - Carolyn R Baylor
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Kathryn M Yorkston
- Department of Rehabilitation Medicine, University of Washington, Seattle
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Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis. Dysphagia 2019; 35:32-41. [PMID: 30859305 DOI: 10.1007/s00455-019-09997-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/05/2019] [Indexed: 12/13/2022]
Abstract
The purpose of the study is to describe experiences of swallowing with two forms of noninvasive positive-pressure ventilation (NPPV): mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP) in people with muscular dystrophy. Ten men (ages 22-42 years; M = 29.3; SD = 7.1) with muscular dystrophy (9 with Duchenne's; 1 with Becker's) completed the Eating Assessment Tool (EAT-10; Ann Otol Rhinol Laryngol 117(12):919-924 [33]) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code (Dedoose.com) and develop themes. All participants affirmed dysphagia symptoms via responses on the EAT-10 (M = 11.3; SD = 6.38; Range = 3-22) and reported eating and drinking with M-NPPV and, to a lesser extent, nasal BPAP. Analysis of interview data revealed three primary themes: (1) M-NPPV improves the eating/drinking experience: Most indicated that using M-NPPV reduced swallowing-related dyspnea. (2) NPPV affects breathing-swallowing coordination: Participants described challenges and compensations in coordinating swallowing with ventilator-delivered inspirations, and that the time needed to chew solid foods between ventilator breaths may lead to dyspnea and fatigue. (3) M-NPPV aids cough effectiveness: Participants described improved cough strength following large M-NPPV delivered inspirations (with or without breath stacking). Although breathing-swallowing coordination is challenging with NPPV, participants reported that eating and drinking is more comfortable than when not using it. Overall, eating and drinking with NPPV delivered via a mouthpiece is preferred and is likely safer for swallowing than with nasal BPAP. M-NPPV (but not nasal BPAP) is reported to improve cough effectiveness, an important pulmonary defense in this population.
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Human SOD1 ALS Mutations in a Drosophila Knock-In Model Cause Severe Phenotypes and Reveal Dosage-Sensitive Gain- and Loss-of-Function Components. Genetics 2016; 205:707-723. [PMID: 27974499 DOI: 10.1534/genetics.116.190850] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 11/13/2016] [Indexed: 12/13/2022] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is the most common adult-onset motor neuron disease and familial forms can be caused by numerous dominant mutations of the copper-zinc superoxide dismutase 1 (SOD1) gene. Substantial efforts have been invested in studying SOD1-ALS transgenic animal models; yet, the molecular mechanisms by which ALS-mutant SOD1 protein acquires toxicity are not well understood. ALS-like phenotypes in animal models are highly dependent on transgene dosage. Thus, issues of whether the ALS-like phenotypes of these models stem from overexpression of mutant alleles or from aspects of the SOD1 mutation itself are not easily deconvolved. To address concerns about levels of mutant SOD1 in disease pathogenesis, we have genetically engineered four human ALS-causing SOD1 point mutations (G37R, H48R, H71Y, and G85R) into the endogenous locus of Drosophila SOD1 (dsod) via ends-out homologous recombination and analyzed the resulting molecular, biochemical, and behavioral phenotypes. Contrary to previous transgenic models, we have recapitulated ALS-like phenotypes without overexpression of the mutant protein. Drosophila carrying homozygous mutations rendering SOD1 protein enzymatically inactive (G85R, H48R, and H71Y) exhibited neurodegeneration, locomotor deficits, and shortened life span. The mutation retaining enzymatic activity (G37R) was phenotypically indistinguishable from controls. While the observed mutant dsod phenotypes were recessive, a gain-of-function component was uncovered through dosage studies and comparisons with age-matched dsod null animals, which failed to show severe locomotor defects or nerve degeneration. We conclude that the Drosophila knock-in model captures important aspects of human SOD1-based ALS and provides a powerful and useful tool for further genetic studies.
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Theme 6 Respiratory and Nutritional Management. Amyotroph Lateral Scler Frontotemporal Degener 2015; 16 Suppl 1:124-35. [DOI: 10.3109/21678421.2015.1098811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Morino A, Shida M, Tanaka M, Sato K, Seko T, Ito S, Ogawa S, Takahashi N. Test-retest reliability of expiratory abdominal compression with a handheld dynamometer in patients with prolonged mechanical ventilation. J Phys Ther Sci 2015; 27:2163-5. [PMID: 26311946 PMCID: PMC4540841 DOI: 10.1589/jpts.27.2163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/03/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The present study aimed to examine the test-retest reliability of expiratory
abdominal compression with a handheld dynamometer in patients with prolonged mechanical
ventilation. [Subjects and Methods] We recruited 18 patients with prolonged mechanical
ventilation. All patients had impaired consciousness. The mode of the ventilator was
synchronized intermittent mandatory ventilation. The abdomen above the navel was
vertically compressed using a handheld dynamometer in synchronization with expiration.
Expiratory abdominal compression was performed two times. We measured the tidal volume
during expiratory abdominal compression. There was an interval of 5 minutes between the
first and second measurements. Intraclass correlation coefficient (ICC) and Bland-Altman
analysis were performed to examine the test-retest reliability of expiratory abdominal
compression with a handheld dynamometer. [Results] The test-retest reliability of
expiratory abdominal compression was excellent (ICC(1, 1): 0.987). Bland-Altman analysis
showed that there was no fixed bias and no proportional bias. [Conclusion] The findings of
this study suggest that expiratory abdominal compression with a handheld dynamometer is
reliable and useful for patients with respiratory failure and prolonged mechanical
ventilation.
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Affiliation(s)
- Akira Morino
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Masahiro Shida
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Masashi Tanaka
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Kimihiro Sato
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Toshiaki Seko
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Shunsuke Ito
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Shunichi Ogawa
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Naoaki Takahashi
- Department of Physical Therapy, School of Rehabilitation Sciences, Health Sciences University of Hokkaido, Japan
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Morino A, Shida M, Tanaka M, Sato K, Seko T, Ito S, Ogawa S, Takahashi N. Comparison of changes in tidal volume associated with expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation. J Phys Ther Sci 2015; 27:2253-6. [PMID: 26311963 PMCID: PMC4540858 DOI: 10.1589/jpts.27.2253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/13/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study was designed to compare and clarify the relationship between
expiratory rib cage compression and expiratory abdominal compression in patients on
prolonged mechanical ventilation, with a focus on tidal volume. [Subjects and Methods] The
subjects were 18 patients on prolonged mechanical ventilation, who had undergone
tracheostomy. Each patient received expiratory rib cage compression and expiratory
abdominal compression; the order of implementation was randomized. Subjects were
positioned in a 30° lateral recumbent position, and a 2-kgf compression was applied. For
expiratory rib cage compression, the rib cage was compressed unilaterally; for expiratory
abdominal compression, the area directly above the navel was compressed. Tidal volume
values were the actual measured values divided by body weight. [Results] Tidal volume
values were as follows: at rest, 7.2 ± 1.7 mL/kg; during expiratory rib cage compression,
8.3 ± 2.1 mL/kg; during expiratory abdominal compression, 9.1 ± 2.2 mL/kg. There was a
significant difference between the tidal volume during expiratory abdominal compression
and that at rest. The tidal volume in expiratory rib cage compression was strongly
correlated with that in expiratory abdominal compression. [Conclusion] These results
indicate that expiratory abdominal compression may be an effective alternative to the
manual breathing assist procedure.
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Affiliation(s)
- Akira Morino
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Masahiro Shida
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Masashi Tanaka
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Kimihiro Sato
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Toshiaki Seko
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Shunsuke Ito
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Shunichi Ogawa
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Naoaki Takahashi
- Department of Physical Therapy, Health Sciences University of Hokkaido School of Rehabilitation Sciences, Japan
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THEME 4 RESPIRATORY AND NUTRITIONAL MANAGEMENT. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15 Suppl 1:93-106. [DOI: 10.3109/21678421.2014.960177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Britton D, Benditt JO, Merati AL, Miller RM, Stepp CE, Boitano L, Hu A, Ciol MA, Yorkston KM. Associations between laryngeal and cough dysfunction in motor neuron disease with bulbar involvement. Dysphagia 2014; 29:637-46. [PMID: 25037590 DOI: 10.1007/s00455-014-9554-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 06/21/2014] [Indexed: 02/07/2023]
Abstract
True vocal fold (TVF) dysfunction may lead to cough ineffectiveness. In individuals with motor neuron disease (MND), cough impairment in the context of dysphagia increases risk for aspiration and respiratory failure. This study characterizes differences and associations between TVF kinematics and airflow during cough in individuals with bulbar MND. Sequential glottal angles associated with TVF movements during volitional cough were analyzed from laryngeal video endoscopy examinations of adults with bulbar MND (n = 12) and healthy controls (n = 12) and compared with simultaneously collected cough-related airflow measures. Significant group differences were observed with airflow and TVF measures: volume acceleration (p ≤ 0.001) and post-compression abduction TVF angle average velocity (p = 0.002) were lower and expiratory phase rise time (p = 0.001) was higher in the MND group. Reductions in maximum TVF angle during post-compression abduction in the MND group approached significance (p = 0.09). All subjects demonstrated complete TVF and supraglottic closure during the compression phase of cough, except for incomplete supraglottic closure in 2/12 MND participants. A strong positive relationship between post-compression maximum TVF abduction angle and peak expiratory cough flow was observed in the MND group, though it was not statistically significant (r = 0.55; p = 0.098). Reductions in the speed and extent of TVF abduction are seen during the expulsion phase of cough in individuals with MND. This may contribute to cough impairment and morbidity.
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Affiliation(s)
- Deanna Britton
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific Street, Box 356490, Seattle, WA, 98195, USA,
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Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurological disease with high risk of malnutrition. Symptoms of dysphagia, depression, cognitive impairment, difficulty with self-feeding and meal preparation, hypermetabolism, anxiety, respiratory insufficiency, and fatigue with meals increase the risk of malnutrition. Malnutrition negatively affects prognosis and quality of life, making early and frequent nutrition assessment and intervention essential. Implementation of an adequate calorie diet, dietary texture modification, use of adaptive eating utensils, and placement of a feeding tube aid in preventing malnutrition. When nutrition status is compromised by dysphagia and weight loss (5%-10% of usual body weight) or body mass index <20 kg/m(2) without weight loss and when forced vital capacity is >50%, a percutaneous endoscopic gastrostomy placement is indicated. When forced vital capacity is <50%, a radiologically inserted gastrostomy is the preferred means of enteral placement due to lessened aspiration and respiratory risk. Parenteral nutrition (PN) is indicated only when enteral nutrition (EN) is contraindicated or impossible. This article reviews the background of ALS, nutrition implications and risk of malnutrition, treatment strategies to prevent malnutrition, the role of EN and PN, and feeding tube placement methods according to disease stage.
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Affiliation(s)
- Daniel I Greenwood
- Minneapolis Veterans Affairs Health Care System, Minneapolis VA Medical Center, Minneapolis, MN 55417, USA.
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Britton D, Cleary S, Miller R. What is ALS and What is the Philosophy of Care? ACTA ACUST UNITED AC 2013. [DOI: 10.1044/sasd22.1.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Deanna Britton
- University of Washington—Rehabilitation MedicineSeattle, WA
| | - Stuart Cleary
- University of Alberta—Rehabilitation MedicineEdmonton, Alberta, Canada
| | - Robert Miller
- University of Washington—Speech & Hearing SciencesSeattle, WA
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Ellis AC, Rosenfeld J. Which equation best predicts energy expenditure in amyotrophic lateral sclerosis? ACTA ACUST UNITED AC 2011; 111:1680-7. [PMID: 22027050 DOI: 10.1016/j.jada.2011.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 03/18/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of this study was to compare measured resting energy expenditure (REE) with estimates from three common prediction equations with the goal of determining which equation best estimates REE in amyotrophic lateral sclerosis (ALS). DESIGN Cross-sectional measurements of REE from indirect calorimetry were compared to calculations from the Harris Benedict, Mifflin-St Jeor, and Ireton-Jones equations. Additional measurements to identify predictors of REE included pulmonary function tests, fat-free mass by bioelectrical impedance, and anthropometrics. SUBJECTS/SETTING Participants were 56 men and women with ALS. For comparison, subjects were categorized by disease progression into three groups. STATISTICAL ANALYSES Pearson correlations and paired t tests were used to compare measured REE with predicted REE from each equation, and the accuracy of each equation was quantified by the root mean squared prediction error and the percentage of REE estimates within 10% of measured values. Bias for each equation was calculated as the mean percentage difference between calculated and measured REE. Multiple linear regression was used to determine the best predictor variables for REE. RESULTS Across the disease spectrum, the Harris Benedict and Mifflin-St Jeor equations provided clinically acceptable estimates of REE, whereas the Ireton-Jones equations consistently overestimated REE. The best predictors of REE among this cohort were fat-free mass, sex, and age. CONCLUSIONS When estimating energy requirements for patients with ALS, clinicians should choose prediction equations that incorporate sex and age as predictor variables, such as the Harris Benedict and Mifflin-St Jeor equations.
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Affiliation(s)
- Amy C Ellis
- Department of Nutrition Sciences, University of Alabama at Birmingham, AL, USA.
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Bach JR, Gonçalves MR, Hamdani I, Winck JC. Extubation of patients with neuromuscular weakness: a new management paradigm. Chest 2009; 137:1033-9. [PMID: 20040608 DOI: 10.1378/chest.09-2144] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Successful extubation conventionally necessitates the passing of spontaneous breathing trials (SBTs) and ventilator weaning parameters. We report successful extubation of patients with neuromuscular disease (NMD) and weakness who could not pass them. METHODS NMD-specific extubation criteria and a new extubation protocol were developed. Data were collected on 157 consecutive "unweanable" patients, including 83 transferred from other hospitals who refused tracheostomies. They could not pass the SBTs before or after extubation. Once the pulse oxyhemoglobin saturation (Spo(2)) was maintained at > or = 95% in ambient air, patients were extubated to full noninvasive mechanical ventilation (NIV) support and aggressive mechanically assisted coughing (MAC). Rather than oxygen, NIV and MAC were used to maintain or return the Spo(2) to > or = 95%. Extubation success was defined as not requiring reintubation during the hospitalization and was considered as a function of diagnosis, preintubation NIV experience, and vital capacity and assisted cough peak flows (CPF) at extubation. RESULTS Before hospitalization 96 (61%) patients had no experience with NIV, 41 (26%) used it < 24 h per day, and 20 (13%) were continuously NIV dependent. The first-attempt protocol extubation success rate was 95% (149 patients). All 98 extubation attempts on patients with assisted CPF > or = 160 L/m were successful. The dependence on continuous NIV and the duration of dependence prior to intubation correlated with extubation success (P < .005). Six of eight patients who initially failed extubation succeeded on subsequent attempts, so only two with no measurable assisted CPF underwent tracheotomy. CONCLUSIONS Continuous volume-cycled NIV via oral interfaces and masks and MAC with oximetry feedback in ambient air can permit safe extubation of unweanable patients with NMD.
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Affiliation(s)
- John Robert Bach
- Department of Physical Medicine and Rehabilitation, University Hospital B-403, 150 Bergen St, Newark, NJ 07103, USA.
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