Noninvasive ventilation in neuromuscular disease

Neuromuscular disorders and chronic ventilation

Morbidity and mortality have decreased in patients with neuromuscular disease due to implementation of therapies to augment cough and improve ventilation. Infants with progressive neuromuscular disease will eventually develop respiratory complications as a result of muscle weakness and their inability to compensate during periods of increased respiratory loads. The finding of nocturnal hypercapnia is often the trigger for initiating non-invasive ventilation and studies have shown that its use not only may improve sleep-disordered breathing, but also that it may have an effect on daytime function, symptoms related to hypercapnia, and partial pressure of CO₂. It is important to understand the respiratory physiology of this population and to understand the benefits and limitations of assisted ventilation.

Airway management in neurological emergencies

Several neurological conditions may present to the emergency department (ED) with airway compromise or respiratory failure. The severity of respiratory involvement in these patients may not always be obvious. Proper pulmonary management can significantly reduce the respiratory complications associated with the morbidity and mortality of these patients. Rapid sequence intubation (RSI) is the method of choice for definitive airway management in the ED and is used for the majority of intubations. The unique clinical circumstances of each patient dictates which pharmacological agents can be used for RSI. Several precautions must be taken when using these drugs to minimize potentially fatal complications. Noninvasive positive pressure ventilation may obviate the need for intubation in a select population of patients. This article reviews airway management, with a particular emphasis on the use of RSI for common neurological problems presenting to the ED.

Evaluation and initial management of the patient in respiratory distress

Evaluation of the patient in acute respiratory distress poses a complex problem to the emergency physician. Because of the heterogeneity of the population of patients presenting in acute respiratory distress, there is a paucity of evidence-based medicine recommendations. Practice habit dictates most of our diagnostic and therapeutic approach. It is of paramount importance to understand the limitations of history, physical examination, and diagnostic screening studies in evaluating and treating patients with respiratory distress. The emergency physician should become aware of the benefits of NPPV in the management of respiratory failure. Essential to the management of these patients is the ability to anticipate difficulty in airway management and the formulation of alternative airway strategies.