Faculty Bibliography

The purpose of this article is to present a cost analysis of in-home vs institutionalization for severely physically disabled ventilator-assisted individuals (VAIs). Following rehabilitation and adaptation to noninvasive methods of ventilatory support, 30 VAIs were maintained in the community for 12.9 +/- 1.1 years with personal care attendants organized by a home care vendor reimbursed by New York City Medicaid. The program permitted self-directed severely disabled clients, including these 30 exclusively nontracheostomized VAIs, to live in the community and direct their attendant care and personal affairs. Prior to discharge home, the 30 patients resided in the respiratory unit of a long-term care facility for a mean of 8.9 +/- 10.1 years. The unit is currently reimbursed at a mean rate of $718.80 per patient per day. The current mean total cost of maintaining these VAIs in the community is $235.13 +/- 56.73 per patient per day. The conversion to and/or maintenance on 24-h nontracheostomy ventilatory support permitted discharge to the community by allowing the VAI to be attended by trained but uncredentialed home care attendants, thus avoiding prohibitively expensive in-home nursing for tracheostomy care. This created a savings to the public of 77 percent or $176,137 per year per client. We conclude that conversion to and/or use of noninvasive methods of ventilatory aid can be a reasonable and cost-saving goal. More respiratory rehabilitation centers are needed to free up hospital beds and facilitate discharge of VAIs to the community. There is also evidence that trained attendants should be permitted to suction tracheostomized VAIs in the home

The purpose of this work is to present 640 patient-years of experience using the intermittent abdominal pressure ventilator (IAPV) in a regimen of noninvasive ventilatory support for patients with paralytic/restrictive respiratory insufficiency. Fifty-two of the 54 patients who used the IAPV used 24-hour noninvasive ventilatory support. Thirty-eight of the 52 patients could tolerate less than 15 minutes of free time off their ventilators except by the successful use of glossopharyngeal breathing (GPB). No patient, however, retained an indwelling tracheostomy and none required or used supplemental oxygen therapy. Forty-eight of the 54 patients used the IAPV for daytime support for a mean of 12.9 +/- 11.5 years (3 months to 39 years) while using other forms of noninvasive support overnight. All 48 patients maintained normal minute ventilation and end-tidal PCO2 on the IAPV. One patient used the IAPV only for nocturnal ventilatory support for six months. Five patients relied on the IAPV as their sole method of ventilatory support 24 hours a day for a mean of 13.4 +/- 11.2 years (range, 2 to 31 years). Three of these five patients had no free time and were studied by nocturnal SaO2 monitoring that demonstrated a mean SaO2 of 95 percent or greater and a minimum SaO2 of 86 percent. The maximum end-tidal PCO2 was 49 mm Hg during sleep on the IAPV. The 48 patients receiving daytime IAPV support reported few difficulties. However, two of the five patients using the IAPV 24 hours a day had development of sacral decubiti. The IAPV became ineffective for 12 patients after 12.3 +/- 9.5 years of use. These patients then switched to daytime mouth IPPV. We conclude that the IAPV is a safe and effective method of long-term daytime ventilatory support for patients with paralytic/restrictive respiratory insufficiency. Its use is optimized when employed in combination with other noninvasive methods of ventilatory support, thus eliminating the need for tracheostomy, and optimizing the use of GPB. Regular follow-up is important because the IAPV can become less effective with time

Fibrocartilaginous emboli to spinal cord vessels are a rare and fatal cause of spinal cord injury. We reviewed the medical literature and discovered only 24 cases reported, all in the last 28 years. For all previously reported patients, onset of initial symptoms to maximal neurologic deficit was from a few minutes to as much as two days. All 24 of these patients died an average of 9.6 weeks post-onset (range = three hours to 11 months) due to complications related to their spinal cord injury; in all cases, the pathologic diagnosis was made postmortem. We report a 20-year-old man with high-level quadriplegia and respiratory paralysis due to fibrocartilaginous emboli to spinal cord vessels, which occurred after a minor automobile accident. He was the longest-surviving patient reported with this diagnosis. He died six years and seven months after onset, having been on 24-hour ventilatory support. The pathologic diagnosis was not suspected before his death; it was made during postmortem examination

The ventilation of 25 ventilator-dependent traumatic quadriplegic patients was supported by noninvasive means of ventilatory assistance. Twenty-four of the 25 were initially managed by endotracheal intubation, and 23 of these went on to tracheostomy intermittent positive pressure ventilation before being converted to NVA. Seventeen of the 23 patients had their tracheostomies closed. This included three patients with no significant free time except with the use of glossopharyngeal breathing. Seven of the 25 patients who used NVA for at least one year with no significant free time have employed NVA for a mean of 7.4 +/- 7.4 years (1 to 22 years). Mouth IPPV was the most common form of NVA used both during the daytime and overnight. The wrap ventilators, intermittent abdominal pressure ventilator, and GPB were also employed for long-term respiratory support. It was concluded that, in general, because of their youth, intact mental status and bulbar musculature, and absence of obstructive lung disease, patients with traumatic high level spinal cord injury are candidates to benefit from these techniques

The purpose of this study was to evaluate the effectiveness of long-term tracheostomy intermittent positive pressure ventilation (TIPPV) with deflated cuffs or cuffless tracheostomy tubes for patients with neuromuscular ventilatory failure. One hundred four unweanable ventilator-dependent patients with neuromuscular ventilatory insufficiency were referred for pulmonary rehabilitation. Ninety-one of the 104 patients converted from TIPPV with an inflated cuff to either a deflated cuff (28 patients) or no cuff (63 patients). Arterial blood gas (ABG) and routine daytime monitoring of end-tidal PCo2 were performed on all patients during this transition. In addition, periodic daytime and continuous overnight oximetry were performed on 21 of these patients receiving TIPPV with deflated cuffs or cuffless tubes. Thirteen of the 21 patients also had continuous overnight end-tidal PCo2 monitoring. Despite a mean vital capacity of 17 +/- 12.3 percent and the fact that 16 of the 21 patients could tolerate only 60 minutes or less of autonomous respiration (free time), ABG, daytime SaO2 and end-tidal PCo2 were within normal limits for all 21 patients and mean overnight SaO2 was 94 percent or greater for all except one patient who used a cuffless tracheostomy tube. Six patients experienced very transient desaturations below 90 percent but no one had a maximum end-tidal PCo2 greater than 47 mm Hg. Patients with adequate pulmonary compliance and sufficient oropharyngeal muscle strength for functional swallowing and articulation are candidates for conversion to TIPPV with deflated cuffs or cuffless tracheostomy tubes despite little or no autonomous respiration

This self-directed learning module highlights advances in pulmonary rehabilitation. It is a section of the chapter on cardiovascular, pulmonary, and cancer rehabilitation for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section reviews the anatomy and physiology, pathophysiology, and clinical and laboratory findings in pulmonary disorders. Therapeutic modalities for obstructive and restrictive pulmonary disorders are discussed. Advances covered in this section include the pulmonary rehabilitation of chronic obstructive pulmonary disease patients with elevated pCO2, techniques of respiratory muscle rest, pulmonary rehabilitation of the patient with paralytic restrictive respiratory disorders, and the use of noninvasive intermittent positive-airway-pressure-assisted ventilation for long-term assisted ventilation

A treadmill training protocol was implemented to examine the effects of a 12-week exercise program on the physiologic status of a patient who had a heart transplant in 1980. The patient was tested for exercise tolerance before programming, midway through the study, and immediately upon completing endurance training. Maximal METS levels achieved were 3.2 METS, 5.6 METS, and 6.3 METS, respectively. The subject began an anaerobic program consisting of 48 exercise sessions over a three-month period. Exercise sessions were interval in nature, walking at 2.5 mph, 0% grade, three repetitions, five minutes each and increasing to 3.0 mph, 2.5% grade, two repetitions, 15 minutes each. The patient improved from Class III (METS = 3.0), where less than ordinary physical activity causes fatigue, to Class I (METS = 6.5), where ordinary physical activity can be sustained without undue fatigue. These findings suggest that selected heart transplant patients may achieve up to 85% maximum oxygen consumption and maximum heart rate which demonstrates the need for endurance training programs in this population. This form of cardiovascular conditioning has enabled the participant to engage in higher levels of activities of daily living within the community.

This is a study of the effect of nocturnal nasal intermittent positive pressure ventilation (NIPPV) on symptoms of chronic alveolar hypoventilation (CAH), sleep oxygen saturation (SaO2), and frequency of hospitalization of patients with progressive neuromuscular respiratory insufficiency or restrictive lung disease from thoracic wall deformity. The nocturnal use of NIPPV is explored in combination with other noninvasive methods of supported ventilation for daytime support as alternatives to tracheostomy and long-term tracheostomy intermittent positive pressure ventilation (TIPPV). Sixteen patients with less than 400 ml of vital capacity (VC) supine and less than 15 minutes of autonomous respiration (free time) maintained a mean SaO2 of 95.9 +/- 2.6 percent (SD) during sleep on NIPPV without added oxygen. Seventeen other patients with adequate free time for a sleep trial unaided had an average SaO2 of 81.8 +/- 11.0 percent which improved to 94.1 +/- 3.4 percent on NIPPV alone. The average length of use of NIPPV by the 42 patients who have used it for one month or more is 21 (3-67) months. All 34 patients who were not dependent on ventilatory support 24 hours a day demonstrated significant improvement and in most cases normalization of ABG when off aid. Thirteen patients were converted from IPPV via an endotracheal tube or TIPPV to NIPPV. Long-term use of a custom molded thermoplastic nasal interface for the delivery of NIPPV is reported for 17 patients. Unnecessary morbidity and hospitalizations can be avoided by early awareness and appropriate management of CAH. NIPPV can be an effective alternative to TIPPV, body ventilators, or oxygen therapy

Post-poliomyelitis patients may develop insidious respiratory failure. Chronic alveolar hypoventilation symptoms are often misdiagnosed and the condition is frequently treated inappropriately by oxygen therapy. Physicians are often at a loss to offer assisted ventilation by noninvasive methods and tracheostomy and long-term tracheostomy intermittent positive pressure ventilation is often refused. We studied the use of two noninvasive positive airway pressure alternatives for the nocturnal ventilatory support of 31 post-poliomyelitis patients. These methods were intermittent positive pressure ventilation via nasal access (NIPPV) and via a strapless oral-nasal interface (SONI IPPV). The use of custom fabricated interfaces was also evaluated. Practical alternatives for assisted daytime ventilation included glossopharyngeal breathing, the pneumobelt ventilator and mouth intermittent positive pressure ventilation. Overnight sleep monitoring was performed on 10 patients breathing autonomously or with body ventilators then repeated on NIPPV and/or SONI IPPV. The mean sleep oxygen saturation (SaO2) increased from 87.5 +/- 9.1% on unassisted breathing or body ventilators to 96.2 +/- 2.0% (P less than 0.01) on NIPPV or SONI IPPV. Of 12 other patients with a mean vital capacity of 472 +/- 480 ml and no significant free time supine, 11 patients also maintained SaO2 greater than 94% during sleep supine on NIPPV and/or SONI IPPV. Twenty-one patients have been on nocturnal NIPPV for an average of 23 (3-70) months. Six have been on nocturnal SONI IPPV for an average of 35 (5-66) months. All patients' hypoventilation symptoms were relieved. In conclusion, NIPPV and SONI IPPV can improve the nocturnal ventilation of post-poliomyelitis patients with chronic alveolar hypoventilation.(ABSTRACT TRUNCATED AT 250 WORDS)