Noninvasive Mechanical Ventilation at Home
2002; Elsevier BV; Volume: 121; Issue: 2 Linguagem: Inglês
10.1378/chest.121.2.321
ISSN1931-3543
Autores Tópico(s)Phonocardiography and Auscultation Techniques
ResumoThe modern era of mechanical ventilation began during the poliomyelitis epidemics of the mid-20th century. According to personal accounts from the late historian Gini Laurie and innovative engineer Jack Emerson, deaths from bulbar poliomyelitis inspired a dramatic global response similar to an allied army fighting a war against a merciless enemy.1Laurie G Introductory remarks.in: Faure EAF Goldberg AI What ever happened to the polio patient? Northwestern University Press, Chicago, IL1992: 37-39Google Scholar2Dickenson DD Affeldt J Emerson JH et al.Poliomyelitis equipment conference, New York, May 28–29, 1953. The National Foundation for Infantile Paralysis, New York, NY1953Google Scholar Noninvasive negative-pressure ventilation by the iron lung and other means had been the only weapons available.3Drinker F Shaw LA An apparatus for the prolonged administration of artificial ventilation.J Clin Invest. 1929; 7: 229-247Crossref PubMed Google Scholar Mounting deaths from bulbar poliomyelitis demanded another maneuver: the modern positive-pressure ventilator (Engström4Engström CG Treatment of a severe case of respiratory paralysis by the Engström Universal Respirator.BMJ. 1954; 2: 666Crossref PubMed Scopus (44) Google Scholar) and the use of positive-pressure ventilation by tracheostomy.5Kristensen HS Neukirch F Very long-term mechanical ventilation (28 years).in: Rattenborg CC Via-Requé E Clinical use of mechanical ventilation. Year Book, Chicago, IL1980: 222Google Scholar These advances led to a reduction in mortality from bulbar polio from 90 to 20%, and the era of long-term invasive positive pressure ventilation was begun.5Kristensen HS Neukirch F Very long-term mechanical ventilation (28 years).in: Rattenborg CC Via-Requé E Clinical use of mechanical ventilation. Year Book, Chicago, IL1980: 222Google Scholar Victory came because of the dedication of voluntary organizations and public awareness and support.1Laurie G Introductory remarks.in: Faure EAF Goldberg AI What ever happened to the polio patient? Northwestern University Press, Chicago, IL1992: 37-39Google Scholar In the United States, the work of the National Foundation-March of Dimes and the public made possible what would never have occurred otherwise.1Laurie G Introductory remarks.in: Faure EAF Goldberg AI What ever happened to the polio patient? Northwestern University Press, Chicago, IL1992: 37-39Google Scholar6Lewis L Memorandum to Dr. John E Affeldt, Rancho los Amigos Hospital. The Spokesman, Downey, CAAugust 1960: 2Google Scholar The definitive defeat of polio came from teamwork: the public responding to a crisis, clinicians and engineers developing innovative technologies, and interdisciplinary clinical teams—including patients—applying new techniques in dedicated respiratory-care centers building upon a foundation of combined extensive experience.1Laurie G Introductory remarks.in: Faure EAF Goldberg AI What ever happened to the polio patient? Northwestern University Press, Chicago, IL1992: 37-39Google Scholar2Dickenson DD Affeldt J Emerson JH et al.Poliomyelitis equipment conference, New York, May 28–29, 1953. The National Foundation for Infantile Paralysis, New York, NY1953Google Scholar One unexpected by-product of success was development of a population of survivors dependent upon prolonged life-sustaining technology who had no option but to remain in the hospital for an indefinite future. Doctors, therapists, engineers worked again with patients and families to find technologic and organizational solutions. According to personal accounts from CHEST 2001 Margaret Pfrommer Memorial Award Winner Augusta Alba, MD, they discovered together that noninvasive mouth positive-pressure ventilation by mouthpiece or lip-seal permitted safe noninvasive ventilation with freedom from constraints of cumbersome negative-pressure devices (iron lung, cuirass) and the risks of tracheostomy.7Alba AS Khan A Lee M Mouth IPPV for sleep.Rehabil Gaz. 1981; 24: 47-49Google Scholar8Bach JR Alba AS Saporito LR Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users.Chest. 1993; 103: 174-182Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar (Margaret Pfrommer, a noninvasive ventilator user over 40 years, innovated solutions with noninvasive ventilation with such a team.9Goldberg AI Cane RD Childress YW et al.Combined nasal intermittent positive pressure ventilation and rocking bed in chronic respiratory insufficiency: nocturnal ventilatory support of a disabled person at home.Chest. 1991; 99: 627-629Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Other post-polio survivors have had similar experiences.10Woods R Tales from inside the iron lung (and how I got out of it). University of Pennsylvania Press, Philadelphia, PA1994Crossref Google Scholar11Crowley M Called to rise: a journey through disability. Western Book/Journal Press, Reno, NV2001Google Scholar) With safety ensured, such teams continued to find an alternative to prolonged “life” in an institution for post-polio survivors: long-term mechanical ventilation at home.1Laurie G Introductory remarks.in: Faure EAF Goldberg AI What ever happened to the polio patient? Northwestern University Press, Chicago, IL1992: 37-39Google Scholar These dedicated respiratory centers then adapted techniques successfully used for patients with poliomyelitis to other conditions due to CNS-neuromuscular disorders and/or skeletal deformities. In the United States, the discovery of the poliomyelitis vaccine brought a response not unlike the declaration of peace after wartime.1Laurie G Introductory remarks.in: Faure EAF Goldberg AI What ever happened to the polio patient? Northwestern University Press, Chicago, IL1992: 37-39Google Scholar Similar to disarmament after combat with an enemy, dedicated respiratory care centers in the United States were disassembled with the exception of a those in a few public-supported institutions (Goldwater Memorial Hospital, New York, NY; Rancho los Amigos, Downey, CA; and Texas Institute for Rehabilitation and Research, Houston, TX).12Goldberg AI The regional approach to home care for life-supported persons.Chest. 1984; 86: 345-346Crossref PubMed Scopus (6) Google Scholar Professional “polio experts” then became intensive-care pioneers. Their interdisciplinary team approach evolved into the practice of critical care medicine. Similarly, international polio centers where the first Engström ventilators were used became pioneering intensive care centers: St. Thomas Hospital, London, UK; Hotel Dieu, Paris, France; and Croix-Rousse, Lyon, France.13Goldberg AI Faure EAF Home care for life-supported persons in England: the Responaut Program.Chest. 1984; 86: 910-914Crossref PubMed Scopus (15) Google Scholar14Goldberg AI Faure EAF Home care for life-supported persons in France: the Regional Association.Rehabil Lit. 1986; 47 (103): 60-63PubMed Google Scholar Critical care medicine had other roots as well: anesthesia, cardiopulmonary medicine, cardiothoracic surgery. Young clinicians who were trained there were less likely to know about the poliomyelitis experience with noninvasive ventilation and home care. As years went by, interdisciplinary teams saved more lives and, with progress in physical and rehabilitation medicine, team members enhanced their patients' functional potential. A second generation of children and adults requiring prolonged mechanical ventilation at home was created. Professionals and patients knew little about the first generation.15Goldberg AI Pediatric high-technology home care.in: Rothkopf MH Askanazi J Home intensive care. Williams and Wilkins, Baltimore, MD1992Google Scholar Discoveries in medicine can result when dedicated caring professionals working together in partnership with their patients come up with ideas that make a difference. Success comes after expiration of frustrating trials of failure, or they may be due to spontaneous inspiration. In the early 1980s, two situations in different parts of the world stimulated the rebirth of noninvasive ventilation for newer applications, as revealed by these personal accounts: In France, Professor Rideau had wanted to apply earlier mechanical ventilation to his patients in his large national practice of Duchenne muscular dystrophy. Being in Poitiers (not convenient to train or highway transportation at that time), he preferred not to use a tracheostomy. Knowing Dr. Alba's experience with “mouth positive-pressure breathing,” Professor Rideau related to me that he decided to try the noninvasive route by “placing two urinary catheters in the nose at one end, joined together by T-piece at the other end and connected to a conventional positive pressure ventilator used at home.” Spirometric evidence revealed effective ventilation.16Rideau V Detaubier A Management of respiratory neuromuscular weakness.Muscle Nerve. 1988; 11: 407-408PubMed Google Scholar In Australia, Professor Colin Sullivan, working with Nancy Ellis and others, was applying noninvasive positive airway pressure by nasal mask to patients with obstructive sleep apnea and monitoring the results with polysomnography. Nancy Ellis mentioned to me that they spontaneously added cyclical pressure that resulted in marked improvement in central control of breathing parameters for central apnea.17Ellis ER McCauley VB Mellis C et al.Treatment of alveolar hypo-ventilation in a six-year-old girl with intermittent positive ventilation through a nose mask.Am Rev Respir Dis. 1987; 136: 188-191Crossref PubMed Scopus (69) Google Scholar Both of these independent discoveries permeated rapidly through medical communities and patient networks around the world. Others18Bach JR O'Brien J Krotenberg M et al.Management of end-stage respiratory failure in Duchenne muscular dystrophy.Muscle Nerve. 1987; 10: 177-182Crossref PubMed Scopus (102) Google Scholar19Leger P Jennequin J Gerard M et al.Home positive pressure ventilation via nasal mask for patients with neuromuscular weakness or restrictive lung or chest-wall disease.Respir Care. 1989; 34: 73-79Google Scholar20Raphael J Chevret S Chastang C et al.French multi-center trial of prophylactic nasal ventilation in Duchenne muscular dystrophy.Lancet. 1994; 343: 1600-1604Abstract PubMed Scopus (249) Google Scholar21Cazolli P Oppenheimer E Home mechanical ventilation for amyotrophic lateral sclerosis: nasal compared to tracheostomy-intermittent positive pressure ventilation.J Neurol Sci. 1996; 139: 123-128Abstract Full Text PDF PubMed Scopus (170) Google Scholar22Goldstein R Hypoventilation: neuromuscular and chest wall disorders.Clin Chest Med. 1992; 13: 507-521Abstract Full Text PDF PubMed Google Scholar23Bach JR Niranjan V Weaver B Spinal muscular atrophy type 1: a noninvasive respiratory management approach.Chest. 2000; 117: 1100-1105Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar began to consider application of noninvasive ventilation and more convenient technologies and with improvement in the interfaces. It is important to note that the initial application of noninvasive positive-pressure ventilation for long-term use in the home focused on patients with hypoventilation due to neuromuscular diseases, central control of breathing disorders, and skeletal deformities. In that tradition, in the current issue of CHEST (see page 459), Nugent et al provide an excellent review of a well-documented and evaluated application of noninvasive ventilation for muscular dystrophy in their respiratory-care center. The authors are to be commended for their attention to technical and practical details, including assessment of patient clinical status before, during, and after application; patient compliance with treatment; and determination of outcomes, including quality of life. Currently, there has been a growing interest in mechanical ventilation beyond the ICU and an explosion in the use of noninvasive positive-pressure ventilation for many purposes. The “state of the art” of noninvasive ventilation and/or home mechanical ventilation has been well described in several consensus conferences convened over the years by the European Respiratory Society, the American Association of Respiratory Care, the American College of Chest Physicians, and the American Thoracic Society.24Robert D Willig TN Paulus J et al.Long-term mechanical ventilation in neuromuscular disorders: report of a consensus conference.Eur Respir J. 1993; 6: 599-606PubMed Google Scholar25Make B Bach JR Criner CG et al.ACCP Consensus Conference on mechanical ventilation outside the critical care unit.Chest. 1998; 113: 289S-344SAbstract Full Text Full Text PDF PubMed Google Scholar26American Respiratory Care Foundation Consensus conference: non-invasive positive pressure ventilation.Respir Care. 1997; 42: 364-369Google Scholar27International consensus conference in intensive care medicine: noninvasive positive pressure ventilation in acute respiratory failure.Am J Respir Crit Care Med. 2001; 163: 283-291Crossref PubMed Scopus (574) Google Scholar Regarding noninvasive positive-pressure ventilation, there have been both acute and long-term applications in many clinical settings: emergency department, acute ICUs, subacute and chronic care environments, and home and home-like alternative sites. Biannual updates from experiences around the world take place at the International Home Mechanical Ventilation (JIVD) Congress held alternatively in the United States and Lyon, France, since the late 1980s, and numerous articles and books have been written about the subject.28Robert D Make BJ Leger P et al.Home mechanical ventilation. Arnett-Blackwell, Paris, France1985Google Scholar29Long-term mechanical ventilation Lenfant C, exec ed.in: Hill N Lung biology in health and disease. vol 152. Marcel Decker, New York, NY2001Crossref Google Scholar30Hill N Noninvasive ventilation: state of the art.Am J Respir Crit Care Med. 2001; 163: 540-577Crossref Scopus (939) Google Scholar31Bach JR Pulmonary rehabilitation: the obstructive and paralytic conditions. Henley and Bellus, Philadelphia, PA1996Google Scholar32Bach JR Guide to the evaluation and management of neuromuscular disease. Henley and Bellus, Philadelphia, PA1998Google Scholar Of no surprise, the economic impact of the growth of the application of noninvasive ventilation has been significant. This was noted by public health-care finance officials, which led to convening of an invitational consensus conference on noninvasive ventilation by the National Association for Medical Direction of Respiratory Care, with a task force of experts from professional associations, governmental authorities, and industry representatives. It is essential to carefully review and recognize the conclusions of that conference to understand current practice and policy discussions.33Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD, and nocturnal hypoventilation: a consensus conference report.Chest. 1999; 116: 521-534Abstract Full Text Full Text PDF PubMed Scopus (755) Google Scholar Patients who require prolonged life-sustaining technology and their families can benefit from home care. The application of long-term noninvasive mechanical ventilation to appropriately selected patients at home can dramatically simplify the complexity of the organization of the home-care program and potentially reduce its cost. This technique is easier to learn and use, and the technology requires less professional surveillance. People who experience long-term mechanical ventilation have practical knowledge and experience to teach us.34King AJ UnMASKing the issue: a subjective review of seven masks/headgear.IVUN News Fall. 2000; 14 (8. Available at: www.post-polio.org/ivun/ivunback2.html. Accessed January 2, 2002): 1-2Google Scholar Noninvasive ventilation does represent a simpler technologic solution and requires less professional on-site care. This is more true now with innovative use of telemedicine for interactive communication to support patients and families at home.35Miyasaka K Susuki Y Sakai H et al.Interactive communication in high-technology home care: video phones for pediatric ventilatory care.Pediatrics. 1997; 99: 1e-6eCrossref PubMed Scopus (47) Google Scholar However, it is essential that appropriate candidates for home care are selected according to predetermined medical, psychosocial, environmental, technologic, organizational, and financial criteria.15Goldberg AI Pediatric high-technology home care.in: Rothkopf MH Askanazi J Home intensive care. Williams and Wilkins, Baltimore, MD1992Google Scholar Home mechanical ventilation requires a medical prescription written by a physician after an initial clinical assessment, determination of medical necessity, evaluation of the home environment, home-care documentation of plan organization and patient/family education, and continuous reassessment and evaluation of progress. Similarly, any new technology or technique requires initial technologic assessment and later reassessment.36Goldberg AI Technology assessment and support of life-sustaining devices in home care: the home care physician perspective.Chest. 1994; 105: 1448-1453Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar It is highly advisable that patients be initially evaluated and treatment implemented with experienced professionals in experienced centers. Nugent et al have demonstrated the value of this advice. Their work justifies support of efforts by others to conduct similar clinical studies that may provide broader opportunities for appropriately selected patients and families to benefit from this technique. Current and future applications of noninvasive ventilation and growth of home mechanical ventilation demand evidence-based practice built upon rigorous outcome evaluation of the clinical, patient, and family experience, and economic impact. Building on the tradition of noninvasive ventilation, health-care and engineering professionals, patients and families, and others working together can again make a difference!
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