regimen of noninvasive ventilatory support ...

Intermittent abdominal pressure ventilator in a regimen of noninvasive ventilatory support. J R Bach and A S Alba Chest 1991;99;630-636 DOI 10.1378/chest.99.3.630 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/99/3/630

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Intermittent Abdominal Pressure Ventilator in a Regimen of Noninvasive Ventilatory Support* John

R. Bach,

M.D.;t

and

Augusta

S. Mba,

M.D4

The purpose of this work is to present 640 patient-years of experience using the intermittent abdominal pressure yentilator (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. Thirtyeight 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 SaO, monitoring that demonstrated a mean Sa02 of 95 percent or greater

T first

he prototype intermittent abdominal pressure ventilator (IAPV), the Bragg-Paul Pulsator, was described

apparatus

by .

.

.

C.

consists

J.

McSweeney’

in

1938.

of a distensible

“The

rubber

bag

applied around the patient’s chest in the form of a belt, this belt being rhythmically filled with, and emptied of, air. The rate of compression can be modified to suit the respiratory rate of the patient.” This was successfully used in treating 34 patients with acute diphtheritic modern IAPV,2 Lafayette,

CO)

Boulder, *From

respiratory the Exsuffiation

CO), the

or

Pneumobelt

consists

Department

muscle belt

The mc,

(Puritan-Bennett

of an elastic of Physical

paralysis. (Lifecare

Medicine

Inc,

inflatable and

bladder

Rehabilitation,

University Hospital, The New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark (Dr. Bach); and the Department ofRehabilitation Medicine, Goldwater Memorial Hospital, New York University, Roosevelt Island, NY. tAssistant Professor of Physical Medicine and Rehabilitation. tAssociate Clinical Professor of Physical Medicine and Rehabilitation.

This work was supported by the Department of Education Crants and Contracts Service RED: Innovation Grant C008720331. This work was performed on patients referred to University Hospital, Newark, NJ, and Goldwater Memorial Hospital, Rousevelt Island, NY. Manuscript received October 25, 1989; revision accepted July 11. Reprint requests: Dt Bach, University of Medicine and Dentistry

ofNJ,

630

Newark

07103

and a minimum Sa02 tidal Pco2 was 49 mm 48 patients receiving

endThe 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 ineffe#{233}tivefor 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 insufliciency. Its use is optimized when employed in combination with other noninvasive methods ofventilatory 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. (Chest 1991; 99:630-36)

=

GPB

glossopharyngeal

sopharyngeal mittent dominal

breathing;

maximum

positive pressure

single

pressure ventilator;

GPmaxSBC

breath

glosinterab-

capacity;

IPPV IAPV intermittent saturation

ventilation; SaO4oxygen

within an abdominal corset worn beneath outer clothing. The bladder compresses when cyclically inflated by a positive

incorporated

the the

of 86 percent. The maximum Hg during sleep on the JAPY.

patient’s abdomen

pressure ventilator. The abdominal contents then move the diaphragm upwards causing a forced exsufflation. With bladder deflation, the abdominal contents and diaphragm fall to the resting position as a result of gravity and inspiration occurs passively. Since the passive inspiration that to return the diaphragm position,

a trunk

follows is dependent to its prebladder

angle

of

3O

or

on gravity insuffiation

more

from

the

horizontal is necessary for adequate tidal volumes to occur.2 If the patient has any inspiratory capacity or is capable ofeffective glossopharyngeal breathing (GPB), he can add his autonomous tidal inspiration. There have been numerous long-term

use

of negative

volume

to the

publications

pressure

body

passive on

the

ventilators

such as the Iron Lung and Chest Shell Ventilator (Lifecare Inc, Lafayette, CO; Emerson Co, Cambridge, MA). However, there have been only scattered reports on the use of the IAPV, and then for only a few patients. There has been one publication concerning tomies.7

its use in a large patient series We report its use in a regimen Noninvasive

Wnthatory


with tracheosof noninvasive Support

(Bach, Alba)

ventilatory

support

by

54

patients

without

up

tracheos-

to 22 breaths

patient PATIENTS

The

maximum

assisted

ventilation

lime.8

The to

back

with

patients

with

24-hour

vital

both

with

and maximum were

the

four

studies,

of CPB. breath

five

an

ventilatory

equivalent

both

on the IAPV

unassisted

breathing,

were

also

and,

obtained

time

inability

for

each VC a 9-L

IAPV

Brain-

free

14,

England). rate,

volume, when

the

9-L

support

during

None

A trial

of IAPV

restrictive time,

who

who

use

little

sufficient

swallow,

and

indicated

clear

oral

had

severe

who

refused

tracheostomy,

secretions.

Although

oropharyngeal was

exsufflation

device’#{176}” to prevent

No

with underwent

The

240

patients

45 Duchenne

myopathy;

ventilatory

assistance

ventilate were

on noninvasive

mouth

IPPV,

breaths

insafficiency had

become

ventilator patients

who

ostomy

sites

despite

need

had

Once

IAPV GPB

two

an IAPV from IPPV

the

and

delivering

daytime

IAPV

trials

IPPV’’6

They placed

When

his

either for

time,

their

res-

their

free

every

breath All

had

was

of

their

these trache-

to the

aid.

on

taking

that

optimal.

IAPV,

No patient

introduction

months. after

One

her return

never

tried

were

to

or

used during

to Nigeria.

the

up to 2,500-mI

marginally Four too

Eighteen mouth

IPPV

patients

209 ofthese All

31

only

continues

anticipated

ofdaytime

of portable

who

of an IAPV. patient

hours

to continue

patient

Seven

IPPV, support.

wished

one

aid.

mouth

did

who

mouth

to use

much

IPPV

the

ambulatory required

not

Chest

and

did

aid

for less

difficulty

using

patients

went

to 24 hours

quickly

and

volumes

pressure or pressures

ventilators to 60 cm

capable H,O,

the

monitoring turned when the

yearly

was

any need

IAPV

IAPV

for

home

per-

to modify off to assess the

patient

end-tidal

Pco

nocturnal

sleep

free

performed

time.

saturation with

has

been

in nocturnal ventilatory not

end-

demon-

ventilation

for

assistance.’8’’

in gauging

for patients

monitoring.

Oxygen

polysomnography

useful

ventilatory

SaO,

in conjunction

improvements

be

secretions

by chest

by use

ofa

the adequacy requiring

were

therapy,

mechanical

of and

209 patients

IAPV,

31 continued

than hours

2 h and chose ofdaily

This of nocturnal

supplemental

oxy-

managed

during

vigorous

manual

forced

exsufflation

respiratory

assisted

coughing,

device.’#{176}”

The

support lack

who to have

were

evaluated

periods

offree

to use mouth IPPV’’ despite a successful

of continuous

need

using time

the

greater

for up to 20 trial on the

for assisted

venti-

lation made mouth IPPV preferable to donning and using the IAPV. The remaining 178 patients used ventilatory aid 24 hours a day with less than 1 h of free time. Eleven patients with no free IAPV but preferred

time had successful to use mouth IPPV

during the day. shell ventilator

Of 11 other for daytime

the one

2.3

IAPV after has continued

± 1.8 daytime

tidal globin

PCO2

scoliosis

13 had scoliosis the

elevation

on the GPB

and/or

such patients using a chest support, ten switched to

the

178 patients failed to support by the IAPV as less than 200 ml IAPV persistent dyspnea, end-

(>45

mm

Hg),

Of

these

112

desaturation.

trials

years on the chest shell and chest shell use for 34 years.

One hundred twelve of achieve adequate ventilatory documented by generally augmented tidal volumes,

severe

of mouth

IAPV volume

often

IAPV.

until

to introduction

ventilatory

encumbrance

six to eight

A variety

of

except

for daytime want

than

mastered

trials

undergo

of

to

or were

point

of ventilatory

time

of

learned

IAPV.

having

underwent

the

breaths

became prior

non-

12 hours

support.

tracheostomies

cases

25,

use.

in

adequate

and

RESULTS

polio;

alternated

no free

use

indwelling

at

by mouth

to the

With

IAPV

injury;

successfully

unassisted

progressed

for up to 24 hours

ofthe

all

for ventilatory

in some

oxygen

his use

and/or

had

closed,

supplemental

not

and

indwelling

than

characteristically

negligible.

assisted

cord

via tracheostomy

with

had

and

(94,

greater

hours

IPPV

patients

forced secretions.

the

noninvasive

tract

tract infections

or

the may

and

deformity,

successful

and

Hg,

therapy.’ Pulmonary

who

the

signfficant

and/or

assistance

Of the

spinal

They

aids”

these

ventilator-assisted

31,

daytime

from

alone

expul-

and

hypoventilation

required

day.

during

of food osteotomy

alveolar

others)

and

had or when

reflect

technique

gen

using

patients

receiving

mm lung

used

to determine

continuous

monitoring

to

to his

45 of hypoventilation)

at pressures

50 cm H20 and volumes greater than optimal IAPV pressures

six

the

while

in favor of continuous mouth years of successful IAPV use.

IAPV pressures

volumes

ml on the

of

All

years 11.9

exhibited a decreased IAPV pressures. For

and

sole

mean

use

13 to 72 years).

to use it at age 50.7 had to abandon IAPV

H2O

pressure

lie supine.

speech

cases, however, did this significantly supplemental inspiratory volumes, and

tidal

years IAPV

for nocturnal ventilatory support for six months. former switched to nocturnal nasal IPPV so that

only The

±

to

(range,

ineffective for symptoms

14.5 13.8

patients’

began

years

continue patients

±

of the

patients

discontinuing IPPV, IAPV

IPPV to mouth or to preventing leak from

tracheostomy

patients

for daytime (one week

she

tracheostomy was paid

patients Twelve

48.2 after

rhythm

15.8

±

become intervening

by the use of body ventilators16a1, for 30 patients (ten, chest shell; eight, pulmowrap; five, rocking bed; six, IAPV; one, iron lung) and noninvasive intermittent positive airway pressure ventilation for 17 patients (16, mouth IPPV; one, nasal IPP.8.115.17 When switching from nocturnal nasal IPPV, attention

and

IAPV The 54

supple-

ml by the

VC attained before bladder

the

One assistance

greater

than 1,900 ml. also frequently

other after

patient

than Greater caused

was

weaned IAPV

six months

of

polio patient with oropharyngeal switched to tracheostomy IPPV

muscle during an

episode of pneumonia and three patients (two with amyotrophic lateral sclerosis, one with muscular dystrophy) switched because of severe oropharyngeal muscle weakness after 29, 18, 6 and 1 years of IAPV use,

respectively. Eleven patients

mean

of9.3

died

4.4

±

years

while

causes of death were lung lion, sepsis from decubitus, drug

abuse,

unknown

mortality IAPV use

figures compare

comparable

cluded has

the

cases),

in more favorably

patient

patient

because other

switches

regularly

of food patients,

on the abdominal motility.

difficulties

whose

whom

to IPPV

while

catching

Ventilatory


One

during

on the

the

IAPV

use.

no difficulty

on

the

meals

IAPV. eating

The while

the rhythmic by increasing corset

buckles,

which was once a problem, has been resolved newly designed IAPV girdles with straps and closures. The use of Velcro closures also make Noninvasive

in-

survival

use

to mouth

have

of in

treatment

daytime

IAPV and some believe that compression aids in digestion Clothing

(two

inadequate bed. These

three-year

during

regurgitation however,

infarcaccident,

pneumonia

been cited at 60 to 75 percent.’ The 26 patients who continue few

a

The

than 640 patient-years with mortality figures

populations

for

after use.

myocardial vehicle

on mouth IPPV, and support on a rocking

tracheostomy

reported

IAPV

2 to 22 years)

cancer, motor

(two

cases), seizures while nocturnal ventilatory

using

(range,

Support

by the Velcro tight-

(Bach,

Nb.)

ening

or loosening

and pressure the abdominal and

the

belt

easier

for position

modification. The muscles by helping

to pass

flatus.

By glottic

to the

changes

IAPV substitutes for the patient to belch

closure

just

prior

to an

abdominal compression, the IAPV also assists the patient in clearing secretions. Two of the five patients on 24-hour IAPV use, however, had development of sacral

decubiti

fatal

with

complications

in one

case.

et al noted

per minute He stated rate greater

average

of 50 cm

H2O.

Our

per minute and pressures correlate better with the that are pressures

IAPV

with routine pressures that no patient was than 16. Alexander

pressures

and

only

one

rates

of 12 to 14

ofSO to 60 cm H20. safely ventilated at a et al also noted using mean

rate

of 42. 1 recommendations

for rates of 16 to 28 breaths less than 45 cm H20. Hill,

leaks active

were relatively difficult in their wheelchairs.

were

also

impeded

forward in their there is extensive

for

of 17.3 4.6

±

2.8

±

cm H20 of Hill

per minute and however, stated

for

daytime

been

aid.

reported

lation,8”7’9 requiring and

inconvenience

continuous lator tubing, for one

sion

to conveniently

VC, were successfully ventilated two years or more . The reasons

the

previous

ports

did

authors not

pressures with unclear; however,

those prior

and

are

indicate

used. Although we effective in patients

by the for the

the

size

of the

found the with severe

IAPV

IAPV to scoliosis,

of re-

patient

girdles

be rarely four such

fear of accidental during tracheostomy IAPV

and

patients

were

patients were adequately ventilated by it for greater than four years with scoliosis exceeding 75#{176}. Since its effectiveness may decrease with time and loss of

ventilated phrenic

pulmonary

master GPB off ventilatory

yearly. Our in

that

compliance,

its use

experience

agreed

patients

with

with

severe

adjusted well to and were the IAPV while patients failure erally

should previous

tracheostomies

Patients

who

had

respiratory

had

a mouth

30-

to 60-minute

periods

offree

time

generally

the

greater

the

need

for and

use

time

hours and of an IAPV. of free

time

but maintained to supplement with less than

assisted

by mouth IPPV. The less the free the preference for the IAPV over

and genwithout

2 h of free

than

6 to 16 daytime encumbrance

used their ventilators 24 hours a day normal ventilation without the need every breath by mouth IPPV. Patients 30 minutes

insufficiency

time, mouth

each

breath

the greater IPPV, and

of GPB.

11 switched

to daytime

mouth

IPPV

and

ten

switched

that of the

was

failure

or

IAPV

of IAPV tube. The

tube disconnection eliminated when

easier

and

louder.

or

on

All of his

dependent

on

34 ofour patients all were effectively to tracheostomy or absence of tracheos-

patients

to

increase freeing VC

sufficiently

their them

disconnection.

measurable

adjacent the

the advantages tracheostomy

19 of these

for

excur-

fixed

for whom

without resorting pacemakers. The

no

neck

piece

and

need

who

free time of the fear

Indeed,

one

been

using

has

an IAPV for daytime aid since 1962 and a chest shell for overnight aid for 25 years experienced sudden equipment failure during sleep on two occasions and awoke GPB before he realized that his ventilator was no longer functioning. Since the IAPV girdle is placed under the and unlike

patient’s the use

for mouth

stick

patient’s

rent

GPB.

outer clothing, of mouth IPPV,

activities.

not,

however,

risk

of developing not

be used

supplements

the

it is ideal for concurthat, when effective,

for 24-hour

sacral

permit

the

aid because

decubiti

comfort

and and

the

fact

physiologic

of reclining.

ACKNOWLEDGMENTS: R.R.T

is inconspicuous, it frees the patient

it

preferred method oflong-term noninassistance in the sitting position. It

should

effects

IAPV

volumes and It is for these reasons

of the

it does

The

tidal

own

the IAPV is the vasive mechanical

that

Other than the IAPV, the only body ventilator that can be used for daytime ventilatory assistance while sitting is the chest shell. Of our 22 patients who have used this ventilator for long-term daytime assistance,

IPPV

to significanfly support, thus

with

the

tracheostomized

of ventilator

has venti-

nose to ventifor daytime aid

insufficient

tracheostomy IPPV was

permitted

patient

ventilated by respiratory

difficulties7 IPPV. Patients

greater

used mouth IPPV its use over the with

suggestions

successfully with minimal

had greater adjustment preferred daytime mouth

generally preferred

he reevaluated

tomy

IPPV

nocturnal

accompanies

stimulation. Although 10 mm of free time,

nerve

we its use

nasal

assist

who

speech

phrenic nerve had less than

to lean Although use of this

assistance,’6’2” recommending

grab

Miller et al reported included plugging

the

needed

function. on the

of the patient’s found it useful

measurable IAPV for

rates

who

although

that

attachment we have

only

his

one report was it used for patients aid.8 Because of the poor cosmesis

use

our

patients

Likewise,

in only 24-hour

to use

the chest shell and pressure

to prevent for patients Activities of daily living

to successfully

to the mouth for mouth was not effective.

in

continues

chairs for optimal medical literature

that the IAPV was ineffective for patients with severe respiratory failure. Fifteen of our patients with VCs of 100 ml or less, including ten patients with no

differences

patient

for daytime aid. In all cases, to be relatively cumbersome

device for nocturnal ventilatory are not aware of any literature

DIsCussIoN Miller

IAPV,

chest shell was found

,

and

Ira Holland

The

authors

for their

wish

assistance

to thank with

this

Lou

Saporito,

work.

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with

Exsufllation

for patients or chest-wall

1312

Scm 1953;

1987; 23:99-113 14

Mayer

experience

Cough

mask lung

Bruderer during

via nasal

CM . Home

MO

Am

22

care.

226:24148 12

CR,

1979;

methods

Purtable CJ,

Assoc

alveolar 97:52-7

J,

Askanazi

St Louis,

AL,

1990;

& Wilkins

Cof-flator

Industries

ofchronic

Chest F. Alternative

In Rothkopf

Baltimore:

11

A. Management

by nasal

9 Bach

Kerby

twelve

1987; 135:148-52

Dis

Prosthodont

high

VIP,

positive-pressure

Respir

interfaces

HJ, Thomas

8 Bach

Bye

ventilation

70:707-11

via nasal

or restrictive

failure

disease,

in Duchenne syndrome:

34:73-9

respiratory

B, Cilmartin

ventilator

management

postpoliomyelitis

Arch Phys Med Rehabil 1989; 70:180-85 J, Gerard M, RObert D. Home positive

ventilation weakness

Ventilator

and

P. Jennequin

cular

60:289-92

5 Make

Leger

Mechanical

Duchenne

AR

experience.

pressure

73:1206-07

4 Alexander

Colbert dystrophy

years’

169:153-57

M.

FJ,

muscular

spinal

Harrison

GM,

cord

and injury.

Paraple-

RE,

Jefferson

Carter

ventilation:

twenty

of body

ventilators.

Corn-

median-

years’

experi-

84:376-82

applications

Chest

1986;

90:897-905

1987; 91:859-64

Nonivashe

4bntatory


Support

(Bach, Nb.)

Intermittent abdominal pressure ventilator in a regimen of noninvasive ventilatory support. J R Bach and A S Alba Chest 1991;99; 630-636 DOI 10.1378/chest.99.3.630 This information is current as of July 10, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/99/3/630 Cited Bys This article has been cited by 10 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/99/3/630#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
