intermittent ab- dominal pressure ventilator;. SaO4oxygen saturation. T he prototype intermittent abdominal pressure ventilator. (IAPV), the. Bragg-Paul. Pulsator,.
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
Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1991by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians
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
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians
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
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians
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.
REFERENCES 1 McSweeney
CJ. The
Bragg-Paul
CHEST
pulsator
in treatment
I 99 I 3 I MARCH,
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1991 American College of Chest Physicians
of respi-
1991
635
ratory
paralysis.
2 Adamson pressure
Lewis
L,
for artificial
3 Alberion
C,
1973;
J
Br Med
JP,
1938;
1:1206-07
Stein
JD.
respiration.
Mba
A,
Lee
16 Curran
Application
JAMA
MH,
of
1959;
Solomon
abdominal
NY
J
State
Med
17
MA,
Johnson
ventilation
of
dystrophy:
management
1979;
EW,
patients
J, Stauch
Petty
with
late
in the
stage
home.
D.
muscular
Care
1989;
Arch
Phys
Ellis
ER,
Med
Behabil
18
M,
dependent
Brady
JS,
subjects
Snider
with
CL.
lung
Rehabilitation
disease.
of
Chest
1984;
for sleep
in the
86:358-65 6 Yang
19
CW,
Alba
A, Lee
user:
clinical
ventilator 1989;
Rev
M,
Khan
A. Pneumobelt
7 Miller
Arch
experience.
Phys
Med
Rehabil
20
quadriplegic
E, Wilmot
population.
CB.
Arch
Pneumobelt
Phys
Med
use
Rehabil
among 1988;
69:369-
21
72 tion
JR.
Mba
JR.
port.
ventilation.
Beltrame
10 The
MM,
Williams
OEM
Inc,
Barach expiratory
Beck flow
Transactions
rates
hypoventila-
eds.
of ventilatory Home
sup-
intensive
(in press)
13
Bickerman
HA,
Arch
Intern
Bach
JR,
Machine.
Shampamne 23
Smith
RH.
surpassing
Itkin
Med
Mechanical
the capacity
Phys, S.
1954;
Mba
AS,
Clossopharyngeal agement
May
1953.
production
ofhuman
J
Am
of
coughing.
Med
24
negative
pressure.
Bach end
JR. stage
Muscle 15
E, and
Curran
FJ,
non-invasive
respiratory
Schultheiss aids
insufficiency.
M.
in the Birth
Bach postpolio
636
respiratory
JR.
Alba
Krotenberg failure
1987;
10:177-82
AS,
Bohatiuk
positive respiratory
R,
Mba
in Duchenne
pressure
25
man-
I, Bach
C,
Saporito Chest
for
L, in the
Lee
M.
JR.
1989;
Respir
CE.
Treatment
with
of
neuromuscular a nose
mask.
Am
Rev
Parker
Nocturnal Respir
C, Sortor
positive
positive
pressure
1987; 135:738-40
Dis
S. Custom-fabricated
pressure
mt
ventilation.
j
2:224-33
of
dystrophy:
management
Johnson
EW,
patients
J,
Petty
with
late
in the
Stauch
stage
Arch
home.
Mechanical muscular
D.
Duchenne Phys
Med
Behabil
60:289-92
Splaingard
ML,
Med
Rehabil
Segall
D.
ratory
failure
Frates
RC,
Jefferson
negative
pressure
in patients
with
LS,
ventilation:
Rosen
CL,
report
of 20 years
neuromuscular
disease.
mask-assisted
ventilation
Harrison Arch
of
Phys
1985; 66:239-42
Noninvasive
nasal
of
Duchenne
Cuilleminault
C,
Stoohs
von
P. Central
Wichert
muscular
of
26
Mouth
27 of
R,
dystrophy.
in respi-
1988;
Donovan
study
Chest WH,
support
gia 1987;
25:86-91
Splaingard
ML,
LS.
positive-pressure
Hill
Home Chest NS.
1989;
93:1298-
1983;
Clinical
Podszus
Frates
Peter
and
JH,
sleep:
ventilation
through
L, Wilkerson
nerve
MA.
stimulation
in traumatic RC,
T,
96:1210-14
Halstead
ofelectrophrenic
ventilatory
H,
hypoventilation
positive-pressure
in an adult.
RE,
Schneider
alveolar
by intermittent mask
Carter ical
dystrophy.
management
neuromus-
disease.
through
5K.
Am
intermittent
MA,
parative
Defects
Management
muscular
with
Sullivan
in patients
Pingleton mask.
ventilation
ence. ventilation
insufficiency.
AS.
JW,
sleep
ventilation
IS,
Alexander
nasal
Bodofsky
J,
O’Brien
Nerve
intermittent
McDermott
treatment
93:698-704
breathing
of post-polio
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
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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.
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