Ventilator-Assisted Living©

Winter 1999, Vol. 13, No. 4

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Sip Technology Instead of Tracheostomy

Joshua Benditt, MD

Adapted from an article in Spinal Cord Injury Update, Spring 1998. Reprinted with the permission of the Northwest Regional Spinal Cord Injury System, University of Washington, Department of Rehabilitation Medicine, Seattle WA.

An alternative for tracheostomy for full-time ventilator users is a noninvasive system that delivers air through a mouthpiece (intermittent positive pressure ventilation or IPPV) instead of a tracheostomy. This mouthpiece or "sip" intermittent positive pressure ventilation (IPPV) has been used in some European countries for several years and in this country by John R. Bach, MD, at the University of Medicine and Dentistry of New Jersey. The University of Washington is the first medical center to offer this in the Northwest.

The mouthpiece is attached to standard ventilator tubing and positioned close to the face by a bracket on the wheelchair or bed frame. The individual turns toward the mouthpiece and grabs it with the lips, which triggers the ventilator to send a breath. (To avoid orthodontic problems that can develop with long-term use, some people have a custom acrylic mouthpiece made for them by a dentist.)

In order for people to use the sip IPPV, they must be able to breathe on their own for at least one to two hours in case of an emergency and they must be very motivated. While an individual with a tracheostomy does not have to think about breathing, the sip system requires the person to be conscious of every breath.

People who choose the sip IPPV system need to use an alternate system while sleeping, usually a nasal mask. Indeed, the transition to noninvasive ventilation from the trach begins with nasal ventilation at night with the trach temporarily plugged. It can take a while for people to become accustomed to the feeling of having air pushed through the nose and still be able to sleep.

Once the individual can tolerate the night-time mask, the ventilator settings for day-time use are adjusted. The person is taught how to trigger a breath (using the mouthpiece), and the ventilator is set to be very sensitive to the point at which the person wants to take a breath. Comfort is very important for compliance. Too much air makes people feel light-headed, while too little can lead to panic or a sense of impending doom. Pulse oximeters and blood gas tests that monitor the oxygen saturation level of the arterial blood are used to measure how well someone is being ventilated. When the individual is properly ventilated noninvasively, the stoma is allowed to close and heal.

Javier Perez, C2 quad with a tracheostomy since 1990, spent two weeks in our hospital, practicing with sip IPPV, gradually increasing the time he spent using it. In between the practice sessions, Perez continued to receive ventilation through his trach. By discharge, Perez could use the sip technique continuously for 5-6 hours during the day, switching to nasal positive pressure ventilation for 7-8 hours during the night.

Cold weather, a chronic stuffy nose, and other health problems caused setbacks for Perez after he returned home, but he preferred the benefits of full-time noninvasive ventilation in reducing his risk of infection and in breathing air filtered through his mouth and nose. With the trach, he had been bothered by smoky or polluted air, but without the trach, he noticed the difference in the purer air.

The biggest challenge is integrating sip IPPV with activities of daily living such as eating, speaking, and driving a chin-controlled chair. "It is hard work for the individual. If you and I have a bad day, we can still breathe. If the patient has a bad day, he might not have enough stamina to breathe," according to respiratory therapist Marilyn Hilsen. However, noninvasive ventilation can have significant health and quality of life benefits and is a desirable alternative for certain people.

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