Ventilator-Assisted Living©

Fall 2000, Vol. 14, No. 3

(continued)

Adapted from a presentation during GINI's Eighth International Post-Polio and Independent Living Conference, June 8-10, 2000, Saint Louis, Missouri

Tracheostomy or Noninvasive Ventilation?

E.A. ("Tony") Oppenheimer, MD, Los Angeles, California

Who decides whether to use non-invasive (NPPV) or tracheostomy positive pressure ventilation (TPPV) in respiratory polio survivors and individuals with other long-term neuromuscular diseases and conditions such as ALS, SMA, or muscular dystrophy? You, the individual, should have an important say, but you should collect very good information based on your clinical condition, the clinical experience and advice of your physician, the risks and benefits of each method, and your goals and quality of life issues.

Indications for tracheostomy are primarily the failure of NPPV, excessive secretions, facial trauma, or upper airway obstruction that would not allow for NPPV. NPPV may eventually fail in people with post-polio because of difficulty clearing secretions, need to use the ventilator up to 24 hours daily, discomfort with a mask constantly on your face, work of breathing difficulty, and/or a desire for more efficient and safer equipment.

Sometimes ill-informed decisions about tracheostomy are made because people (both health professional and patient) believe they will no longer be able to speak and communicate. Indeed, the loss of oral communication can occur with tracheostomy, because air cannot get up to the vocal cords to enable speech if a tracheostomy tube with an inflated cuff is used. Speech IS possible by using a deflated or cuffless tracheostomy tube, by adjusting the ventilator to obtain enough air flow for speech, or by using a cuffless tube with a Passy-Muir (P-M) Tracheostomy Speaking Valve (www.passy-muir.com).

Eating and swallowing can cause problems because tracheostomy decreases the mobility of the trachea. If the cuff is inflated, there is a pressure effect on swallowing and esophageal function, but use of a cuffless tube and the P-M valve facilitates swallowing. Taste and smell and humidification bypass the nose and upper airway with a tracheostomy tube if the tracheostomy cuff is inflated.

With NPPV, there is no incision to become infected. Infection is more common with tracheostomy due to the incision (stoma) allowing bacteria direct access to lower airways. During the first year, there is a certain amount of inflammation as the stoma goes through a healing process. Sometimes excessive proliferation (granulation tissue) accumulates inside the stoma and may need to be removed by a head and neck surgeon. To decrease the risk of infection with tracheostomy: Avoid H2 blockers, such as Tagamet. Use only clean suctioning equipment and consider using a closed suctioning system. Dry everything. Use liquid nebulizers only if necessary (metered-dose inhalers are better), avoid using wet systems that can transmit infections. Use a humidifier only if necessary; a heat-moisture exchanger may be safer.

The presence of other lung diseases may influence the choice of tracheostomy over NPPV, such as vocal cord or upper airway problems, COPD, bronchiectasis, etc. If an upper airway obstruction is making NPPV difficult, tracheostomy avoids that problem.

Respiratory care is more complicated in TPPV due to stoma care and increased secretions with tracheostomy, as well as the need for suctioning or use of assisted coughing techniques (manual or mechanical).

Assisted coughing techniques are essential in NPPV to eliminate secretions, e.g. the huff and squeeze technique; augmenting volume by glossopharyngeal (frog) breathing; manually assisted techniques, such as abdominal thrusts, percussion, postural drainage; and mechanical assist devices such as the In-Exsufflator (www.jhemerson.com).

Mobility and independence may be more complicated with tracheostomy depending on how individuals manage their equipment and supplies. Portable suctioning equipment is usually necessary. Preferred for tracheostomy use, the volume ventilator, such as the PLV®-100 (www.respironics.com), is usually heavier and involves batteries. Back-up battery operation is a standard safety and convenience function with TPPV, but not with the bi-level positive airway pressure units generally used for NPPV.

However, newer ventilators, such as the Achieva™ (www.mallinckrodt.com) and LTV™ series (www.pulmonetic.com), allow various modes, include excellent alarms, and can be used for both NPPV and TPPV. The difference between the bi-level units and the volume ventilators may become history. Unfortunately, due to the higher cost of a volume ventilator, most people may have to choose between a bi-level unit and a volume ventilator. Some people having difficulty using a bi-level unit for NPPV may do better with a volume ventilator and not need to give up on NPPV.

If used for 24 hours, NPPV can require multiple interfaces and ventilators, and safety becomes an issue. One-third of all long-term ventilator users are 24-hour ventilator users. TPPV may be better and safer for 24-hour use due to improved alarms on the volume ventilators, more secure connection with the interface, and built-in battery. The face is free, and TPPV can be more comfortable. TPPV can also provide better ventilation with more volume than NPPV and breath stacking to improve cough.

Considerations of tracheostomy instead of NPPV must involve the physiological, medical aspects, such as bulbar functions and elimination of secretions; and personal choice. If NPPV is failing, then tracheostomy is necessary. The skill of the head and neck surgeon performing the tracheotomy is important. The wishes of the patient should be based on information and not fear, as well as family support and availability of equipment and other resources.

The cost of equipment and supplies, as well as nursing or attendant care is more expensive with tracheostomy. Many people are afraid of burdening their families with home care and they fear institutionalization. In the Scandinavian countries, the choice of tracheostomy is an easier one, due to their social services system that can provide 24-hour “home helper” attendant care.

A trial of NPPV can be initiated at home, and it is easy to stop if the person no longer wishes to use it. It is a useful decision-making tool for anyone new to mechanical ventilation, and better than making a decision in a crisis situation. A trial with TPPV is obviously not possible, and stopping TPPV is more complex. Using NPPV can avoid emergency hospitalization due to sepsis, aspiration, and respiratory failure. Planning an elective hospital admission for tracheostomy also avoids a crisis situation, but it still requires a hospital stay for the procedure and training afterward. Collaborative decision-making requires good information and discussion between the individual and the physician.

The trachea (windpipe) is composed of semicircular, cartilaginous rings extending from the larynx to the bronchi of the lungs. Tracheotomy is the surgical incision into the trachea through the skin and muscles of the neck to place a tube, either plastic or metal, in the trachea at the level of the second or third ring to create an artificial airway. The incision is usually performed by a head and neck surgeon. Tracheostomy is the creation of the opening into the trachea and refers to the “stoma” or opening so created. The tracheostomy tube is a metal or plastic airway through the stoma. Some tubes have a disposable or reusable inner cannula that may be removed for cleaning. The size of the tube is based on the age, weight, and height of the individual. Depending on the preference of the physician, the tube may be either cuffed or uncuffed, and/or fenestrated. Tracheostomy in the critical care setting is generally performed when there is hemodynamic instability and/or if the patient has been intubated with an endotracheal tube for too long.

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