Ventilator-Assisted Living©

Spring 2004, Vol. 18, No. 1

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Mouth Intermittent Positive Pressure Ventilation: An old technique revisited for a “sip” of fresh air

Miguel R. Gonçalves, PT, and João Carlos Winck, MD, PhD, Rehabilitation and Lung Function Unit, Pneumology Department, Hospital São João, Faculdade de Medicina-Porto, Portugal

The use of mouth intermittent positive pressure ventilation (M-IPPV) was first reported in 1969, although its use had begun over a decade earlier during the polio epidemics when iron lungs were opened to permit nursing care of the patient’s body. Patients received ventilation by positive pressure with a mouthpiece used for pulmonary function testing. These patients often had no breathing tolerance and were encouraged to leave their iron lungs during the day and to use other alternatives like chest shells or intermittent abdominal pressure ventilation (pneumobelt). But M-IPPV was described as the most important method of daytime ventilatory support.1 With the increasing availability of portable ventilators, the use of M-IPPV also increased.

During M-IPPV, air is delivered to the individual via tubing or a circuit attached to a simple angled mouthpiece (Respironics, Inc.) held in the mouth or just near it.

A mouthpiece is an inexpensive interface that requires no specialized fitting or maintenance. M-IPPV is ideal for seated individuals — a metal clamp attached to the wheelchair can be used to hold the circuit in place so that the person can easily grab the mouthpiece with his or her mouth. (It is also refer-red to as “sip” intermittent positive pressure ventilation.) For optimal use of M-IPPV, the individual must have sufficient neck rotation and oral motor and soft palate functions. Leakage must be prevented; in rare cases, nostril plugging is necessary.

Generally the ventilator is set for large tidal volumes, often 1000–2000 ml. The person, according to the physician’s instructions, can vary the ventilator parameters (tidal volume and breath rate) to vary speech volume and cough flows as well as to practice air stacking for full expansion of the lungs. The low-pressure alarms of volume-cycled ventilators often cannot be turned off. To prevent alarm sounding during the day when the individual does not need every delivered volume, the angle of the mouthpiece creates adequate back pressure to prevent low-pressure alarm sounding. A humidifier can also be used for this effect.2

Although M-IPPV has been demonstrated to be ideal for 24-hour support, it has not gained widespread use. Individuals can learn to sleep with the mouthpiece without it falling out of the mouth. Nocturnal use can be accomplished with a lipseal (Puritan Bennett) or a wider gauge mouthpiece that prevents air leakage through the mouth. Some-times customized dental appliances are required for better comfort. The recent introduction of the Oracle™, an oral interface designed for CPAP delivery with no need for headgear (Fisher & Paykel), may become popular for nocturnal M-IPPV.

Side effects of M-IPPV may include excessive salivation, abdominal distension and, in long-term users, mild orthodontic deformities. The former two, although initially a source of discomfort, generally improve and almost never constitute reason to discontinue M-IPPV.3

Based on the work of John R. Bach, MD, and his team (Center for Ventilator Management Alternatives, University of Medicine and Dentistry of New Jersey, USA, www.doctorbach.com), we have also been using M-IPPV as a technique for extubation and tracheostomy tube removal for patients with neuromuscular diseases (mainly spinal cord injury and ALS) and as first-line intervention during ventilatory failure caused by respiratory tract infections in ALS.

With this protocol, patients with un-measurable lung function recover ventilatory autonomy using M-IPPV during the day and “high-span” bilevel positive airway pressure (BiPAP) during sleep. Moreover, in a sub-group of our ventilator users (>16 hours), M-IPPV has provided optimal ventilation without the need for invasive intervention, particularly when combined with airway secretion clearance techniques, both manually assisted cough and mechanically assisted cough with the CoughAssist™ (J.H. Emerson Co.).

References

1. Bach, J.R. & Lee, H.J. (1993). New therapeutic techniques and strategies in pulmonary rehabilitation. Yonsei Medical Journal, 34(3), 201-211.

2. Bach, J.R. Alba, A.S. & Saporito, L.R. (1993). Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users. Chest, 103(1), 174-182.

3. Bach, J.R. et al. (1987). Mouth intermittent positive pressure ventilation in the management of post-polio respiratory insufficiency. Chest, 91(6), 859-864.


Photo of Pedro Miguel Silva using noninvasive ventilation.“I feel much better since I have been switched to M-IPPV. I had been using nasal high-span bilevel nasal ventilation for the past four years, and I felt that I needed more ventilatory support during the day. Using M-IPPV with the PV 501 (BREAS Medical AB) was the best solution to ventilate my lungs during the day. Thanks to this technique I can take deep breaths whenever I want and that allows me to speak better and even achieve good coughs. I was taught to air stack several times a day, and now I can even lie down with no kind of shortness of breath. It’s really very good!”

Pedro Miguel Silva, 29, who has Duchenne muscular dystrophy, uses long-term noninvasive ventilation at home.

“I love my ‘blower pipe!’ It feels very good to take some deep breaths whenever I want to, and then leave it and try to breathe on my own. Thanks to this technique I am able to speak clearer and cough harder. I was very frightened with the possibility of a tracheostomy tube, but thanks to M-IPPV and other respiratory muscle aids (manual and assisted cough plus nasal bilevel ventilation overnight) that will never happen. The improvements on my respiratory symptoms are amazing.”

Elsa Cristina, 22, who has a C3/C4 spinal cord injury, recovered from acute respiratory failure using noninvasive respiratory muscle aids.

Photo of man using Nippy“When I came to the ER feeling breathless, I saw death in front of my eyes! I never thought it could be so simple to ventilate my lungs with such a small device. After a couple of days I can hear my voice and feel like I am breathing again.”

Manuel Correia, 58, who has nonbulbar ALS, started M-IPPV during hospital admission due to acute respiratory failure.

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