Ventilator-Assisted Living©

Summer 2004, Vol. 18, No. 2


Preparing for a Respiratory Emergency

Louie Boitano, MS, RRT, Northwest Assistive Breathing Center, Pulmonary Clinic, University of Washington, Seattle

People with respiratory muscle weakness due to a neuromuscular disease or condition that limits their breathing are at risk for respiratory infection.

They may go to a hospital emergency room (ER) with shortness of breath due to either infection or lung congestion caused by the inability to cough and clear increased mucus associated with a respiratory infection. Yet, their underlying respiratory problems may go unrecognized and they may not receive the appropriate respiratory support.

On initial evaluation in the ER, the symptoms may be associated with a primary lung disease, such as COPD. Although a lower respiratory tract infection is certainly a primary lung problem, congestion can result from inadequate cough strength to clear the increased secretions associated with the infection.

Respiratory health professionals who have considerable experience working with neuromuscular patients know that frequent and timely manual and/or mechanical cough augmentation therapy, supported by noninvasive ventilation, is key to relieving pulmonary congestion.

Healthcare providers unfamiliar with neuromuscular respiratory muscle weakness and cough augmentation therapy may provide supplemental oxygen, and use chest physiotherapy alone to clear pulmonary secretions.

Providing oxygen therapy without ventilatory support may depress the respiratory drive to breathe, causing a dangerous increase in blood carbon dioxide levels that can lead to acute respiratory failure and even death.

The use of noninvasive ventilation with incorrect or inadequate bilevel positive airway pressures may also fail to provide the emergency support necessary to relieve shortness of breath associated with lung congestion.

Any delay in providing the correct and timely therapy may result in acute respiratory failure and the potential for assisted mechanical ventilation by invasive means such as intubation (the placement of a breathing tube down the throat).

This use of invasive mechanical ventilation may be necessary for short-term interim support, but the transition back to noninvasive ventilation can occur after acute respiratory failure is resolved.

People with respiratory muscle weakness due to neuromuscular disease should practice good self-management and pulmonary hygiene, and make preparations for a possible ER visit in order to decrease the potential for inappropriate or inadequate medical intervention. Good self-management means being aware of the symptoms of developing respiratory infection and possible complications.

Early intervention is essential in minimizing the impact of an infection. Individuals should contact their pulmonary physician to determine whether antibiotic therapy is necessary, and they should increase cough augmentation therapy to relieve congestion and shortness of breath. These measures will help avoid hospitalization.

Having a good understanding of one's medical condition and respiratory support needs is important, but the best contingency plan is to have:

This is vital information. Indicating the types of respiratory support equipment without specific setting information may either delay urgently needed support in the ER or result in inadequate support. Individuals and/or their caregivers/attendants should carry this medical information at all times in order to immediately inform medical staff of the specific condition and the appropriate respiratory therapy in case an ER visit is necessary.

Medical Alert cards can detail an individual's specific neuromuscular condition, medications, allergies, physician information, and a photo. An ER directive that alerts medical staff about how to care for neuromuscular patients with respiratory insufficiency should also be readily on hand. Both are available at

Wearing a medical identification bracelet or medallion (American Medical Identification, Inc., Houston TX,, 800-363-5985) can also be beneficial in alerting medical staff to one's diagnosis, respiratory status, and respiratory support needs.

Norma Braun, MD, St. Luke's-Roosevelt Hospital, New York City, suggests, "When and where possible take your equipment with you to the ER so that there will be no need to use the wrong piece of equipment with the wrong settings. The hospital may not have the type of equipment you use, and a substitute is difficult to adjust to, making anxiety worse, and delaying appropriate therapy. Your equipment may need to be adjusted only during the ER situation."

Letter to the Editor

We noted with interest the sidebar entitled "Talking with Tracheostomy Ventilation" in Ventilator-Assisted Living, Vol. 17, No. 4, Winter 2004. We heartily endorse Dr. Oppenheimer's reassurance that people will be able to speak with cuff deflation (or use of a cuffless tube) when tracheostomized.

But we would like to add that there are simple adjustments to ventilator settings that offer attractive alternatives to a one-way valve (such as a Passy-Muir valve). These include lengthening inspiratory time and applying 5 to 10 cm H2O of positive end-expiratory pressure when using volume-controlled ventilation.

The advantages of such adjustments are that they can produce speech that is just as good as the one-way valve, but with greater safety and at a lower cost. Another way to improve speech with invasive ventilation is the use of bilevel positive pressure ventilation; however, this form of ventilation is only approved for in-hospital use in the United States.

Jeannette Hoit, PhD, CCC-SLP, and Robert Banzett, PhD
Department of Speech and Hearing Sciences
University of Arizona, Tucson

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