Postpolio patients receiving nocturnal ventilation may develop respiratory muscle fatigue in the daytime. Treatment should then also include respiratory assistance during the daytime in order to minimize respiratory muscle fatigue. For mobility, this requires an external battery to operate the ventilator and can be adapted to a wheelchair or cart mount. For daytime use, often a mouth hook or mouthpiece are more practical. flovent inhaler
In some of these patients, the symptoms frequently attributable to the “postpolio syndrome” were linked to the sleep breathing abnormalities because the symptoms regressed when nocturnal ventilation was improved. It is thus reasonable to perform a sleep study on patients with poliomyelitis whose symptomatology is unexplained and whose daytime features suggest the development of abnormalities in respiration during sleep and subsequent poor sleep quality. Continue reading
In all cases, the patients far preferred nasal ventilation to rocking beds in part because of the psychosocial aspects and the mobility afforded by the portable ventilator.
Our experience in being able to nasally ventilate postpolio patients is similar to findings recently reported by other centers. In most patients using nasal mask ventilation, there are several practical aspects to consider for successful long-term ventilation. First, there may be leaks in the system, particularly through the mouth during the inspiratory phase initiated by the mechanical ventilator. Leak compensation is best achieved by increasing tidal volumes and pressure limiting these volumes. Continue reading
Sleep quality may be very poor in postpolio patients and the poor sleep quality may be related to abnormal breathing during sleep. Because of the effect of polio on respiratory control and respiratory function, the variability in these results was not unexpected. Somewhat unexpected was the fact that several of the patients who were receiving mechanical ventilatory assistance (rocking beds) were clearly not being optimally treated. In two patients on rocking beds, there was paradoxic rib cage abdominal breathing. In two patients, there was the desynchronization of respirations with the patient attempting a breath between breaths generated by the bed, at times leading to upper airway obstruction likely secondary to desynchronization between the patients upper airway and the rocking bed. The fact that they had been apparently stable for so long led to a false impression of the stability of their ventilatory status. buy ortho tri-cyclen
Complications: While receiving mechanical ventilation, mask leaks or leaks through the mouth were present in all the patients. The mechanical ventilator was set to deliver a much greater volume (Table 4) than the patient actually received. The goal was to increase the machine-delivered volume until that actually delivered to the patient was about 10 ml/kg. One of the patients required a chin strap. All the patients were given two masks to take home. One of the patients who had had a carcinoma of the skin removed in the area of his nose had irritation when he first started on nasal ventilation and required the evaluation of several different nasal masks and oral/ nasal masks before the system was adequate. Two patients had traumatic accidents with fractures and required nasal mask ventilation continuously for several days. These patients had a breakdown of the soft tissue on the bridge of the nose by the nasal mask as it was not rotated with any regularity by nursing staff in acute care facilities. These areas healed with time and the introduction of alternate mouth and nasal masks which changed pressure points. Buy Asthma Inhalers Online Continue reading
It is likely that there was significant hypoventilation secondary to the vocal cord paralysis with increased resistance in the larynx in these patients. Both patients had excessive daytime sleepiness. These patients were started on nasal CPAP with improvement of their symptoms. Both patients had dysphagia and complained of stridor with exercise.
Of the remaining two patients, one (No. 12) had symptoms of morning headaches, nausea, vomiting, excessive daytime sleepiness, ankle edema, and fatigue. Studies demonstrated mixed apnea that was severe in REM sleep. This patient was started on nasal CPAP with a slight reduction in the number of episodes. The headaches were ameliorated, but she refused long-term treatment. Continue reading
These patients were then evaluated on the mechanical ventilator, without rocking bed, and again there was a wide variability in response. All but one patient showed a dramatic improvement in their sleep quality and gas exchange. In one patient (No. 1), even though there was improvement in gas exchange, sleep quality did not improve. Continue reading
Group I Patients
Patients on rocking beds had consistently poor quality sleep with a lower than normal TST and an increased number of arousals and stage 1 sleep (Table 2). Differing degrees of respiratory abnormality were apparent during sleep. In some cases, there was a desynchronization of respirations with the patient attempting a breath between breaths generated by the bed to intermittent hypoventilation (Fig 3) which occurred throughout the night. In two patients (1 and 2), there were paradoxic respirations during NREM sleep as well as when the patients were awake. Significant oxygen desaturations occurred in all patients (Table 3). Continue reading
The 13 patients (Table 1) with a mean number of years since polio onset of 39.6 years ±5.8 SD were studied. Group 1, (36.6±0.4 SD years since onset of polio), had all required ventilatory support at the initial onset of polio in the form of a tank respirator for an average of 9.3 months (range 1.5 to 18 months) prior to attempted weaning. Patients 3 and 4 could not be weaned and required the rocking bed only for nocturnal support but otherwise breathed spontaneously while sitting up. The remaining patients were weaned completely for an average of 8.6 years (range ten to 168 months) after which they were started on rocking beds at night. At the time of the study, all the patients were using nocturnal respiratory assistance for a mean of 10.7 hours per day (range ten to 14 hours) (Fig 2). All of the patients had subjective complaints of respiratory or sleep problems.
There were 39.4 ± 7.3 years since the onset of polio in the eight group 2 patients. Continue reading
Details of CPAP and Mechanical Ventilation Application
The patients who demonstrated obstructive sleep apnea, mixed apnea, or hypoventilation syndrome were first tried on nasal CPAP with an appropriately fitting nasal mask. The CPAP was started at 5 cmll20 at night while polysomnography was being done. The CPAP was titrated in increments of 2.5 cmll20 pressure in order to determine a proper level and the efficacy of the treatment. Those who were treated were followed up in four to six months with night polysomnography to ensure continuing effectiveness of treatment and a clinical evaluation of patients general condition. Continue reading
The following definitions were used to classify breathing patterns and arousals: apnea was defined as the absence of airflow for more than 10 seconds. In central apnea, respiratory effort was absent, whereas in obstructive apnea, respiratory efforts continued. Hy-popnea was defined as a reduction the amplitude of respiratory movement for more than 10 seconds to less than 50 percent of the maximum thoracoabdominal amplitude during the breathing cycle. Paradoxic respirations were defined as out of phase chest and abdominal wall movement as indicated by inductance plethysmography. An arousal was defined as an awakening from sleep for >5 seconds as shown by alpha activity on the EEG, EMG activation, and eye movements which occurred simultaneously. The apnea hypopnea index is the number of apneas and hypopneas per hour of total sleep time. Continue reading