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Efficacy of new intermittent abdominal pressure ventilator for post-ischemic cervical myelopathy ventilatory insufficiency

  • Paolo I. Banfi
  • Eleonora VolpatoEmail author
  • John R. Bach
Open Access
Case report
  • 82 Downloads

Abstract

Non-invasive ventilation (NIV) is the treatment of choice for patients symptomatic for respiratory muscle dysfunction. It can normalize gas exchange and provide up to continuous non-invasive ventilator support (CNVS) as an alternative to intubation and tracheotomy. It is usually provided via non-invasive facial interfaces or mouthpieces, but these can be uncomfortable and uncosmetic. The intermittent abdominal pressure ventilator (IAPV) has been used for diurnal ventilatory support since 1938 but has been off the market since about 1990. Now, however, with greater emphasis on non-invasive management, a new IAPV is available. A patient with chronic ventilatory insufficiency post-ischemic cervical myelopathy, dependent on sleep NVS since 2003, developed symptomatic daytime hypercapnia for which he also used diurnal NVS via nasal pillows. However, he preferred not having to use facial interfaces. When not using diurnal NVS he was becoming dyspnoeic. Diurnal use of an IAPV was introduced. Arterial blood gas analysis using the IAPV decreased his blood pH from 7.45 to 7.42, PaCO2 from 58 to 37 mmHg, and improved PaO2 from 62 to 92 mmHg. At discharge, the patient used the IAPV 8 h/day with improved mood and quality of life. Consequently, he returned to work as a painter.

Keywords

Non-invasive ventilation (NIV) Tracheostomy mechanical ventilation (TMV) Intermittent abdominal pressure ventilator (IAPV) Quality of life (QoL) 

Abbreviations

ABG

Arterial Blood Gases

CNVS

Continuous Non-Invasive Ventilatory Support

CPAP

Continuous Positive Airway Pressure

EPAP

Expiratory Positive Air Pressure

IAPV

Intermittent Abdominal Pressure Ventilator

IPAP

Inspiratory Positive Air Pressure

NIV

Non-invasive Ventilation

NVS

Non-Invasive Ventilator Support

TMV

Tracheostomy Mechanical Ventilation

Introduction

Non-invasive ventilation or “NIV” has come to refer to continuous positive airway pressure (CPAP) or bi-level PAP used at setting inadequate for full non-invasive ventilator support (NVS). However, non-invasive positive pressure ventilation is increasingly being used for continuous NVS (CNVS) as an alternative to tracheostomy mechanical ventilation (TMV) for patients with ventilatory pump failure. Over 1000 CNVS users have been described [1, 2, 3, 4]. It improves gas exchange, symptoms [5], quality of life [6], decreases the incidence of pneumonia [7], and can be used to avert need for intubation and tracheotomy [8]. Whereas tracheostomy tends to increase ventilator dependence, detracts from quality of life, and is associated with reactive depression, NIV/NVS facilitates ventilator weaning and extubation [9, 10]. It is delivered via facial interfaces including nasal, oronasal, nasal prongs, and mouthpieces for diurnal and sleep ventilatory assistance/support [3]. However, the interfaces can cause skin discomfort and, at times, ulcerations, airway dryness and congestion and can impact negatively on quality of life and gas-exchange [11, 12, 13]. Moreover, oxyhemoglobin desaturations and dyspnea can occur with interface disconnection from NVS [11].

The LUNA DS (Dima Italia Inc., Bologna, Italy) is a portable ventilator, that along with the PBAir™ corset is an easy to use IAPV. The LUNA has an internal battery capacity that can also be used for NVS for sleep. It provides a dedicated IAPV ventilation mode. The IAPV corset is lightweight (Fig. 1), comfortable, and easy to don and fit with Velcro fasteners. Like earlier IAPVs, cyclical inflation of a rubber bladder inside the corset moves the diaphragm upwards to expel air from residual volume. This causes air to enter the lungs via the upper airway as gravity draws the diaphragm back to its resting position. The IAPV eliminates need for facial ventilation interfaces.
Fig. 1

The PBAir™ corset and air bladder of the new IAPV

The following IAPV parameters can be set: PBelt™ (pressure inside the bladder), Tinsp (real inspiratory time when the diaphragm moves down), frequency (respiratory rate), and Rise Time (time to inflate the bladder). The IAPV only works efficiently when a patient is in sitting position at an angle of 30° or greater and is optimal at 75° [14]. It optimizes cosmesis, facilitates social interaction and communication, leaves the field of vision free, and allows the patient a more normal sense of smell by eliminating facial interfaces that are colonized by often pathogenic bacteria, thereby favouring oral nutrition [15, 16].

Case report

A 51-year-old male painter with a 40 pack/years history of cigarette smoking and a diagnosis of chronic respiratory failure due to post ischemic cervical myelopathy was trained in bi-level PAP which he used up to 16 h per day since 2003 at 25 inspiratory cm H2O (IPAP) and 7 cm H2O expiratory (EPAP) pressures and rate 15/min. However, during the last year he experienced daytime dyspnoea, tachypnoea, orthopnea, and deterioration of gas exchange when not using it and complained of the interface causing discomfort and interfering with his daytime employment. His arterial blood gases (ABG) breathing unassisted in ambient air 4 h after discontinuing nocturnal bi-level PAP was PaO2 62 and PaCO2 58 mmHg. On admission, he was placed on IAPV ventilation. He wore the IAPV corset’s horizontal upper border two fingers below the costophrenic junction.

His spontaneous tidal volumes of 172–180 ml increased to 771–908 ml using the IAPV with the LUNA ventilator set at 24 cm H2O pressure, rate 15/min (Table 1). Arterial blood gases were monitored after the second hour of IAPV use. Table 2 demonstrates normalization of the diurnal breathing pattern and gas exchange. After 3 months his PaO2 breathing unassisted in ambient air was 75 and PaCO2 44 mmHg (Table 2).
Table 1

Respiratory assessment: a comparison between spontaneous breathing and the intermittent abdominal pressure ventilator

 

Spontaneous Breathing

IAPV/PBAir

 

Min

Max

Min

Max

Frequency

25.4 cpm

35.3 cpm

14.2 cpm

14.2 cpm

Inspiratory Volume

172 mL

280 mL

771 mL

908 mL

Expiratory Volume

165 mL

277 mL

791 mL

923 mL

Flow

−32.2 Llpm

+ 33.5 lpm

−61.9 lpm

+ 56.1 lpm

Table 2

Pulmonary gas exchange

 

Baseline SB

After 2 h during IAPV

1 month SB

3 months SB

Ph

7.45

7.42

7.45

7.42

PaO2

62

92

71

75

PaCO2

58

37

48

44

HCO3-/EB

31.5/4.9

28.2/1.9

27.4/2.6

25.2/0.9

ABG Arterial Blood Gas Analysis, SB Spontaneous breathing, IAPV Intermittent Abdominal Pressure Ventilation

Quality of life parameters were measured and at discharge thanks to the EuroQoL (EQ-5D) [17] and the World Health Organization Quality of Life Questionnaire (WHOQOL-Bref) [18], the patient used the IAPV 8 h/day with improved mood (assessed by the Hospital Anxiety and Depression Scale (HADS) [19]) and cognition (as assessed by the Mini Mental Status Examination [20] and the Addenbrooke’s Cognitive Examination Revised (ACE-R) [21] (Table 3). Moreover, three months later he reported that the IAPV was still effectively relieving his former daytime dyspnoea but that he had achieved up to 6 h/d of autonomous breathing without dyspnoea or tachypnea.
Table 3

Principal data of the psychological evaluation pre- and post- use of the IAPV

Psychological Evaluation

Age, years:

51

 

Profession:

Artist

 

Manual predominance:

Dx

 

Test

Admission

Discharge

Raw Score

Adjusted Score

Equivalent Score

Raw Score

Adjusted Score

Equivalent Score

Spatial orientation [20]:

5/5

  

5/5

  

Time orientation [20]:

5/5

  

5/5

  

Mini Mental State Examination (MMSE) [20]:

27

 

Non Case

29

 

Non Case

Addenbroke’s Examination (ACE-R) [21]:

86/100

84.89

3

88/100

86.89

3

EuroQoL (EQ-5D) [17]:

31211

  

21111

  

Index EQ-5D [17]:

0.3

  

0.85

  

Visual Analogue Scale (VAS EQ-5D) [17]:

60

  

100

  

World Health Organization Quality of Life Questionnaire-Bref (WHOQoL-Bref) [18]:

92

  

109

  

Physical Domain:

10.66

41.66

 

19.33

95.83

 

Psychological Domain:

20

100

 

21.6

110

 

Environment Domain:

20

100

 

20.66

104.16

 

Social Domain:

26

137.5

 

28

150

 

Hospital Anxiety and Depression Scale (HADS) [19]:

25/42

  

5/42

  

HAD-A:

11/21

 

Moderate

4/21

 

Non Case

HAD-D:

7/21

 

Non Case

1/21

 

Non Case

Discussion

C. J. McSweeney described the Bragg-Paul Pulsator, a IAPV that was used for 34 patients with acute diphtheritic respiratory muscle paralysis in 1938 [22, 23, 24]. The IAPV was perfected by Dr. Alvin Barach and his engineer William Smith in the 1940s [23]. Until the 1990s it was used in combination with NVS modalities instead of tracheostomy mechanical ventilation (TMV). However, with the treatment paradigm shift to TMV in the 1960s, the IAPV went off the market and there have been no major publications of patients using it since 1991 [22]. Now, however, with the paradigm shifting back to non-invasive management and over the last decade over 1500 750 CNVS users described [1, 2, 3, 4], the IAPV is back on the European market [12, 13, 25, 26] and consideration of this practical, convenient, and comfortable daytime ventilation alternative is warranted. IAPV use had been limited by the relative lack of portability and inconvenience of formerly available large and heavy powerful ventilators needed to operate them, and the fact that clothing could catch on the corset buckles. Use of the IAPV had also never been reported by patients with cervical myelopathies. In our patient, the IAPV improved blood gases, relieved dyspnoea, and continued to be a comfortable alternative to bi-level PAP.

Conclusion

This case of IAPV use for ventilatory assistance for a patient with a post-ischemic cervical myelopathy suggests that it can be a safe and comfortable alternative to daytime NIV and TMV leading to a better quality of life for this patient population.

Notes

Acknowledgements

We would like to thank Dima Italia S.r.l. for providing the LUNA DS device and to have performed PbAir corset.

Confidentiality of data

The authors declare that they have followed the protocols of their work centre on the publication of patient data.

Right to privacy and informed consent

The authors have obtained the written informed consent of the patient mentioned in the article. The corresponding author is in possession of this document.

Authors’ contributions

BP contributed to the study design, VE contributed to the literature search, implementation and data collection of the case report as well as to the psychological assessments. JRB supervised and revised the manuscript, including the English language. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study protocol was submitted to the Ethics Committee of the Section "IRCCS Fondazione Don Carlo Gnocchi" IRCCS Regione Lombardia. Protection of human and animal subjects. The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki). The authors have obtained the written informed consent of the patient mentioned in the article.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  1. 1.IRCCS Santa Maria Nascente, Fondazione Don Carlo GnocchiMilanItaly
  2. 2.Department of PsychologyUniversità Cattolica del Sacro CuoreMilanItaly
  3. 3.Department of Physical Medicine and RehabilitationRutgers University New Jersey Medical SchoolNewarkUSA

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