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Eur Respir J 2007; 30:180-181
Copyright ©ERS Journals Ltd 2007

From the authors

F. Lofaso1,2, D. Orlikowski1 and J-C. Raphael1

1 Intensive Care Unit and Dept of Physiology-Functional Testing and Centre for Technological Innovation, Raymond Poincaré Teaching Hospital, Garches, and 2 Inserm UMR 651, Créteil, France.

We would like to thank J.R. Bach and co-workers for their interest in our editorial. While we note their comments, our experience based on more than 500 neuromuscular patients, 60% of whom are receiving long-term noninvasive mechanical ventilation (NIMV) with manually and mechanically assisted coughing techniques 1 and 40% of whom are tracheostomised, differs from theirs.

NIMV is not always tolerated and does not avoid some severe complications, including acute respiratory failure followed by death, as observed by Toussaint et al. 2 despite their undoubted competency in the field.

Our intensive care unit experience allowed us to demystify tracheostomy and to reduce tracheostomy complications. It probably explains why some patients, when asked, considered tracheostomy as a more secure ventilator interface when they had no respiratory reserve, poor tolerance of the different NIMV interfaces and/or the risk of severe complications in nonmedical settings, in particular at home. These points concur with the recent American Thoracic Society consensus 3 mentioned in the letter by J.R. Bach and co-workers. Moreover, we note that when acute respiratory failure is not present tracheostomy can be performed under local anaesthesia while the patient is undergoing noninvasive ventilation 4.

In contrast with the comments of J.R. Bach and co-workers, we believe that respiratory autonomy was better after tracheostomy, probably due to the reduction of dead space and work of breathing as we demonstrated 5. Furthermore, we use the less resistive phonation valve 6 and try to avoid the suppression of respiratory effort in order to prevent an additional worsening of inspiratory muscle strength 7 by virtue of ventilator-induced diaphragm dysfunction. In addition, we observed improved speech after tracheostomy. This is probably due to our competency in adjusting the ventilator parameters in order to allow patients to speak 8.

The study of swallowing performance did not demonstrate a negative effect of tracheostomy 9. Moreover, we are currently testing swallowing performances before and after tracheostomy and our first results in three patients suggest that invasive mechanical ventilation may improve swallowing efficacy (unpublished data). Furthermore, invasive ventilation does not limit the use of electrically powered wheelchairs 10.

Markström et al. 11 observed a better quality of life in tracheostomised neuromuscular patients. However, this is contested by Bach 12. In accordance with Markström et al. 11, and although our tracheostomised Duchenne muscular dystrophy (DMD) patients were more severe than our DMD patients under NIMV, quality of life was similar in both groups 13. We trained families to perform airway suctioning and to change tracheostomy in order to allow them to face anxiety over airway occlusion.

Therefore, in these conditions, tracheostomy may avoid, rather than facilitate, institutionalisation for some patients and we consider that it is dangerous to state that there is no indication that tracheostomy is effective in DMD patients. Each case has to be considered on its merits, without any dogma.

We would like to thank the editors for allowing us to extend this important debate about tracheostomy in neuromuscular patients which underlines that the team’s experience and expertise is an important determinant of the choice of the time to switch to tracheostomy.

REFERENCES

  1. Trebbia G, Lacombe M, Fermanian C, et al. Cough determinants in patients with neuromuscular disease. Respir Physiol Neurobiol 2005;146:291–300.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  2. Toussaint M, Steens M, Wasteels G, Soudon P. Diurnal ventilation via mouthpiece: survival in end-stage Duchenne patients. Eur Respir J 2006;28:549–555.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  3. American Thoracic Society/European Respiratory Society. ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med 2002;166:518–624.[Free Full Text]
  4. Orlikowski D, Prigent H, Gonzalez-Bermejo J, et al. Noninvasive ventilation as alternative to endotracheal intubation for tracheostomy in advanced neuromuscular disease. Respir Care 2007 (in revision)
  5. Chadda K, Louis B, Benaissa L, et al. Physiological effects of decannulation in tracheostomized patients. Intensive Care Med 2002;28:1761–1767.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  6. Prigent H, Orlikowski D, Blumen MB, et al. Characteristics of tracheostomy phonation valves. Eur Respir J 2006;27:992–996.[Abstract/Free Full Text]
  7. Vassilakopoulos T, Petrof BJ. Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 2004;169:336–341.[Free Full Text]
  8. Prigent H, Samuel C, Louis B, et al. Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. Am J Respir Crit Care Med 2003;167:114–119.[Abstract/Free Full Text]
  9. Terzi N, Orlikowski D, Aegerter P, et al. Breathing–swallowing interaction in neuromuscular patients: a physiological evaluation. Am J Respir Crit Care Med 2007;175:269–276.[Abstract/Free Full Text]
  10. Pellegrini N, Guillon B, Prigent H, et al. Optimization of power wheelchair control for patients with severe Duchenne muscular dystrophy. Neuromuscul Disord 2004;14:297–300.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  11. Markström A, Sundell K, Lysdahl M, Andersson G, Schedin U, Klang B. Quality-of-life evaluation of patients with neuromuscular and skeletal diseases treated with noninvasive and invasive home mechanical ventilation. Chest 2002;122:1695–1700.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  12. Bach JR. Noninvasive ventilation is more than mask ventilation. Chest 2003;123:2156–2157.[CrossRef][Medline] [Order article via Infotrieve]
  13. Raphael JC, Dazord A, Jaillard P, et al. Indices de satisfaction des patients atteints d’une dystrophie musculaire de Duchenne de Boulogne et ventilés à domicile. [Assessment of quality of life for home ventilated patients with Duchenne muscular dystrophy.]. Rev Neurol (Paris) 2002;158:453–460.[Medline] [Order article via Infotrieve]




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