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Biomedical subjects

J R Bach

Publications and source records attributed to J R Bach.

At least 19 recordsLinked to original sources
PubMed1992

Spinal epidural abscess complicating vertebral osteomyelitis: an insidious cause of deteriorating spinal cord function.

Spinal epidural abscess may complicate vertebral osteomyelitis. The purpose of this report is to discuss its course in two patients with sensory/motor and cognitive impairment and to demonstrate the need for its early detection. Delayed detection may lead to spinal cord injury or meningitis. It may also delay functional return and hinder intensive rehabilitation efforts. Two patients are presented.

Abscess↗
PubMed1992

Walker modification for ventilator-assisted individuals. Case report.

A case is presented of a 53-yr-old ambulatory ventilator-dependent individual who demonstrated that functional ambulation could be possible with a modified rolling walker. The patient used intermittent positive pressure ventilation delivered by noninvasive methods 24 h a day. For potentially ambulatory ventilator users, intensive rehabilitation and the use of a modified walker can improve medical, psychological and social status and permit the resumption of vocational activities. Mouth intermittent positive pressure ventilation is the method of choice for daytime ventilatory support during ambulation for individuals with severe chronic alveolar hypoventilation because of predominantly restrictive pulmonary syndromes.

Activities of Daily Living↗
PubMed1992

The ventilator-assisted individual. Cost analysis of institutionalization vs rehabilitation and in-home management.

The purpose of this article is to present a cost analysis of in-home vs institutionalization for severely physically disabled ventilator-assisted individuals (VAIs). Following rehabilitation and adaptation to noninvasive methods of ventilatory support, 30 VAIs were maintained in the community for 12.9 +/- 1.1 years with personal care attendants organized by a home care vendor reimbursed by New York City Medicaid. The program permitted self-directed severely disabled clients, including these 30 exclusively nontracheostomized VAIs, to live in the community and direct their attendant care and personal affairs. Prior to discharge home, the 30 patients resided in the respiratory unit of a long-term care facility for a mean of 8.9 +/- 10.1 years. The unit is currently reimbursed at a mean rate of $718.80 per patient per day. The current mean total cost of maintaining these VAIs in the community is $235.13 +/- 56.73 per patient per day. The conversion to and/or maintenance on 24-h nontracheostomy ventilatory support permitted discharge to the community by allowing the VAI to be attended by trained but uncredentialed home care attendants, thus avoiding prohibitively expensive in-home nursing for tracheostomy care. This created a savings to the public of 77 percent or $176,137 per year per client. We conclude that conversion to and/or use of noninvasive methods of ventilatory aid can be a reasonable and cost-saving goal. More respiratory rehabilitation centers are needed to free up hospital beds and facilitate discharge of VAIs to the community. There is also evidence that trained attendants should be permitted to suction tracheostomized VAIs in the home.

Costs and Cost Analysis↗
PubMed1992

Psychosocial adjustment of post-poliomyelitis ventilator assisted individuals.

The effect of severe disability, tracheostomy, and ventilator use on psychosocial functioning, gainful employment, life satisfaction, and perceived well-being were studied for a population of 395 ventilator assisted post-poliomyelitis individuals (PVAIs). Standard psychosocial survey instruments and other general questioning were used. Two-hundred-seventy-three physically intact health care professionals served as controls. They were surveyed about their own life satisfaction and perceived well-being and were asked to judge how severely disabled ventilator assisted individuals would respond to such questioning. The relative distress associated with ventilator use was also evaluated in a similar manner. Fifty six of 380 responding PVAIs (14.7%) expressed dissatisfaction with their lives in general. This compares with 8.5% of the controls and 7% of a previously studied general population. The controls significantly underestimated the patients' life satisfaction and well-being scores and significantly overestimated the relative hardship associated with ventilator use. The post-polio individuals using noninvasive methods of assisted ventilation were also significantly more satisfied with their lives than were those ventilated via tracheostomy. Fifty-seven of 148 (39%) individuals married and 165 of 395 (42%) individuals were gainfully employed during long-term ventilator use. We conclude that many severely disabled post-poliomyelitis ventilator users lead productive lives. The vast majority have a positive affect and are satisfied with life. Noninvasive ventilatory support alternatives may lend to greater life satisfaction for these individuals than ventilation delivered via an indwelling tracheostomy. Health care professionals may significantly underestimate their patients' satisfaction with life and this may have a bearing on patient management.

Adult↗
PubMed1992

Ventilator use by muscular dystrophy association patients.

Two hundred seventy-three Muscular Dystrophy Association (MDA) clinic directors and codirectors of 167 of the 220 clinics responded to a survey designed to study patterns of use of mechanical ventilation. Ventilatory assistance was recommended and used on an elective basis in 43 of the 167 clinics. In 68 clinics, the policy was to discourage its use, and 62 clinics were managing no ventilator users at the time of the survey. The most common reason given for discouraging ventilator use was poor patient quality of life. Only two physicians who discouraged use of mechanical ventilation were familiar with newly described methods of noninvasive ventilatory aid. The clinic directors were also asked to estimate the satisfaction with life of Duchenne muscular dystrophy (DMD) ventilator users. Eighty DMD ventilator users also responded to a separate and identical life satisfaction survey. The clinic directors significantly underestimated the users' reported life satisfaction. The directors who discouraged ventilator use more significantly underestimated the users' life satisfaction than those who recommended it. We conclude that the MDA clinic directors' estimation of ventilator users' quality of life and satisfaction with life is positively correlated with the likelihood of their discussing and recommending ventilator use to prolong life. Despite the wider recognition and availability of more convenient noninvasive methods of ventilatory assistance, the use of mechanical ventilation by MDA clinics has not changed significantly since 1985.

Adult↗
PubMed1991

Electrophrenic ventilation: a different perspective.

Since 1972, radio-frequency electrophrenic nerve pacing (EPP) has been an option for assisting the ventilation of patients with chronic paralytic respiratory insufficiency. Most of the medical literature has been favorable regarding its continued application. We reviewed the literature to determine how "successful" application of EPP was defined. Our studies indicated that long-term follow-up of EPP patients has been generally inadequate with little emphasis placed on incidence and severity of complications. There was no standardization in defining successful experiences with EPP. Upper airway instability during pacing, lack of internal pacemaker alarms, and the risk of sudden pacemaker failure necessitate permanent tracheostomy in the great majority of patients but complications of the presence of a tracheostomy were not considered in evaluating the desirability of EPP. Some EPP patients became independent of any ventilatory support thus benefiting minimally from the time commitment, effort, and extreme expense needed for EPP placement and training. We conclude that EPP is a valid option for the properly screened patient but that expense, failure rate, morbidity and mortality remain excessive and that alternative methods of ventilatory support should be explored.

Diaphragm↗
PubMed1991

Alternative methods of ventilatory support for the patient with ventilatory failure due to spinal cord injury.

Ventilatory insufficiency and impaired airway secretion clearance are common complications of spinal cord injury (SCI) and can lead to respiratory failure which is the leading cause of death in both the acute and chronic stages. Standard invasive management options such as intubation, tracheostomy and electrophrenic respiration have been reviewed. The review findings are consistent with our clinical experience in that these invasive options appear to entail unacceptably high morbidity and risks of mortality. A number of detailed parameters are suggested for evaluating the respiratory functioning of the individual in order to determine the most acceptable and successful noninvasive systems for both ventilatory support and evacuation of airway secretions. They are physiological substitutes for the action of the inspiratory and expiratory muscles. These techniques are described in detail. We conclude that noninvasive techniques can safely and effectively obviate the need for intubation, tracheostomy and electrophrenic pacemakers in appropriate individuals with SCI.

Humans↗
PubMed1991

New approaches in the rehabilitation of the traumatic high level quadriplegic.

The use of noninvasive alternatives to tracheostomy for ventilatory support have been described in the patient management of various neuromuscular disorders. The use of these techniques for patients with traumatic high level quadriplegia, however, is hampered by the resort to tracheostomy in the acute hospital setting. Twenty traumatic high level quadriplegic patients on intermittent positive pressure ventilation (IPPV) via tracheostomy with little or no ability for unassisted breathing were converted to noninvasive ventilatory support methods and had their tracheostomy sites closed. Four additional patients were ventilated by noninvasive methods without tracheostomy. These methods included the use of body ventilators and the noninvasive intermittent positive airway pressure alternatives of IPPV via the mouth, nose, or custom acrylic strapless oral-nasal interface (SONI). Overnight end-tidal pCO2 studies and monitoring of oxyhemoglobin saturation (SaO2) were used to adjust ventilator volumes and to document effective ventilation during sleep. No significant complications have resulted from the use of these methods over a period of 45 patient-years. Elimination of the tracheostomy permitted significant free time by glossopharyngeal breathing for four patients, two of whom had no measurable vital capacity. We conclude that noninvasive ventilatory support alternatives can be effective and deserve further study in this patient population.

Adolescent↗
PubMed1991

Life satisfaction of individuals with Duchenne muscular dystrophy using long-term mechanical ventilatory support.

The Life Domain Satisfaction Measures and Semantic Differential Scale of General Affect are instruments designed by Campbell to measure perceived well-being. They were used to survey 82 ventilator-assisted individuals with Duchenne muscular dystrophy (DMD) and 273 physically intact health care professionals. A third instrument was devised to study the relative undesirability of dependence on mechanical ventilation. Ten of 80 responding patients (12.5%) expressed dissatisfaction with their lives in general. This compares with 9% of the surveyed health care professionals and 7% of the general population studied by Campbell. The health care professionals significantly underestimated the patients' scores in the life satisfaction and general affect instruments and significantly overestimated the patients' assessment of the relative hardship associated with ventilator dependence. We conclude that the vast majority of severely disabled chronic ventilator-assisted individuals with DMD have a positive affect and are satisfied with life despite the physical dependence which precludes many of the activities most commonly associated with perceived quality of life for physically intact individuals. Health care professionals should not use their judgment of the patient's quality of life to justify withholding life-sustaining therapy.

Adolescent↗
PubMed1991

Delayed presentation of a carotid-cavernous sinus fistula in a patient with traumatic brain injury.

Carotid-cavernous sinus fistulas are rare complications of traumatic brain injury, facial trauma and postorthognathic surgery. A high level of clinical suspicion is necessary, particularly for patients who are unable to communicate, to establish the diagnosis. A case of delayed presentation of a carotid-cavernous sinus fistula after traumatic brain injury is presented. This case illustrates that early recognition of this disorder is crucial to prevent significant morbidity.

Adult↗
PubMed1991

Intermittent abdominal pressure ventilator in a regimen of noninvasive ventilatory support.

The purpose of this work is to present 640 patient-years of experience using the intermittent abdominal pressure ventilator (IAPV) in a regimen of noninvasive ventilatory support for patients with paralytic/restrictive respiratory insufficiency. Fifty-two of the 54 patients who used the IAPV used 24-hour noninvasive ventilatory support. Thirty-eight of the 52 patients could tolerate less than 15 minutes of free time off their ventilators except by the successful use of glossopharyngeal breathing (GPB). No patient, however, retained an indwelling tracheostomy and none required or used supplemental oxygen therapy. Forty-eight of the 54 patients used the IAPV for daytime support for a mean of 12.9 +/- 11.5 years (3 months to 39 years) while using other forms of noninvasive support overnight. All 48 patients maintained normal minute ventilation and end-tidal PCO2 on the IAPV. One patient used the IAPV only for nocturnal ventilatory support for six months. Five patients relied on the IAPV as their sole method of ventilatory support 24 hours a day for a mean of 13.4 +/- 11.2 years (range, 2 to 31 years). Three of these five patients had no free time and were studied by nocturnal SaO2 monitoring that demonstrated a mean SaO2 of 95 percent or greater and a minimum SaO2 of 86 percent. The maximum end-tidal PCO2 was 49 mm Hg during sleep on the IAPV. The 48 patients receiving daytime IAPV support reported few difficulties. However, two of the five patients using the IAPV 24 hours a day had development of sacral decubiti. The IAPV became ineffective for 12 patients after 12.3 +/- 9.5 years of use. These patients then switched to daytime mouth IPPV. We conclude that the IAPV is a safe and effective method of long-term daytime ventilatory support for patients with paralytic/restrictive respiratory insufficiency. Its use is optimized when employed in combination with other noninvasive methods of ventilatory support, thus eliminating the need for tracheostomy, and optimizing the use of GPB. Regular follow-up is important because the IAPV can become less effective with time.

Abdomen↗
PubMed1991

Obstructive sleep apnea complicating negative-pressure ventilatory support in patients with chronic paralytic/restrictive ventilatory dysfunction.

The purpose of this study was to determine the incidence and severity of obstructive events and oxyhemoglobin desaturation (dSaO2) in 37 patients with paralytic/restrictive ventilatory insufficiency during use of nocturnal ventilatory assistance provided by means of negative-pressure body ventilators (BVs). Thirteen of the 37 patients had mean oxyhemoglobin saturation (SaO2) less than 95 percent and a mean of ten or more episodes per hour when the dSaO2 was greater than or equal to 4 percent (4%dSaO2/h). In all, 26 of the 37 patients had evidence of significant multiple episodes of dSaO2 while asleep on BVs. Polysomnography performed on three of these patients substantiated the obstructive nature of the dSaO2. Twenty-two of the 37 patients who had a mean SaO2 of 90.6 +/- 7.2 percent and a mean of 17.7 +/- 16.1 4%dSaO2/h on BVs were switched to noninvasive ventilatory assistance by intermittent positive airway pressure (NV-PAP). Their mean SaO2 improved to 96.0 +/- 2.2 percent, and the 4%dSaO2/h decreased to 1.2 +/- 1.8 per hour. All symptoms similar to those of obstructive sleep apnea were relieved. We conclude that BV use is associated with significant dSaO2 in over 50 percent of patients. The dSaO2 is predominantly obstructive in nature but may be due to chronic underventilation in patients using less effective BVs. Patients with a mean SaO2 less than 95 percent or 10 or more 4%dSaO2/h may benefit from conversion to NV-PAP via the nose, the mouth, or an oral-nasal interface.

Chronic Disease↗
PubMed1991

Orthopedic surgery and rehabilitation for the prolongation of brace-free ambulation of patients with Duchenne muscular dystrophy.

The purpose of this study was to prospectively evaluate the results of a short comprehensive program involving early lower extremity musculotendinous surgery followed by a definitive course of rehabilitation on contractures and the duration of ambulation for patients with Duchenne muscular dystrophy. Seven patients were treated while ambulating with little difficulty and six were treated just before or after becoming wheelchair-dependent. Predicted post-treatment duration of ambulation was calculated from established clinical criteria. Actual prolongation of brace-free ambulation after treatment was a mean of 0.8 yr greater than predicted for the group as a whole but 0.93 yr for the group treated early by comparison with 0.63 yr for those treated according to the customary approach. The number of falls significantly decreased from 84 +/- 87 to 1 +/- 1 per month postoperatively (P less than 0.05); however, the speed of ambulation over a distance of 10 yards decreased from 10.2 +/- 4 s to 12.1 +/- 7.3 s. Three patients who had tibialis posterior transfers retained antigravity plus dorsiflexor strength and continue to wear normal footwear 2.5, 3.7 and 4.0 yr after loss of ambulation. We conclude that ambulation becomes more stable and brace-free ambulation may be prolonged by a comprehensive program of early orthopedic surgery and rehabilitation. Earlier intervention is also better tolerated.

Adolescent↗
PubMed1991

Ventilatory support alternatives to tracheostomy and intubation: current status of the application of this technology.

Intermittent positive pressure ventilation (IPPV) via tracheostomy has been the most common method of providing long-term ventilatory support since the late 1950s. Likewise, intubation for the delivery of IPPV is standard treatment for acute ventilatory failure. Because of poor patient acceptance of elective tracheostomy, numerous reports of complications by these invasive methods, and the recent development of noninvasive ventilatory assistance by intermittent positive airway pressure (NV-PAP), there has been increasing interest in all forms of noninvasive ventilatory support. This report reviews the current application of noninvasive ventilatory support alternatives in both the acute and long-term settings. Assistive technology for the noninvasive evacuation of airway secretions, which facilitates up to 24-hour, long-term noninvasive ventilatory support is also discussed. We conclude that wider familiarity with and application of these techniques are warranted.

Humans↗
PubMed1990

Fibrocartilaginous emboli to the spinal cord: a review of the literature.

Fibrocartilaginous emboli to spinal cord vessels is an apparently rare cause of spinal cord injury. A review of the medical literature reveals only 24 reported cases, none of which were noted prior to 1961. The authors have reviewed an additional, but as yet unpublished, case. The majority of patients presented with the acute onset of pain located around the vertebral column which was followed by progressive paresis/paralysis and respiratory insufficiency. Minor trauma to the vertebrae prior to onset was noted in most cases. The time to maximum neurologic deficit (typically paraplegia or quadriplegia) ranged from minutes to 24 to 48 hours. In all but one case the spinal cord injury resulted in death within 11 months of onset with a median of 2.5 to 4 months. One patient lived six years and seven months with respiratory support. In yet another case, a fibrocartilaginous embolus to a sacral nerve root was found as an incidental finding at autopsy. The incidence of both asymptomatic and clinically significant emboli may be more common and depends on the awareness of the medical community to consider this in the differential diagnosis of spinal cord injury.

Cartilage↗