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Biomedical subjects

J R Bach

Publications and source records attributed to J R Bach.

At least 73 records · Page 4Linked to original sources
PubMed1994

Normalization of blood carbon dioxide levels by transition from conventional ventilatory support to noninvasive inspiratory aids.

Chronic hypocapnia seems to be common in long-term ventilator assisted individuals (VAIs) with paralytic/restrictive respiratory conditions. It has predominantly been reported for VAIs using intermittent positive pressure ventilation (IPPV) delivered via tracheostomy tubes. Chronic hypocapnia decreases ventilator-free breathing time (VFBT) and may be associated with increased bone resorption. Attempts to reverse chronic hypocapnia by decreasing minute ventilation and providing supplemental carbon dioxide have failed because of air hunger and patient resistance. We maintained normocapnia in 22 24-hour-a-day VAIs by using noninvasive IPPV. Chronic hypocapnia was corrected in three VAIs and hypercapnia in two VAIs by switching from conventional ventilatory support to the use of noninvasive inspiratory muscle aids. The other 17 VAIs remained normocapneic by being managed by noninvasive ventilatory support from onset of ventilatory failure. Eleven of these VAIs had been intubated or tracheostomized for brief periods but were successfully returned to noninvasive support. We conclude that alveolar ventilation can be maintained within normal range for VAIs who use noninvasive IPPV and can be normalized by transition from conventional tracheostomy IPPV to noninvasive IPPV.

Adolescent↗
PubMed1994

Life satisfaction and well-being measures in ventilator assisted individuals with traumatic tetraplegia.

This study evaluates the effect of complete traumatic tetraplegia on the life satisfaction and well-being of 87 individuals, 42 of whom are ventilator supported, 2 years or more postinjury. Standard psychosocial instruments were used. The relative distress comparing ventilator dependence with loss of extremity function was also evaluated. The ventilator assisted individuals with tetraplegia (VAITs) were significantly more satisfied with their housing, family life, and employment when applicable, than were the autonomously breathing individuals with tetraplegia (ABITs). The VAITs' life satisfaction and other well-being and quality of life indicators were generally positive, and were significantly underestimated by a control group of health care professionals. Only 23.8% of the VAITs expressed general dissatisfaction with their lives compared with 35.6% of the ABITs. The ABITs and the control group significantly overestimated the distress which the VAITs associated with ventilator use by comparison with loss of upper extremity function. We conclude that long-term life satisfaction and well-being are considered to be positive by the majority of both ABITs and VAITs, are at least as high in the latter as in the former, correlate best with family and social interaction, and are severely underestimated for both ABITs and VAITs by health care professionals.

Adult↗
PubMed1994

Ethical considerations in the management of individuals with severe neuromuscular disorders.

There have been many recent advances in improving the quality of life and prolonging life for individuals with advanced neuromuscular disease. These include the use of physical medicine techniques to balance extremity muscle strength and improve range of motion and noninvasive techniques to provide inspiratory and expiratory muscle assistance to prolong life without resort to tracheostomy. Such advances help eliminate the "crisis" decision making about "going on a respirator" and sophisticated assistive equipment and robotic aids. Physicians and society in general use quality of life issues inappropriately derived by questioning physically able individuals to justify withholding or implementing life-sustaining therapeutic interventions for these individuals. Informed decisions about ethically and financially complex matters such as long-term ventilator use should be made by examining the life satisfaction of competent individuals who have already chosen these options. The great majority of severely disabled ventilator-assisted individuals with neuromuscular disease are satisfied with their lives despite the inability to achieve many of the "usual" goals associated with quality of life in the physically able population. Their principle life satisfaction derives from social relationships, the reorganization of goals and from their immediate environment. Although the Americans with Disabilities Act is seen as an important step to prevent discrimination against disabled individuals, it does little or nothing for the self-directed disabled individual who is not informed by his/her physicians regarding potentially vital therapeutic options nor does it help those who are warehoused in institutions because of lack of a national personal assistance services policy.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Control↗
PubMed1994

Survival of individuals with spinal muscular atrophy on ventilatory support.

Six ventilator-assisted individuals (VAIs) with spinal muscular atrophy (SMA) are described. All six survived by using intermittent positive pressure ventilation via an indwelling tracheostomy for a mean of 11.7 +/- 17.7 yr despite frequent episodes of mucus plugging and pneumonia. Four of the VAIs also received all nutrition via indwelling gastrostomy tubes because of severe bulbar muscle weakness. Four VAIs used tracheostomy intermittent positive pressure ventilation with their tracheostomy cuffs deflated and could communicate verbally. Five of the six VAIs remained institutionalized from the onset of ventilatory use. Two SMA VAIs survived for 15 and 4 yr, respectively, despite need for ventilatory support since early infancy. All four SMA VAIs who could communicate remained socially active and one, gainfully employed. We conclude that for patients with advanced SMA markedly prolonged survival is possible with ventilatory assistance despite severe respiratory and bulbar muscle dysfunction.

Activities of Daily Living↗
PubMed1994

Sleep and nocturnal mouthpiece IPPV efficiency in postpoliomyelitis ventilator users.

STUDY OBJECTIVE: Intermittent positive pressure ventilation (IPPV) can be delivered via various oral, nasal, or oronasal interfaces as an alternative to tracheostomy for up to 24 h of ventilatory support. Nocturnal nasal IPPV is often associated with frequent transient but at times severe oxyhemoglobin desaturations (dSaO2s) and sleep fragmentation. The purpose of this study was to determine if nocturnal mouthpiece IPPV is also associated with dSaO2s and sleep disruption. DESIGN: Twenty-seven postpolio ventilator-assisted individuals (VAIs) using mouthpiece IPPV with little or no ventilator-free breathing time (VFBT) underwent nocturnal oxyhemoglobin saturation (SaO2) monitoring. In addition, 15 underwent nocturnal capnography and 13 underwent polysomnography. RESULTS: Mean nocturnal SaO2 was normal in 22 of 27 and maximum end-tidal PCO2 was normal in 12 of 15 VAIs. Use of lipseal retention for nocturnal mouthpiece IPPV significantly improved blood gas values during sleep. The polysomnography results demonstrated relatively normal sleep efficiency. CONCLUSIONS: Nocturnal mouthpiece IPPV is most effective with lipseal retention. It can provide normal alveolar ventilation and SaO2 during sleep for VAIs with little or no measurable vital capacity or VFBT. Because transient dSaO2s can be eliminated with lipseal retention, it may disrupt sleep less than nasal IPPV.

Carbon Dioxide↗
PubMed1993

Inappropriate weaning and late onset ventilatory failure of individuals with traumatic spinal cord injury.

Eight traumatic spinal cord injured (SCI) individuals are described. Four tetraplegic patients who were weaned from initial ventilator use despite severe restrictive pulmonary syndromes experienced multiple pulmonary complications, episodes of acute respiratory failure, and 3 of the 4 required long term ventilatory support within 2 years of initial weaning. Three other SCI individuals developed chronic late-onset ventilatory failure 17, 25, and 29 years postinjury. One other tetraplegic patient was mechanically ventilated for 8.2 years post-injury despite complete recovery of autonomous ventilatory function years earlier. Of the 6 patients requiring long term ventilatory support, 4 were managed by noninvasive techniques of intermittent positive pressure ventilation (IPPV), one by negative pressure body ventilators, and one by tracheostomy IPPV. At least one and possibly as many as 5 patients were spared bronchoscopy and/or pulmonary complications by using mechanical insufflation-exsufflation (MI-E). We conclude that patients who are weaned despite having significant restrictive pulmonary syndromes are at risk for ventilatory decompensation weeks to decades after weaning. Ongoing clinical assessment, evaluation of respiratory muscle function and, at times, nocturnal blood gas analyses are warranted in the follow up of traumatic SCI individuals.

Adult↗
PubMed1993

Physical medicine and rehabilitation. Trends in academic productivity.

Numerous authorities have emphasized the need for expanding the quantity and quality of physical medicine and rehabilitation (PM&R) research and academic productivity. Thus far, however, attempts to evaluate academic productivity have involved the manual sampling of relevant specialty journals. This approach greatly underestimates productivity. By conducting a computer-facilitated search for PM&R-related publications and then contacting the most academically prolific PM&R departments to verify the computer-generated data, it was found that computer search strategies more accurately estimate PM&R academic productivity. PM&R publication activity increased by 15% in the United States and 46% internationally over the period 1988 to 1990. At least 76% of the United States residency programs in PM&R had scientific publications over this period. With ever increasing emphasis placed on academic productivity, the trend of increasing productivity can only be expected to continue in the future.

Academic Medical Centers↗
PubMed1993

Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users.

Despite wider application of the use of nocturnal intermittent positive pressure ventilation (IPPV) via nasal access for the management of nocturnal hypoventilation, there continues to be a lack of familiarity with the use of IPPV via the mouth for ventilatory support. Unlike nasal IPPV, which is generally practical only for nocturnal use, up to 24-h mouth IPPV was the key method of noninvasive ventilatory support that permitted the avoidance or elimination of tracheostomy for 257 individuals with acute or chronic ventilatory failure. Mouth IPPV was delivered via commercially available mouthpieces for daytime aid and mouthpiece with lip seal or custom orthodontic interfaces for nocturnal support. The use of mouth IPPV alone or in a regimen with other noninvasive ventilatory aids was reviewed for these 257 individuals. Mouth IPPV was used for nocturnal aid by 163 individuals, 61 of whom had little or no measurable vital capacity or significant ventilator-free breathing time, for more than 1,560 patient-years with few complications. It was also the predominant method of daytime ventilatory support for 228 individuals for more than 2,350 patient-years. We conclude that for individuals with adequate bulbar muscle function but chronic respiratory muscle insufficiency, mouth IPPV can be an effective alternative to tracheostomy. It can significantly prolong survival while optimizing convenience, safety, and communication.

Adolescent↗
PubMed1993

Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques.

Pulmonary complications are major causes of morbidity and mortality for patients with severe expiratory muscle weakness. The purpose of this study was to compare peak cough expiratory flows (PCEFs) during unassisted and assisted coughing and review the long-term use of mechanical insufflation-exsufflation (MI-E) for 46 neuromuscular ventilator users. These individuals used noninvasive methods of ventilatory support for a mean of 21.1 h/d for 17.3 +/- 15.5 years. They relied on manually assisted coughing and/or MI-E during periods of productive airway secretion. They reported a mean of 0.7 +/- 1.2 cases of pneumonia and other serious pulmonary complications and 2.8 +/- 5.6 hospitalizations during the 16.4-year period and no complications of MI-E. A sample of 21 of these patients with a mean forced vital capacity of 490 +/- 370 ml had a mean maximum insufflation capacity (MIC) achieved by a combination of air stacking of ventilator insufflations and glossopharyngeal breathing of 1,670 +/- 540 ml. The PCEFs for this sample were: following an unassisted inspiration, 1.81 +/- 1.03 L/s; following a MIC maneuver, 3.37 +/- 1.07 L/s; with manual assistance by abdominal compression following a MIC maneuver, 4.27 +/- 1.29 L/s; and with MI-E, 7.47 +/- 1.02 L/s. Each PCEF was significantly greater than the preceding, respectively (p < 0.01). We conclude that manually assisted coughing and MI-E are effective and safe methods for facilitating airway secretion clearance for neuromuscular ventilator users who would otherwise be managed by endotracheal suctioning. Severely decreased MIC, but not necessarily vital capacity, is an indication for tracheostomy.

Adult↗
PubMed1993

A comparison of long-term ventilatory support alternatives from the perspective of the patient and care giver.

Tracheostomy, noninvasive intermittent positive pressure ventilation (IPPV) methods, and body ventilators can be used for ventilatory support. These methods vary with respect to safety, convenience, effect on speech, sleep, swallowing, appearance, comfort, and general patient acceptability. The purpose of this study was to determine patient and care giver ventilatory support preferences concerning these quality of life issues. One hundred sixty-eight predominantly neuromuscular patients with greater than 1 month of experience in the use of both tracheostomy and noninvasive methods were surveyed. At the time of the study they had a mean age of 54.7 +/- 11.4 years, were using ventilatory aids a mean of 17.1 +/- 6.5 h/d, and had been doing so for 22.7 +/- 13.1 consecutive years. The 59 respondents who switched from tracheostomy to noninvasive aids significantly preferred the latter for every item and unanimously preferred them over all. The 76 respondents switched from body ventilator use to tracheostomy IPPV significantly preferred use of the former for appearance and speech and the latter for sleep and security and had no other significant preferences. However, the 35 respondents switched from a regimen of noninvasive aids including noninvasive IPPV to tracheostomy IPPV significantly preferred the noninvasive aids for each item except for sleep, swallowing, and security for which there were no significant preferences. We conclude that whether patients switched to or from noninvasive ventilatory support regimens which include noninvasive IPPV, noninvasive methods are considered by patients to be more convenient, to have less untoward effects on speech, appearance and comfort, and are preferred overall to tracheostomy IPPV.

Adult↗
PubMed1993

New therapeutic techniques and strategies in pulmonary rehabilitation.

Patients with chronic obstructive pulmonary disease (COPD) or those with paralytic restrictive pulmonary syndromes caused by progressive neuromuscular disease, kyphoscoliosis or traumatic quadriplegia may require frequent hospitalization because of respiratory impairment and have increased morbidity and mortality. Pulmonary rehabilitation has been shown to decrease the frequency of hospitalization, ameliorate symptoms, increase exercise tolerance, and in one study, prolong life for individuals with COPD. It is now recognized that principles of pulmonary rehabilitation can also be used to avoid hospitalization, intubation, tracheostomy and bronchoscopy while enhancing quality of life, decreasing cost, and greatly prolonging life for individuals with paralytic restrictive syndromes and global alveolar hypoventilation as well.

Female↗
PubMed1993

Comprehensive rehabilitation of the severely disabled ventilator-assisted individual.

The lives of many individuals with severe disability and paralytic/restrictive pulmonary conditions, which progress or worsen with time, can be significantly prolonged, and the quality of life greatly enhanced, by noninvasive or conservative rehabilitation interventions. These interventions are devised to maintain or improve the individual's orthopaedic, pulmonary, and functional status. The combination of orthopaedic surgery and rehabilitation can reverse or ameliorate musculotendinous contractures and scoliosis and, thereby, maintain optimal patient comfort, function, and the possibility for nursing or personal care. Recent advances in the use of computers, environmental control systems, robotics, etc., can increase upper extremity functional activities. Non-invasive methods of airway secretion evacuation and ventilatory support can permit individuals with little or no vital capacity to avoid acute pulmonary complications, intubation and tracheostomy indefinitely.

Adult↗