[Home mechanical ventilation-tracheostomy ventilation, for the long-term and variation].

Area of Science:

• Pulmonology
• Neurology
• Critical Care Medicine

Context:

• Focuses on long-term ventilation strategies for patients with respiratory failure, primarily those with amyotrophic lateral sclerosis (ALS).
• Highlights challenges in managing ventilation, including atelectasis, pneumonia, and ventilator-induced lung injury (VILI).
• Discusses the transition from non-invasive positive pressure ventilation (NPPV) to tracheostomy positive pressure ventilation (TPPV).

Purpose:

• To outline optimal settings and methods for long-term mechanical ventilation in patients with respiratory insufficiency.
• To describe strategies for managing ventilation during the transition from NPPV to TPPV.
• To present recommendations for ventilator settings and adjunct therapies to improve patient outcomes.

Summary:

• Recommends tidal volume (TV) exceeding 600 ml for TPPV to prevent atelectasis, unlike the typical 400 ml used in Japan.
• Suggests a breathing frequency of 10 breaths/min and an expiratory time of 2 seconds to balance airway pressure and ventilation.
• Advocates for managing VILI with reduced TV and steroid pulse therapy.
• Proposes using cuffless tracheal cannulas or biphasic ventilation (NPPV/TPPV) during the NPPV-to-TPPV transition for effective sputum management and continued ventilation.
• Emphasizes the utility of bi-level ventilators for TPPV, especially in assisting spontaneous breathing and enabling speech via air leakage.

Impact:

• Provides evidence-based recommendations for optimizing long-term ventilation in ALS and similar conditions.
• Offers practical solutions for managing ventilation transitions and potential complications like VILI.
• Aims to improve the quality of life and respiratory support for patients requiring prolonged mechanical ventilation.