Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes

The purpose of this study was to evaluate the effectiveness of long-term tracheostomy intermittent positive pressure ventilation (TIPPV) with deflated cuffs or cuffless tracheostomy tubes for patients with neuromuscular ventilatory failure. One hundred four unweanable ventilator-dependent patients with neuromuscular ventilatory insufficiency were referred for pulmonary rehabilitation. Ninety-one of the 104 patients converted from TIPPV with an inflated cuff to either a deflated cuff (28 patients) or no cuff (63 patients). Arterial blood gas (ABG) and routine daytime monitoring of end-tidal PCo2 were performed on all patients during this transition. In addition, periodic daytime and continuous overnight oximetry were performed on 21 of these patients receiving TIPPV with deflated cuffs or cuffless tubes. Thirteen of the 21 patients also had continuous overnight end-tidal PCo2 monitoring. Despite a mean vital capacity of 17 +/- 12.3 percent and the fact that 16 of the 21 patients could tolerate only 60 minutes or less of autonomous respiration (free time), ABG, daytime SaO2 and end-tidal PCo2 were within normal limits for all 21 patients and mean overnight SaO2 was 94 percent or greater for all except one patient who used a cuffless tracheostomy tube. Six patients experienced very transient desaturations below 90 percent but no one had a maximum end-tidal PCo2 greater than 47 mm Hg. Patients with adequate pulmonary compliance and sufficient oropharyngeal muscle strength for functional swallowing and articulation are candidates for conversion to TIPPV with deflated cuffs or cuffless tracheostomy tubes despite little or no autonomous respiration.