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(Chest. 1999;116:1498-1499.)
© 1999 American College of Chest Physicians

Wean From the Tube Not Necessarily From the Ventilator

John R. Bach

University of Medicine & Dentistry of New Jersey, Newark, NJ

Correspondence to: John R. Bach, MD, FCCP, Professor of Physical Medicine and Rehabilitation, University of Medicine & Dentistry of New Jersey, University Hospital B-403, 150 Bergen St, University Heights, Newark, NJ 07103-2406; e-mail: bachjr@umdnj.edu

To the Editor:

The recent article by Price and Rizk (May 1999 supplement),1 entitled "Postoperative Ventilatory Management," discusses many aspects of postoperative ventilatory care but fails to consider all of the options for one uncommon, but not rare, situation. Patients with neuromuscular ventilatory impairment for whom postoperative ventilator weaning difficulty may be anticipated can be trained prior to surgery to use noninvasive intermittent positive-pressure ventilation (IPPV) and expiratory muscle aids.2 This training permits the option of extubating such patients even when they are unable to autonomously ventilate the lungs. We come across this situation most commonly in patients with vital capacities of < 30% of the predicted normal rate who require scoliosis reduction surgery. However, it can occur in anyone with advanced neuromuscular disease who requires surgery. Once trained in mouthpiece and nasal IPPV3 and in manually and mechanically assisted coughing,2 the patients can usually be extubated when they meet the following criteria:

  1. no requirement of supplemental oxygen to maintain arterial oxygen saturation at > 94%;
  2. cleared or clearing chest radiograph abnormalities;
  3. full alertness and discontinuation of any respiratory depressants;
  4. extubation to continuous noninvasive IPPV without supplemental oxygen; and
  5. ability to use oximetry feedback to guide the use of inspiratory and expiratory aids to augment cough flows and to reverse any desaturations due to airway mucus accumulation.

Indeed, the "weaning" options are to wean from supplemental oxygen by clearing the airways and restoring normal pulmonary function, to remove any indwelling airway tubes whether the patient can breathe or not, and to let the patient wean from ventilator use by taking fewer and fewer assisted insufflations as needed to avoid dyspnea, oxyhemoglobin desaturation, and hypercapnia.3 Since many patients who require continuous long-term ventilatory support do not have tracheostomy tubes, one cannot expect them to wean from ventilator use before postoperative extubation.

References

  1. Price, J, Rizk, NW (1999) Postoperative ventilatory management. Chest 115(suppl),130S-137S[Abstract/Free Full Text]
  2. Bach, JR (1994) Update and perspectives on noninvasive respiratory muscle aids: Part 2. The expiratory muscle aids. Chest 105,1538-1544[Free Full Text]
  3. Bach, JR (1994) Update and perspectives on noninvasive respiratory muscle aids: Part 1. The inspiratory muscle aids. Chest 105,1230-1240[Free Full Text]
  4. Bach, JR, Saporito, LR (1996) Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure: a different approach to weaning. Chest 110,1566-1571[Abstract/Free Full Text]




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