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Dr. Goldberg is Professor of Pediatrics, Loyola University, Chicago.
Correspondence to: Allen I. Goldberg, MD, FCCP, 1018 W. Diversey Parkway #2, Chicago, IL 60614; e-mail: agoldberg1988{at}kellogg.nwu.edu
The modern era of mechanical ventilation began during the poliomyelitis epidemics of the mid-20th century. According to personal accounts from the late historian Gini Laurie and innovative engineer Jack Emerson, deaths from bulbar poliomyelitis inspired a dramatic global response similar to an allied army fighting a war against a merciless enemy.1 2 Noninvasive negative-pressure ventilation by the iron lung and other means had been the only weapons available.3 Mounting deaths from bulbar poliomyelitis demanded another maneuver: the modern positive-pressure ventilator (Engström4 ) and the use of positive-pressure ventilation by tracheostomy.5 These advances led to a reduction in mortality from bulbar polio from 90 to 20%, and the era of long-term invasive positive pressure ventilation was begun.5 Victory came because of the dedication of voluntary organizations and public awareness and support.1 In the United States, the work of the National Foundation-March of Dimes and the public made possible what would never have occurred otherwise.1 6 The definitive defeat of polio came from teamwork: the public responding to a crisis, clinicians and engineers developing innovative technologies, and interdisciplinary clinical teams—including patients—applying new techniques in dedicated respiratory-care centers building upon a foundation of combined extensive experience.1 2
One unexpected by-product of success was development of a population of survivors dependent upon prolonged life-sustaining technology who had no option but to remain in the hospital for an indefinite future. Doctors, therapists, engineers worked again with patients and families to find technologic and organizational solutions. According to personal accounts from CHEST 2001 Margaret Pfrommer Memorial Award Winner Augusta Alba, MD, they discovered together that noninvasive mouth positive-pressure ventilation by mouthpiece or lip-seal permitted safe noninvasive ventilation with freedom from constraints of cumbersome negative-pressure devices (iron lung, cuirass) and the risks of tracheostomy.7 8 (Margaret Pfrommer, a noninvasive ventilator user over 40 years, innovated solutions with noninvasive ventilation with such a team.9 Other post-polio survivors have had similar experiences.10 11 ) With safety ensured, such teams continued to find an alternative to prolonged "life" in an institution for post-polio survivors: long-term mechanical ventilation at home.1 These dedicated respiratory centers then adapted techniques successfully used for patients with poliomyelitis to other conditions due to CNS-neuromuscular disorders and/or skeletal deformities.
In the United States, the discovery of the poliomyelitis vaccine brought a response not unlike the declaration of peace after wartime.1 Similar to disarmament after combat with an enemy, dedicated respiratory care centers in the United States were disassembled with the exception of a those in a few public-supported institutions (Goldwater Memorial Hospital, New York, NY; Rancho los Amigos, Downey, CA; and Texas Institute for Rehabilitation and Research, Houston, TX).12 Professional "polio experts" then became intensive-care pioneers. Their interdisciplinary team approach evolved into the practice of critical care medicine. Similarly, international polio centers where the first Engström ventilators were used became pioneering intensive care centers: St. Thomas Hospital, London, UK; Hotel Dieu, Paris, France; and Croix-Rousse, Lyon, France.13 14 Critical care medicine had other roots as well: anesthesia, cardiopulmonary medicine, cardiothoracic surgery. Young clinicians who were trained there were less likely to know about the poliomyelitis experience with noninvasive ventilation and home care. As years went by, interdisciplinary teams saved more lives and, with progress in physical and rehabilitation medicine, team members enhanced their patients’ functional potential. A second generation of children and adults requiring prolonged mechanical ventilation at home was created. Professionals and patients knew little about the first generation.15
Discoveries in medicine can result when dedicated caring professionals working together in partnership with their patients come up with ideas that make a difference. Success comes after expiration of frustrating trials of failure, or they may be due to spontaneous inspiration. In the early 1980s, two situations in different parts of the world stimulated the rebirth of noninvasive ventilation for newer applications, as revealed by these personal accounts:
In France, Professor Rideau had wanted to apply earlier mechanical ventilation to his patients in his large national practice of Duchenne muscular dystrophy. Being in Poitiers (not convenient to train or highway transportation at that time), he preferred not to use a tracheostomy. Knowing Dr. Alba’s experience with "mouth positive-pressure breathing," Professor Rideau related to me that he decided to try the noninvasive route by "placing two urinary catheters in the nose at one end, joined together by T-piece at the other end and connected to a conventional positive pressure ventilator used at home." Spirometric evidence revealed effective ventilation.16
In Australia, Professor Colin Sullivan, working with Nancy Ellis and others, was applying noninvasive positive airway pressure by nasal mask to patients with obstructive sleep apnea and monitoring the results with polysomnography. Nancy Ellis mentioned to me that they spontaneously added cyclical pressure that resulted in marked improvement in central control of breathing parameters for central apnea.17
Both of these independent discoveries permeated rapidly through medical communities and patient networks around the world. Others18 19 20 21 22 23 began to consider application of noninvasive ventilation and more convenient technologies and with improvement in the interfaces.
It is important to note that the initial application of noninvasive positive-pressure ventilation for long-term use in the home focused on patients with hypoventilation due to neuromuscular diseases, central control of breathing disorders, and skeletal deformities. In that tradition, in the current issue of CHEST (see page 459), Nugent et al provide an excellent review of a well-documented and evaluated application of noninvasive ventilation for muscular dystrophy in their respiratory-care center. The authors are to be commended for their attention to technical and practical details, including assessment of patient clinical status before, during, and after application; patient compliance with treatment; and determination of outcomes, including quality of life.
Currently, there has been a growing interest in mechanical ventilation beyond the ICU and an explosion in the use of noninvasive positive-pressure ventilation for many purposes. The "state of the art" of noninvasive ventilation and/or home mechanical ventilation has been well described in several consensus conferences convened over the years by the European Respiratory Society, the American Association of Respiratory Care, the American College of Chest Physicians, and the American Thoracic Society.24 25 26 27 Regarding noninvasive positive-pressure ventilation, there have been both acute and long-term applications in many clinical settings: emergency department, acute ICUs, subacute and chronic care environments, and home and home-like alternative sites. Biannual updates from experiences around the world take place at the International Home Mechanical Ventilation (JIVD) Congress held alternatively in the United States and Lyon, France, since the late 1980s, and numerous articles and books have been written about the subject.28 29 30 31 32 Of no surprise, the economic impact of the growth of the application of noninvasive ventilation has been significant. This was noted by public health-care finance officials, which led to convening of an invitational consensus conference on noninvasive ventilation by the National Association for Medical Direction of Respiratory Care, with a task force of experts from professional associations, governmental authorities, and industry representatives. It is essential to carefully review and recognize the conclusions of that conference to understand current practice and policy discussions.33
Patients who require prolonged life-sustaining technology and their families can benefit from home care. The application of long-term noninvasive mechanical ventilation to appropriately selected patients at home can dramatically simplify the complexity of the organization of the home-care program and potentially reduce its cost. This technique is easier to learn and use, and the technology requires less professional surveillance. People who experience long-term mechanical ventilation have practical knowledge and experience to teach us.34 Noninvasive ventilation does represent a simpler technologic solution and requires less professional on-site care. This is more true now with innovative use of telemedicine for interactive communication to support patients and families at home.35 However, it is essential that appropriate candidates for home care are selected according to predetermined medical, psychosocial, environmental, technologic, organizational, and financial criteria.15 Home mechanical ventilation requires a medical prescription written by a physician after an initial clinical assessment, determination of medical necessity, evaluation of the home environment, home-care documentation of plan organization and patient/family education, and continuous reassessment and evaluation of progress. Similarly, any new technology or technique requires initial technologic assessment and later reassessment.36 It is highly advisable that patients be initially evaluated and treatment implemented with experienced professionals in experienced centers. Nugent et al have demonstrated the value of this advice. Their work justifies support of efforts by others to conduct similar clinical studies that may provide broader opportunities for appropriately selected patients and families to benefit from this technique. Current and future applications of noninvasive ventilation and growth of home mechanical ventilation demand evidence-based practice built upon rigorous outcome evaluation of the clinical, patient, and family experience, and economic impact. Building on the tradition of noninvasive ventilation, health-care and engineering professionals, patients and families, and others working together can again make a difference!
References
This article has been cited by other articles:
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  J. S. Lewarski and P. C. Gay Current Issues in Home Mechanical Ventilation Chest, August 1, 2007; 132(2): 671 - 676. [Abstract] [Full Text] [PDF]
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 A K Simonds Risk management of the home ventilator dependent patient Thorax, May 1, 2006; 61(5): 369 - 371. [Full Text] [PDF]
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