DMD patient using sip technology

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curiousgeorge
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DMD patient using sip technology

Postby curiousgeorge » Sun Nov 13, 2016 2:27 pm

I am keen to provide mouthpiece ventilation (MPV) for a DMD patient. I have tried and failed to get him using the ‘sip’ technology provided by Phillips simply because the patient cannot coordinate the ‘sip’ followed by an inspiration. I imagine that you have significant experience of using MPV, in a triggered mode using active exhalation, negating the need for PEEP, without back-up rate. I assume this would eliminate the need to coordinate and the patient could just breath in through the mouth piece to trigger the breath. I have sought advice from colleagues in the UK but they don’t seem to be able to help, would you be willing to provide me with some advice.

A long shot I know but both the patient and myself are keen to get him established on MPV to improve his day time ventilation and quality of life.

(Asked by a provider)

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bachjr
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Re: DMD patient using sip technology

Postby bachjr » Sun Nov 13, 2016 2:28 pm

curiousgeorge wrote:I am keen to provide mouthpiece ventilation (MPV) for a DMD patient. I have tried and failed to get him using the ‘sip’ technology provided by Phillips simply because the patient cannot coordinate the ‘sip’ followed by an inspiration. I imagine that you have significant experience of using MPV, in a triggered mode using active exhalation, negating the need for PEEP, without back-up rate. I assume this would eliminate the need to coordinate and the patient could just breath in through the mouth piece to trigger the breath. I have sought advice from colleagues in the UK but they don’t seem to be able to help, would you be willing to provide me with some advice.

A long shot I know but both the patient and myself are keen to get him established on MPV to improve his day time ventilation and quality of life.

(Asked by a provider)

If you are using the "Kiss Trigger" on the Phillips Trilogy ventilator, then you can use either an active ventilator circuit (with exhalation valve) or passive "BiPAP" circuit (without exhalation valve) and you can set the back up rate anywhere from 0 to 30 or so. At zero, he would have to touch the mouthpiece with his tongue for it to deliver the air, not "sip" on it to trigger. If the back up rate is set over 10, then he also does not need to trigger it at all since it will deliver all the breaths he needs without having to trigger. The problem may be that, about 15% of people with DMD have lips too weak to seal to be able to bring in the air or he may be leaking out of his nose. If he can get the air when you "bag" him using an Ambu bag, then he CAN use mouthpiece ventilation. If you cannot "bag" him, then he cannot. He may have to learn how to seal off the nasopharynx by using his soft palate - another "problem" for some, leading to nose leakage.

NONE of these patients need trach tubes or PEEP/EPAP and none benefit from PEEP/EPAP so that is not relevant and an important reason to not use a passive circuit in most cases (of course, when using an active circuit you must use a non-vented interface, or at least, one with the vent holes covered). I hope that this helps. Simply "bag" him with the manual resuscitator and if OK then you just have to set up the ventilator properly. If not OK, then analyze and address the problem.

JB
Last edited by bachjr on Sun Nov 13, 2016 2:30 pm, edited 1 time in total.
John R. Bach MD
Medical Director, VentilaMed BreatheNVS
Medical Director, Center for Ventilator Management Alternatives
Professor of Physical Medicine and Rehabilitation, Professor of Neurology, Rutgers New Jersey Medical School

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Re: DMD patient using sip technology

Postby curiousgeorge » Sun Nov 13, 2016 2:29 pm

I think it might well be that nasal leakage and mouth seal are an issue although a nose clip didn’t seem to help. The problem with the ‘tongue touch’ is that after the touch he then struggles to coordinate an inspiration, presumably the leakage from lips and nose contribute to this. I will try him with the AMBU Bag and see what happens.

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Re: DMD patient using sip technology

Postby bachjr » Sun Nov 13, 2016 2:29 pm

curiousgeorge wrote:I think it might well be that nasal leakage and mouth seal are an issue although a nose clip didn’t seem to help. The problem with the ‘tongue touch’ is that after the touch he then struggles to coordinate an inspiration, presumably the leakage from lips and nose contribute to this. I will try him with the AMBU Bag and see what happens.

If he cannot do the Ambu bag, then he cannot do mouthpiece ventilation and will have to alternative nasal interfaces eventually for continuous NVS. ALL patients prefer CNVS via nasal interfaces to trach tube ventilation and they live 10 years longer without trach tubes.

JB
John R. Bach MD
Medical Director, VentilaMed BreatheNVS
Medical Director, Center for Ventilator Management Alternatives
Professor of Physical Medicine and Rehabilitation, Professor of Neurology, Rutgers New Jersey Medical School

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Re: DMD patient using sip technology

Postby Noninvasive » Sat Dec 31, 2016 2:26 am

Hello, is there a way to teach somebody how to "seal" their nasopharyngeal during mouthpiece ventilation?

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bachjr
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Re: DMD patient using sip technology

Postby bachjr » Mon May 15, 2017 4:29 pm

It sounds like the machine's sensitivity is too low. It should be no problem to get a deep breath from a mouth piece. Also, there should be no "PEEP" or "EPAP".
John R. Bach MD
Medical Director, VentilaMed BreatheNVS
Medical Director, Center for Ventilator Management Alternatives
Professor of Physical Medicine and Rehabilitation, Professor of Neurology, Rutgers New Jersey Medical School


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