Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders. A comparison with endotracheal intubation

Objective: Prospectively to investigate the efficacy of non-invasive positi ve pressure ventilation (NPPV) combined with cricothyroid "mini-tracheostom y'' (CM) as a first-line intervention in patients with acute respiratory fa ilure (ARF) of neuromuscular origin, in comparison with positive pressure v entilation (PPV) via endotracheal intubation (ETI). Design: Prospective analysis of the short-term outcomes of 14 non-consecuti ve patients suffering from ARF of neuromuscular origin who were administere d NPPV and comparison with the outcomes of 14 matched historical control pa tients receiving conventional mechanical ventilation (MV) via ETI. Setting: Adult five-bedded respiratory intensive care unit in a university hospital. Patients and interventions: Fourteen neuromyopathic patients who developed hypercapnic ARF and were submitted to NPPV (group A) and fourteen matched h istorical control patients, who were administered PPV via ETI (group B). Se ven subjects receiving NPPV also underwent CM. Outcome measures: Mortality during ICU stay and treatment failure were evaluated; treatment failure was defined as death or the need for ETI for the NPPV group and as death or th e inability to wean from MV for the control group. Length of stay in the IC U and time to improvement, defined as the time required for a significant r elief of dyspnea and neurologic impairment and for correction of arterial b lood gases, were also compared. Results: Intra-hospital mortality and treatment failure were lower in the N PPV group than in the conventional PPV via ETI group (2 vs 8 cases and 4 vs 11 cases, respectively). In addition, the duration of ICU stay for subject s who underwent NPPV was shorter than for patients who were intubated (13.6 +/- 9.7 vs 47.1 +/- 51.9 days). "Mini-tracheostomy" was well tolerated and no significant side effects were encountered. Two patient were excluded fr om the study because they showed a severe inability to swallow and needed t o be intubated to protect the upper airway from the risk of aspiration. Conclusions: Non-invasive positive pressure ventilation in combination with CM may be considered as a safer and more effective alternative to ETI in t he treatment of patients with neuromuscular disorders (NMD) who develop ARF and require MV; nevertheless, patient selection remains important, since a significant proportion of neuromyopathic patients might have to be exclude d from NPPV because of severe risk of aspiration.