Abstract
Patients with a variety of neuromuscular diseases including quadraplegia due to high spinal cord lesions can be managed with full-time noninvasive ventilation instead of intermittent positive pressure ventilation (IPPV) via a tracheostomy. This approach is not suitable for patients with severe bulbar involvement. To be successful with full-time noninvasive IPPV, the ventilator user must realize three goals. First, respiratory system compliance should be optimized and maintained by frequent full inflations delivered by stacking breaths from a volume-cycled ventilator or by insufflating air at adequate pressures using a mechanical insufflator-exsufflator. Second, normal levels of alveolar ventilation are sustained using a variety of noninvasive approaches, including nasal, oronasal, or mouthpiece interfaces. Third, patients must be taught to use techniques and devices to enhance cough, particularly the mechanical insufflator-exsufflator. When these goals are met, noninvasive NPPV can offer patients greater comfort, simpler and more convenient ventilator use, and reduced rates of infections, complications, and hospitalizations as compared with tracheostomy IPPV.