Long term non-invasive domiciliary assisted ventilation for respiratory failure following thoracoplasty.

Abstract

Background -Ventilatory failure is a well recognised complication of patients who have had a thoracoplasty for tuberculosis, but there are few data regarding the value of long term non-invasive assisted ventilation in this situation. Methods -Thirty two patients who had had a thoracoplasty 20-46 years previously and who had developed respiratory failure were treated with nocturnal cuirass assisted ventilation or nasal positive pressure ventilation. Their survival and changes in arterial blood gases, nocturnal oximetry, and pulmonary function tests were assessed. Results -The actuarial survival rates at one, three, five, and seven years after starting treatment were 91%, 74%, 64%, and 55%, respectively. Only seven of the 13 deaths were directly attributable to chronic respiratory or cardiac failure. The arterial P02, Pco2, mean nocturnal oxygen saturation, vital capacity, and maximal inspiratory and expiratory pressures had all improved at the time ofthe initial posttreatment assessment (mean 12 days after starting treatment), but no subsequent improvements were seen after up to 48 months of follow up. Neither survival nor physiological improvements were correlated with the patients' age, the interval since thoracoplasty, or the pretreatment arterial blood gas tensions or results of pulmonary function tests. Conclusions -These results show that, even when ventilatory failure has developed, the prognosis with non-invasive assisted ventilation is good and the physiological abnormalities can be partially reversed. Patients who develop respiratory failure after a thoracoplasty should be considered for this type of long term domiciliary treatment. (Thorax 1994;49:915-919) Treatment by surgical collapse, especially thoracoplasty, played an important part in the management of pulmonary tuberculosis before the advent of effective antituberculous chemotherapy. Thoracoplasty causes a restrictive defect as a consequence of pleural thickening, thoracic cage deformity, and secondary scoliosis.lA Airflow obstruction is also common in these patients and, when severe, is associated with hypoxia and hypercapnia.5 Many patients who were treated with a thoracoplasty now have respiratory symptoms and some are at risk of developing respiratory failure.7 Domiciliary assisted ventilation is a well established treatment for respiratory failure in patients with neuromuscular and chest wall disorders, but there is little information about the outcome of this treatment in patients who have had a thoracoplasty. The aims of this study were to document the physiological results and survival of thoracoplasty patients who have been treated with assisted ventilation. MethodsThirty two patients who had undergone thoracoplasty were established on assisted ventilation at our centre between December 1983 and September 1993. There were eight men and 24 women of mean age 62 3 (range 35-78) years. Sixteen had left thoracoplasties, 14 were right sided, and two had bilateral thoracoplasties. Most of the patients had also had an artificial pneu...

Respiratory failure in tuberculosis: a modern perspective

“…Survival at one year is around 90%, at three years 75-85% and at five years over 65%. [19][20][21] The cohort of patients that underwent surgical treatment for tuberculosis has continued to age since these reports but, despite this, analysis of the current results from our Respiratory Support Centre at Papworth Hospital, Cambridge, has shown remarkably similar figures. Our population of 140 subjects has a mean age of 70.0 years (SD 7.3) and is now 6-8 years older than those in the previous series.…”

“…7 The mechanisms by which non-invasive ventilation is effective are uncertain but it not only improves blood gases during sleep, which is when the treatment is usually applied, but also during wakefulness. The arterial PO 2 increased by 1-3 kPa and the PCO 2 fell by 1-2 kPa in published series 19,21 (Fig 3). The vital capacity hardly changes after treatment but the exercise capacity can improve significantly.…”

Noninvasive ventilation for chest wall and neuromuscular disorders

“…The results appear to be similar whether the treatment is provided with a positive or negative pressure system, but there is less data regarding the latter [26]. Patients with a thoracoplasty have a similar outlook despite extensive pulmonary disease due to a previous tuberculous infection [31]. If scoliosis is due to a neuromuscular disorder the prognosis depends as much on the progress of this condition as on the scoliosis itself, but for those who have had poliomyelitis, for instance, the survival figures are as good as in scoliosis without any neuromuscular weakness [14,24].…”

Impact of Ventilation Parameters and Duration of Ventilator Use on Non-Invasive Home Ventilation in Restrictive Thoracic Disorders

“…For such patients, a number of studies have been published in the past several years reporting that NPPV is not only able to improve blood gas parameters but also hemodynamics, exercise performance, sleep quality and health-related quality of life [8,9,10,11,12,13,14,15]. Nevertheless, different effects of NPPV on lung volumes and inspiratory muscle function have been found [8,9,10, 12,16,17,18,19,20,21,22,23,24]. This has contributed to extensive discussions concerning the many different theories on the underlying mechanisms of NPPV in these diseases [1,2,3, 25, 26].…”