title: Alternatives to endotracheal intubation for patients with neuromuscular diseases.
abstract: OBJECTIVE
  To evaluate the usefulness of continuous noninvasive mechanical ventilation and mechanical coughing aids to avoid endotracheal intubation and tracheostomy during episodes of acute respiratory failure in patients with neuromuscular disease.
  
  
  METHODS
  We conducted a prospective cohort study at the respiratory medicine ward of a university hospital to study the success rate of the use of continuous noninvasive mechanical ventilation and manually and mechanically (CoughAssist) assisted coughing to avert endotracheal intubation in 24 consecutive episodes of acute respiratory failure for 17 patients with neuromuscular disease. The noninvasive mechanical ventilation and coughing aids were used to reverse decreases in oxyhemoglobin saturation and relieve respiratory distress that occurred despite oxygen therapy and appropriate medication. Noninvasive mechanical ventilation was delivered by volume ventilators (Breas PV 501) alternating nasal/oronasal and oral interfaces.
  
  
  RESULTS
  Noninvasive management was successful in averting death and endotracheal intubation in 79.2% of the acute episodes. There were no significant differences in respiratory function between the successfully treated and unsuccessfully treated groups before the current episode. Bulbar dysfunction was the independent risk factor for failure of noninvasive treatment (P < 0.05; odds ratio, 35.99%; 95% confidence interval, 1.71-757.68).
  
  
  CONCLUSIONS
  Intubation can be avoided for some patients with neuromuscular disease in acute respiratory failure by some combination of noninvasive mechanical ventilation and mechanically assisted coughing. Severe bulbar involvement can limit the effectiveness of noninvasive management.
authors.affiliation: Rehabilitation and Ventilation Unit, Department of Respiratory Medicine, Hospital Clínico Universitario, Universitat de València, Valencia, Spain.
authors.forename: Emilio
authors.initials: E
authors.lastname: Servera
authors.forename: Jesús
authors.initials: J
authors.lastname: Sancho
authors.forename: Ma Jesús
authors.initials: MJ
authors.lastname: Zafra
authors.forename: Ana
authors.initials: A
authors.lastname: Catalá
authors.forename: Pedro
authors.initials: P
authors.lastname: Vergara
authors.forename: Julio
authors.initials: J
authors.lastname: Marín
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016001:Confidence Intervals; D003371:Cough / Q000503:physiopathology*; D005260:Female; D006801:Humans; D007385:Intermittent Positive-Pressure Ventilation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009468:Neuromuscular Diseases / Q000150:complications* / Q000628:therapy; D016017:Odds Ratio; D011446:Prospective Studies; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*; D013997:Time Factors