Mechanical In-Exsufflation–Expiratory Flows as Indication for Tracheostomy Tube Decannulation: Case Studies

Mechanical insufflation exsufflation–expiratory flows (MIE-EF) correlate with upper airway patency. Patients dependent on continuous noninvasive ventilatory support (CNVS) with severe spinal muscular atrophy type 1, now over 20 years old, have used MIE sufficiently effectively along with CNVS to avoid tracheotomy indefinitely. While MIE-EF can apparently decrease in amyotrophic lateral sclerosis to necessitate tracheotomy, they can increase over time and remain effective in all spinal muscular atrophy types. Two cases demonstrate an association between increasing MIE-EF and ultimately successful decannulation of a continuous tracheostomy mechanical ventilation dependent patient with spinal muscular atrophy type 2 and a patient with obesity hypoventilation syndrome. Only when MIE-EF increased to exceed 200 L/m did the decannulations succeed. Definitive noninvasive management (CNVS) of these patients may only be possible when MIE is effective and the greater the MIE-EF, the greater its effectiveness. Thus, increasing MIE-EF can signal resolution of upper airway obstruction sufficiently to permit decannulation whether a patient is ventilator dependent or not. Correspondence: John R. Bach, MD, Department of Physical Medicine and Rehabilitation, University Hospital B-403, 150 Bergen Street, Newark, NJ 07103, Phone: 1-973-9722085, Fax: 1-973-9725725, E-mail: bachjr@njms.rutgers.edu Author Disclosures: Financial disclosure statements have been obtained and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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