[Home mechanical ventilation-tracheostomy ventilation, for the long-term and variation].

We experienced long-term ventilation for 30 patients mostly with amyotrophic lateral sclerosis (ALS). For long-term ventilation by tracheostomy positive pressure ventilation (TPPV), we must set tidal volume (TV) over 600 ml, because setting 400 ml as TV usually applied in Japan, often develops atelectasis which causes frequent or serious pneumonia. To avoid both the elevation of airway pressure and hyper ventilation, the following intervals are needed: 10 times/min for breathing frequency and 2 seconds for exhaling time. In the cases with ventilator induced lung injury (VILI), it is necessary to lower the TV and to treat with steroid pulse therapy. In the transitional stage from non-invasive positive pressure ventilation (NPPV) to TPPV, we conduct tracheostomy for suction of the sputum. In that stage, by using a cuffless tracheal canule, we can continue NPPV. As another method in that stage, we recommend biphasic management by NPPV at daytime and TPPV at nighttime with a bi-level ventilator. This method can provide certain ventilation also during sleep. When the respiratory failure proceeds further, we manage the ventilation with a bi-level ventilator on TPPV, because a bi-level ventilator is also good adapting to assist spontaneous breathing in that stage. And if the patient does not have bulbar paralysis, the patient can utter by air leakage with using bi-level ventilator and flattening the cuff of the tracheal canule.