Can a person with a tracheostomy use Non-Invasive Ventilation (NIV)?

Using NIV in Patients with Tracheostomy

Yes, a person with a tracheostomy can use non-invasive ventilation (NIV), and in some clinical scenarios, this approach may be preferable to conventional invasive mechanical ventilation through the tracheostomy. 1

Clinical Applications

Scenarios Where NIV Can Be Used with Tracheostomy

1. During Weaning Process

   • NIV can be used in patients with tracheostomy during the weaning process, either:
     • Directly connected to the tracheostomy tube
     • Via mask after capping the tracheostomy tube 1

2. Long-term Home Mechanical Ventilation

   • For patients with neuromuscular diseases requiring long-term ventilation
   • Can serve as an alternative to conventional invasive ventilation 1, 2

3. Post-Extubation Support

   • In patients with COPD and neuromuscular disorders
   • BTS guidelines recommend NIV-supported extubation in preference to inserting a tracheostomy 3

Advantages of NIV with Tracheostomy

• Portability: NIV devices are typically more portable than conventional ventilators
• Ease of operation: Simpler to use and maintain
• Cost-effective: Lower cost compared to conventional ventilators
• Potential for improved communication: May allow better speech capabilities depending on setup 1

Patient Selection

Good Candidates

• Patients with neuromuscular diseases (e.g., Duchenne muscular dystrophy)
• Patients with chronic obstructive pulmonary disease (COPD)
• Patients in the process of weaning from mechanical ventilation 1, 4

Cautions and Considerations

• Secretion Management: Patients with excessive secretions may require additional airway clearance techniques
• Monitoring Requirements: Regular monitoring of gas exchange is essential, including:
  • Oxygen saturation
  • End-tidal CO2 levels (at least annually) 3
  • Arterial blood gas analysis when indicated

Implementation Approaches

Two Main Methods

1. Direct Connection to Tracheostomy

   • NIV device connected directly to the tracheostomy tube
   • Useful for patients who still need the tracheostomy for secretion management

2. Mask Ventilation with Capped Tracheostomy

   • Tracheostomy tube is capped
   • NIV provided via mask interface
   • Can be a step toward potential decannulation 1

Evidence and Outcomes

Research has shown positive outcomes for using NIV in patients with tracheostomy:

• In one study of 72 cases using NIV via tracheostomy tube, 33 patients were successfully weaned and 24 continued with home mechanical ventilation 1
• In another study of 288 cases using mask ventilation with capped tracheostomy, successful decannulation was achieved in 254 patients 1
• A study of patients with Duchenne muscular dystrophy showed that 24-hour NIV (including daytime mouthpiece ventilation) could be a safe alternative to tracheostomy ventilation 5

Clinical Pitfalls to Avoid

• Inadequate Monitoring: Ensure regular monitoring of oxygen saturation to detect mucus plugs 3
• Ignoring Patient Comfort: Select appropriate interfaces and ventilator settings to ensure patient tolerance
• Overlooking Secretion Management: Patients with tracheostomy often have increased secretions that require management
• Failure to Have Backup Plans: Always have contingency plans for equipment failure or clinical deterioration

Conclusion

NIV can be successfully used in patients with tracheostomy in various clinical scenarios, particularly during weaning and for long-term ventilation in selected patients. The decision should be based on patient-specific factors including underlying diagnosis, secretion management needs, and overall clinical status.