1. Historical Perspective
Dr Tom Hilliard
Consultant in Paediatric Respiratory & Sleep Medicine

2. Dr Philip Drinker
Developed ‘iron lung’ ventilator, 1928

3. Drinker’s design for the first electrically powered ventilator
Scottish physician John Dalziel (1848) described a manually powered tank ventilator

4. UK polio epidemic

5. …led to wards full of patients requiring artificial ventilation

6. 1948 US polio epidemic
Bower and colleagues (Los Angeles) reported success with IPPV applied to the airway. They had two Bennett positive pressure valves which they used to supplement tank respirators:
to supply helium-oxygen mixtures during inspiration.
to provide respiration when the tank respirator was opened for nursing procedures.
to provide adequate ventilation in emergencies or transfer.
to inflate or re-expand lung that was collapsed or.was congested by pulmonary oedema.

7. 1952 Copenhagen polio epidemic
Begdam Hospital, Aug-Dec 1952
3000 cases admitted
2241 confirmed poliomyelitis
1250 had paralysis
345 needed treatment for respiratory insufficiency
Overwhelmed the availability of tank ventilators

8. Dr. Bjørn Ibsen, 1952 tracheotomy just below the larynx
inflatable rubber cuff tube in trachea
frequent suction
repeated bronchoscopy
postural drainage
manual positive pressure ventilation using oxygen and nitrogen.
Developed method for manual delivery of PPV – used students from University of Copenhagen to deliver manpower (1700 involved & none contracted polio!)
Mortality in severe cases fell from 87% to 26%

9. Re-emergence of non-invasive ventilation
Motley et al. Am J Med ….use of IPPB via mouthpiece for acute care…….
1960s Goldwater Rehabilitation Center, NY ….nocturnal and daytime IPPB for NM disease…….
Sullivan …introduction of face mask for treatment of OSA……
1983 Rideau …..application in DMD………
Landmarks in development of NIV for neuromuscular disease

10. Seminal paper leading to change in UK practice…….

11. Survival in hypercapnic patients with DMD

12. Health-related QoL
Survival accompanied by good QoL in DMD (cf other conditions)
Replicated in similar populations of young men with DMD

13. Survival by cohort
Michele Eagle’s study of cohort survival including ventilated patients – this Fig includes post 1990 deaths ventilated (n=24) and non-ventilated (n=33)

14. LTV children in the UK 1999 Questionnaire survey Children 0-16 years
141 children identified
Neuromuscular disease (n=62; 46%), congenital central hypoventilation syndrome (n=18; 13%), spinal injury (n=16; 12%), craniofacial syndromes (n=9; 7%), bronchopulmonary dysplasia (n=6; 4%),

15. Long-term ventilation case load 1996 – 2008

16. Questions now being addressed are not how to but whether to provide LTV…….