Reprinted from Post-Polio Health (formerly Polio Network News), Spring 2004 Volume 20, Number 2 with permission of Post-Polio Health International (www.post-polio.org). Any further reproduction must have permission from copyright holder.
Joan L. Headley, Editor, Post-Polio Health (firstname.lastname@example.org)
New breathing and sleep problems in aging polio survivors can be insidious and often go unrecognized by either polio survivors, their family members or their health care providers. Polio survivors may have weakened breathing muscles as a result of the initial damage by the poliovirus; the lungs themselves were not affected. Those who were in an iron lung during the acute phase should be aware of the potential for developing problems later in life and educate themselves in order to recognize important signs and symptoms which may indicate underventilation which may lead to respiratory failure. Even those who did not need ventilatory assistance during the acute phase may also be at risk for underventilation and should be aware of problems with breathing and sleep.
Underventilation (hypoventilation is the medical term) means that not enough air reaches the lungs to fully inflate them. The result may be too little oxygen and too much carbon dioxide (CO2) in the blood. Underventilation can be caused by one or more of the following: weakness of the inspiratory muscles (mainly the diaphragm and rib muscles) for breathing in, weakness of the expiratory muscles (the abdomen) for breathing out and producing an effective cough to clear secretions, scoliosis (curvature of the spine) and sleep apnea. Other factors contributing to a polio survivor’s breathing problems are a history of smoking, obesity, undernutrition and other lung diseases such as asthma, bronchitis and emphysema.
Vital capacity (VC) is the volume of air that can be expelled after taking a big breath and is a measure of how well the lungs inflate. VC normally decreases with age, but this decrease in VC is more serious in an aging polio survivor with weakened breathing muscles. Many polio survivors had impairment of their inspiratory muscles, and the normal changes due to aging may cause them to lose VC at a greater rate. Polio survivors may not experience symptoms of underventilation until their VC falls to 50% or less of predicted (normal). Signs and symptoms of underventilation during sleep include:
Other symptoms may include:
Polio survivors experiencing one or more of the above signs and symptoms should seek a respiratory evaluation (simple and noninvasive pulmonary function tests) by a pulmonologist, preferably one experienced in neuromuscular disorders. Physicians are listed in the Resource Directory for Ventilator-Assisted Living (www.post-polio.org/ivun/d.html).
Pulmonary function tests should include the following measurements. The values that indicate a warning sign for respiratory problems are in parentheses.
Overnight oximetry may be prescribed to detect episodes of oxygen desaturation (<88% during sleep). Management of breathing and sleep problems can be achieved largely through the use of nocturnal noninvasive ventilation, commonly in the form of small, lightweight bilevel positive pressure units. The units have a long tube/circuit that attaches to a mask (nasal, facial or oral), nasal pillows or mouthpiece worn during sleep. Polio survivors may find themselves gradually extending periods of ventilator use, perhaps during a daytime nap. Some polio survivors may need to use a volume ventilator to guarantee delivery of a larger volume of air than a bilevel unit can provide. Noninvasive ventilation may eventually fail, and invasive tracheostomy positive pressure may be necessary.
Treating underventilation with oxygen therapy instead of assisted ventilation can lead to respiratory failure and death because supplemental oxygen can blunt the function of the brain’s respiratory control center. However, polio survivors who use assisted ventilation and have additional medical problems such as COPD, pneumonia or heart problems, or who are undertaking long airplane flights, may benefit from oxygen therapy under careful supervision.
Polio survivors may also have sleep apnea contributing to underventilation. Sleep apnea, an interruption of breathing during sleep, can be obstructive, central or mixed. Obstructive sleep apnea (OSA) is the most common form and is prevalent in the general population. The standard test for OSA is a sleep study; the standard treatment is the use of a continuous positive airway pressure (CPAP) unit with a nasal mask or nasal pillows during sleep. However, polio survivors with both weakened breathing muscles and sleep apnea should use bilevel positive pressure or volume ventilation, not CPAP.
Judith R. Fischer, MSLS, is Editor, Ventilator-Assisted Living. Joan L. Headley, MS, is Editor, Post-Polio Health.