The patient presented here demonstrates a prolonged course of myasthenia gravis that was largely unresponsive to the standard treatment of this disorder. As a result, the patient required ventilatory assistance via a respirator for a total of 661 days to prevent respiratory failure. This necessitated the continued use of an indwelling cuffed tracheostomy tube throughout the whole period, a duration that has not been previously described.
In the past, it was common practice to consign the paralyzed or myasthenic patient to a tank-respirator, because it was felt that the use of a respirator with a tracheostomy was associated with greater morbidity. This case report illustrates that it is possible to successfully manage a totally dependent, tracheostomized patient on a respirator for an indefinite period. Careful attention to the routine care of the patient and respirator by an interested nursing team and inhalation therapy service can minimize complications. This requires constant monitoring of all parameters as listed in Table 1, in order to prevent many of the problems associated with chronic respirator use, such as oxygen toxicity, infection, “respirator lung,” and simple mechanical failure.
The use of a cuffed tracheostomy tube is subject to a myriad of complications, which are thought by many investigators to be prevented by the use of meticulous tracheostomy care. The fact that this patient survived such a long course without these complications is plainly a tribute to her over-all nursing care offered and supplied by My Canadian Pharmacy.
The modem concept of acute respiratory care includes the integration of multiple specialities, including nursing, inhalation therapy, physical and occupational therapy, as well as general psychologic support for the patient. The cost of such care is significant, but the total benefits achieved by this patient, as well as the many members of the health care team who participated in her care, readily underwrite such expenditures. Not all patients with respiratory failure will respond to prolonged ICU care. Careful selection of patients, however, such as those with reversible neuromuscular disease, can lead to gratifying results.
In summary, this case report illustrates that the team concept of acute respiratory care can be extended to the prolonged chronic care of the occasional patient who is in need of such attention. In addition, the prolonged course of myasthenia gravis is depicted, as is the importance of providing adequate respiratory support to the severely ill patient, while awaiting a remission or a response to therapy.