Apoptosis of circulating neutrophils in COPD patients.

we maintain mechanical ventilation for 3 weeks. Then, after the tube is removed, the patient continues with nasal nocturnal ventilation and intermittent positive-pressure ventilation for 20 min three times a day. If, despite this management, the patient requires invasive ventilation more than three times during the same year or requires nasal ventilation not only during sleeping, but also while awake, a tracheostomy is performed. Treatment has changed over the years. We agree with Dr. Bach that patients with respiratory paralysis benefit from preventive noninvasive treatment with hyperinsufflation and noninvasive nocturnal ventilation, which is associated with help in coughing. At the present time, we also use percussion therapy with respiratory physiotherapy every day at home, and these treatments delay the acute respiratory worsening. In our experience, patients with tracheostomy tubes are no longer hospitalized until spine surgery and are less dependent on their environment. Severely affected children cannot attend a boarding school while using noninvasive ventilation. So, even now we perform a tracheostomy in ventilatory-dependent children who require daylong therapy. Dr. Bach said that “many of their patients needed to be intubated on 10 or more occasions before age 5” and that “patients . . . use high span BPPV [bilevel positive pressure ventilation] at least when sleeping and as many as 60 use it up to 24 hours a day.” In our opinion, for a patient who needs continuous nasal ventilation, or requires invasive ventilation more than three times during the same year, we prefer the use of tracheostomy, which allows a better quality of life. Mechanical ventilation with good thoracic expansion prevents pectus excavatum.