By entering information below, the DoctorBach website will build a customized sample Letter of Medical Necessity. When a diagnosis of SMA Type 1 is selected below, other values will be changed to SMA1 sample settings. Click Clear Changes to return to non-SMA1 sample settings. When finished, click Submit.
The information entered is not stored, it is used only for creating the sample letter.
| Inspiratory Muscle... | Failure Dysfunction |
| For SMA1: | Paradoxical chest wall motion |
| (If VC is blank, no results will be displayed) | |
| Sitting Vital Capacity (VC): | ml % of normal |
| Supine Vital Capacity: | ml |
| Maximum Insufflation Capacity (MIC): | ml |
| Peak Cough Flow (PCF) from MIC: | L/s |
| PCF from MIC with Abdominal Thrust: | L/s |
| SaO2 Range: | % to % |
| End-Tidal pCO2: | mm Hg |
| Other: | |
| Trained: Patient Family Caregiver |
| Trained in nasal IPPV |
| Trained in mouthpiece IPPV |
| Trained in manually assisted coughing |
| Trained in mechanical in-exsufflation |
| Practice Air Stacking |
| Practice Sliding Board Transfers |
| Discontinue BiPAP |
| Patient Given Ambubag |
| Other: |
| Portable volume ventilator (PLV-100) Day Night | |
| Mode: | |
| Volume: | ml |
| Rate: | bpm |
| BiPAP-ST (night use) | |
| IPAP: | |
| EPAP: | |
| Rate: | bpm |
| Oxymeter | |
| Mechanical In-Exsufflator (In Home) | |
| Mechanical In-Exsufflator (Rapid Access) | |
| Manual Recuscitator | |
| Chest Percussor | |
| Portable Suction Equipment | |
| Other: | |
| Name: | |
| Title: | |
| Clinic/Hospital: | |
| Phone: | |
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