Non-invasive ventilation, ordinary wards and medical emergency team: Maximizing effectiveness while preserving safety

Abstract

We read we great interest the paper by Schneider et al.1Schneider A.G. Calzavacca P. Mercer I. Hart G. Jones D. Bellomo R. The epidemiology and outcome of medical emergency team call patients treated with non-invasive ventilation.Resucitation. 2011; https://doi.org/10.1016/j.resuscitation.2011.04.009Abstract Full Text Full Text PDF Scopus (23) Google Scholar on non-invasive ventilation (NIV) use in medical emergency team (MET) calls. The paper offers a precious insight into real-life MET interventions for patients suffering from acute respiratory failure (ARF), showing that NIV is a common MET-delivered treatment. In our opinion, two further considerations are required to better define the role of NIV in this context. First, NIV effectiveness is considered to be maximal when applied at an early stage of ARF.2Nava S. Hill N. Non-invasive ventilation in acute respiratory failure.Lancet. 2009; 374: 250-259Abstract Full Text Full Text PDF PubMed Scopus (525) Google Scholar Unfortunately, the Authors did not report data (like arterial blood gas values) on the severity of treated patients, but given their strict MET criteria,3Jones D. Bates S. Warrilow S. et al.Effect of an education programme on the utilization of a medical emergency team in a teaching hospital.Int Med J. 2006; 36: 231-236Crossref Scopus (43) Google Scholar likely patients suffered from moderate-to-severe ARF. This could explain the high rate of immediate admission to ICU/HDU and the high mortality rate in the study. If NIV is to be applied at an earlier stage to avoid patient deterioration (that is the fundamental aim of the MET), a larger number of patients would be treated. The shortage of ICU beds is a worldwide problem, so an increase in the number of treatments forces NIV application on ordinary wards: quoting the British Thoracic Society Guidelines for Non-invasive Ventilation, “…If an acute NIV service is not provided, the shortage of ICU beds means that some patients will die”.4British Thoracic Society Standards of Care Committee Non-invasive ventilation in acute respiratory failure.Thorax. 2002; 57: 192-211Crossref PubMed Scopus (677) Google Scholar As a matter of fact, NIV use for ARF on ordinary ward has been reported from many Countries.5Cabrini L. Antonelli M. Savoia G. Landriscina M. Non-invasive ventilation outside the intensive care unit: an Italian survey.Minerva Anestesiol. 2011; 77: 313-322PubMed Google Scholar Cost-effectiveness is also improved when patients are treated on ordinary wards.2Nava S. Hill N. Non-invasive ventilation in acute respiratory failure.Lancet. 2009; 374: 250-259Abstract Full Text Full Text PDF PubMed Scopus (525) Google Scholar Second, safety of NIV-treated patients in ordinary wards must be guaranteed. The Authors underlined the importance of training the MET. We consider equally crucial to train the ward staff about NIV, with particular attention to prevention and treatment complications, problem-solving, clinical and instrumental monitoring. Ward staff, and above all nurses, must be fully aware of the risk of NIV failure, and should be able to promptly recognize a deteriorating respiratory patient. Ward personnel is expected to cooperate in the daily managing of NIV treatments and should know how to correctly apply the interface, the importance of patient comfort and of patient motivation. A preliminary comprehensive training should be offered to all ward staff before the introduction of NIV. Beside that, patient safety should be maximized using the tools commonly applied in risk management. As an example, in our Institution we introduced explanatory poster attached to the NIV devices depicting the correct connection of the circuit to the interface and the ventilators; on the other side of the poster, a check-list is present reporting the exact sequence to be followed when applying NIV. Finally, manufacturers should address the limitations of general wards and propose specifically designed ventilators. In conclusion, if a dedicated NIV service is not in place, the MET should prepare to manage a growing number of NIV treatments on general wards, with relevant training and organizational implications. Research on the topic is at its beginning, and we are very grateful to the Authors for their brilliant contribution. All authors declare they have not any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.