Benefits Of Noninvasive Ventilation Research Articles

The Efficacy of Noninvasive Ventilation in Patients Affected by Rett Syndrome With Hypoventilation

BackgroundRett syndrome is a progressive neurological disorder associated to several comorbidities that contribute significantly to impair lung function. Respiratory morbidity represents a major cause of death in this population. Little is known about the benefit of noninvasive ventilation. MethodsWe retrospectively enrolled patients with Rett syndrome who underwent a pneumological evaluation combined with a cardiorespiratory polygraphy and/or a pulse oximetry and capnography from 2012 to 2022. ResultsMedical records of 11 patients with Rett syndrome, mean age 13 ± 6 years, were evaluated. Most patients presented with both epilepsy and scoliosis. Five patients showed a pathologic sleep study and/or impaired night gas exchange: mean obstructive apnea-hypopnea index was 4 ± 3 events/hour; mean and minimal SpO2 were, respectively, 93% ± 2% and 83% ± 6%, while mean and maximal transcutaneous carbon dioxide monitoring (PtcCO2) were, respectively, 51 ± 5 mm Hg and 55 ± 8 mm Hg; and mean oxygen desaturation index was 13 ± 11 events/hour. These patients started noninvasive ventilation with clinical benefit and improved gas exchange mostly in terms of PtcCO2 (mean PtcCO2 51 ± 5 mm Hg before and 46 ± 6 mm Hg after noninvasive ventilation). ConclusionsNoninvasive ventilation is a suitable option for patients with Rett syndrome.

Various Aspects of Non-Invasive Ventilation in COVID-19 Patients: A Narrative Review.

Non-invasive ventilation (NIV) is primarily used to treat acute respiratory failure. However, it has broad applications to manage a range of other diseases successfully. The main advantage of NIV lies in its capability to provide the same physiological effects as invasive ventilation while avoiding the placement of an artificial airway and its associated life-threatening complications.The war on the COVID-19 pandemic is far from over. The present narrative review aimed at identifying various aspects of NIV usage, in COVID-19 and other patients, such as the onset time, mode, setting, positioning, sedation, and types of interface. A search for articles published from May 2020 to April 2021 was conducted using MEDLINE, PMC central, Scopus, Web of Science, Cochrane Library, and Embase databases. Of the initially identified 5,450 articles, 73 studies and 24 guidelines on the use of NIV were included. The search was limited to studies involving human cases and English language articles. Despite several reported benefits of NIV, the evidence on the use of NIV in COVID-19 patients does not yet fully support its routine use.

Non-invasive ventilation support for people with amyotrophic lateral sclerosis: multidisciplinary team management.

To summarise recent developments in the use of noninvasive ventilation (NIV) for people with amyotrophic lateral sclerosis (pwALS), with a specific focus on how multidisciplinary teams (MDT) can support best practice. We included 13 papers, 12 with observational designs and one qualitative interview design. The review is structured using four content domains: prognosis, the effectiveness of NIV, NIV tolerance, and MDT structure and delivery. Findings suggest a modest survival benefit of NIV for pwALS. Further evidence is needed to consider the appropriate time of initiation in the context of respiratory status and the influence of NIV on cognitive function over the course of the disease. A key emerging determinant of tolerability of NIV is secretion load. Palliative care professionals within the MDT can play a key role in supporting pwALS to consider the potential benefits of NIV in the context of their preferences, prognosis, symptom burden, and ALS variant. ALS MDTs allow timely information sharing about NIV between experts that is likely to improve outcomes. MDT practice must continually adapt to reflect pwALS's preferences for care and ensure those caring for them at home have access to support using digital innovations.

Protocol for assessing mortality reduction with the early use of noninvasive ventilation in prehospital emergency services: A multicentre, observational cohort study in Madrid, Spain

BackgroundAcute respiratory failure (ARF) has become one of the most prevalent serious pathologies encountered in the emergency medical service (EMS). In hospital settings, noninvasive ventilation (NIV) therapy prevents complications from more aggressive treatments for that condition. However, the scarce evidence on the benefits of NIV in prehospital EMS (i.e., during transport to the hospital) is inconclusive. ObjectivesTo determine whether the administration of NIV during prehospital EMS in cases of ARF reduces in-hospital mortality compared with starting NIV on arrival to in-patient EMS. MethodsThis is a multicentre, observational, prospective cohort study. We recruited a total of 317 patients from the Madrid region (Spain) who were prescribed NIV for their ARF using a nonprobabilistic consecutive sampling method. Analyses of the main outcome (in-hospital mortality) and secondary outcomes (length of hospital stay, readmissions, percentage of intensive care unit admissions, and cost-effectiveness) will include descriptive analyses of patients’ characteristics, as well as bivariate and multivariate analyses and cost-effectiveness analysis. DiscussionThis study will provide data on NIV management in prehospital and in-patient EMS in patients with ARF. Results will contribute to the existing evidence on the benefits of NIV in the context of prehospital EMS while underlining the importance of a standardized formal training for physicians and nurses working in prehospital and in-patient EMSs. ConclusionThe VentilaMadrid study will provide valuable data on the clinical factors of patients receiving NIV in prehospital EMS. Further, were our hypothesis to be confirmed, our results would strongly suggest that the administration of NIV in prehospital EMS by medical and nursing profesionals formally trained in the technique reduces mortality and improves prognoses.

Non-invasive ventilation: a safe and effective respiratory support method in hypoxemic acute respiratoryfailure due to pneumonia with or without acute respiratory distress syndrome.

The benefit of non-invasive ventilation (NIV) in cases of hypercapnic acute respiratory failure (ARF) has already been proven. Still, its safety and efficacy as a respiratory support method for patients with hypoxemic ARF hasn't been studied so well. The aim of our study was to examine the safety and efficacy of NIV in hypoxemic ARF of primary lung origin. This was a prospective observational cohort study of patients with hypoxemic ARF due to communityacquired pneumonia with or without acute respiratory distress syndrome (ARDS) treated using NIV. They were divided into four groups: pneumonia without ARDS, mild, moderate, or severe ARDS. Their clinical and ABG parameters were recorded before initiation of NIV, at 1 hour and 24 hours after ventilation onset and at transition to non-intensive NIV or before endotracheal intubation in NIV failure cases. A total of 63 patients were included. NIV trial was successful in 85.71% of them, while 14.29% experienced NIV failure. In the general population, we observed a significant difference in PaO2/FiO2 only before transition to non-intensive NIV in comparison to the value at admission. This trend was seen in the patients with pneumonia without ARDS and moderate ARDS, but not in those with mild and severe ARDS. The clinical parameters showed improvement early in the course of treatment both in the entire study population and all subgroups. NIV is an effective and safe option for respiratory support in patients with severe CAP only when an adequate etiological treatment has been applied.

The COVID-19 Treatment Landscape: A South African Perspective on a Race Against Time.

The pandemic caused by SARS-CoV-2 has infected more than 94 million people worldwide (as of 17 January 2020). Severe disease is believed to be secondary to the cytokine release syndrome (CRS or “cytokine storm”) which causes local tissue damage as well as multi-organ dysfunction and thrombotic complications. Due to the high mortality rates in patients receiving invasive ventilation, practice has changed from “early-intubation” for acute respiratory distress syndrome (ARDS) to a trial of non-invasive ventilation (NIV) or high flow nasal cannula (HFNC) oxygen. Reports indicating the benefit of NIV and HFNC have been encouraging and have led to more than 20,000 such devices being manufactured and ready for roll-out in South Africa (SA) as of July 2020. The need to identify drugs with clear clinical benefits has led to an array of clinical trials, most of which are repurposing drugs for COVID-19. The treatment landscape reflects the need to target both the virus and its effects such as the CRS and thrombotic complications. Conflicting results have the potential to confuse the implementation of coordinated treatment strategies and guidelines. The purpose of this review is to address pertinent areas in the current literature on the available medical treatment options for COVID-19. Remdesivir, tocilizumab, and dexamethasone are some of the treatment options that have shown the most promise, but further randomized trials are required to particularly address timing and dosages to confidently create standardized protocols. For the SA population, two healthcare sectors exist. In the private sector, patients with medical insurance may have greater access to a wider range of treatment options than those in the public sector. The latter serves >80% of the population, and resource constraints require the identification of drugs with the most cost-effective use for the greatest number of affected patients.

The Benefit of Non-invasive Ventilation in Motor Neuron Disease.

Background:Motor Neuron Disease (MND) is a progressive neurodegenerative disorder leading to respiratory muscle weakness with dyspnoea, morning headaches, orthopnoea, poor concentration, unrefreshing sleep, fatigue and daytime somnolence. Respiratory failure is the primary cause of death in those with MND.Methods:Although guidelines suggest the use of non-invasive ventilation (NIV) in MND, there lacks clear guidance as to when is the optimal time to initiate NIV and which markers of respiratory muscle decline are the best predictors of prognosis. There have been a number of studies that have found a significant survival advantage to the use of NIV in MND. Similarly, in quality-of-life questionnaires, those treated with NIV tend to perform better and maintain a better quality of life for longer. Furthermore, studies also suggest that improved compliance and greater tolerance of NIV confer a survival advantage.Results and Discussion:Forced Vital Capacity (FVC) has traditionally been the main pulmonary function test to determine the respiratory function in those with MND; however, FVC may not be entirely reflective of early respiratory muscle dysfunction. Evidence suggests that sniff nasal inspiratory pressure and maximum mouth inspiratory pressure may be better indicators of early respiratory muscle decline. These measures have been shown to be easier to perform later in the disease, in patients with bulbar onset disease, and may indeed be better prognostic indicators.Conclusion:Despite ongoing research, there remains a paucity of randomised controlled data in this area. This review aims to summarise the evidence to date on these topics.

Ventilation non invasive à domicile chez des patients BPCO sévères hypercapniques (étude SOMNOVENT’)

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, especially in cases of chronic hypercapnic respiratory failure. Following a prolonged debate, the indication and benefits of noninvasive ventilation (NIV) have been recently established. Although improved ventilation and reduction in hyperinflation appear to underlie the positive effect on NIV in COPD, only a few studies have focused on specific ventilatory algorithms for improving PaCO2. The main objective of this study is to analyze the impact of Löwenstein's ventilatory algorithms, supposed to allow a better management of hyperinflation and its consequences on alveolar ventilation and blood gas parameters. This is an interventional study in routine care, prospective, single blind, randomized with cross over. The primary endpoint will be the transcutaneous partial pressure of nocturnal carbon dioxide. Secondary endpoints will be: abnormal respiratory events occurring during nocturnal NIV; the objective quality of sleep via polysomnography; the tolerance of ventilation and the subjective quality of sleep evaluated by auto questionnaires. The results of this study will clarify whether is it necessary to explore more the impact of the ventilatory modes developed by Löwenstein, dedicated to hypercapnic COPD patients, requiring a long-term NIV.

Articles That May Change Your Practice: Novel Strategies for Coronavirus Disease 2019 Respiratory Failure

Articles That May Change Your Practice: Novel Strategies for Coronavirus Disease 2019 Respiratory Failure

Non-invasive ventilation in the treatment of acute respiratory failure with COVID-19

Decades have passed since the first reports of the successful use of mask non-invasive ventilation (NIV) in the treatment of respiratory failure. The aim of the study is determining the benefits of NIV in acute respiratory failure in patients with COVID-19. The study included patients admitted to the intensive care unit of the surgical clinic of the AMU from April 1 to May 1, 2020. NIV has visible advantages over mechanical ventilation. But it must be remembered that even in experienced hands, NIV is successful only in 75–90% of all cases, which depends on many factors, such as the severity of ONE, the training and experience of medical personnel. As with many types of therapy, operations, and technologies, improvement in the results of this method can be expected as experience is gained.

Indications for Non-Invasive Ventilation in Respiratory Failure.

Non-invasive ventilation (NIV) is increasingly being used to treat episodes of acute respiratory failure not only in critical care and respiratory wards, but also in emergency departments. Aim of this review is to summarize the current indications for the management of NIV for respiratory failure. Current literature about the topic was reviewed and critically reported to describe the rationale and physiologic advantages of NIV in various situations of respiratory failure. Early NIV use is commonly associated with the significant decrease in endotracheal intubation rate, the incidence of infective complications (especially ventilatory associated pneumonia), Intensive Care Units and the length of hospital stay and, in selected conditions, also in mortality rates. Severe acute exacerbation of chronic obstructive pulmonary disease (pH<7.35 and relative hypercarbia) and acute cardiogenic pulmonary oedema are the most common NIV indications; in these conditions NIV advantages are clearly documented. Not so evident are the NIV benefits in hypoxaemic respiratory failure occurring without prior chronic respiratory disease (De novo respiratory failure). One recent randomized control trial reported in hypoxaemic respiratory failure a survival benefit of high-flow nasal cannulae over standard oxygen therapy and bilevel NIV. Evidence suggests the advantages of NIV also in respiratory failure in immunocompromised patients or chest trauma patients. Use during a pandemic event has been assessed in several observational studies but remains controversial; there also is not sufficient evidence to support the use of NIV treatment in acute asthma exacerbation. NIV eliminates morbidity related to the endotracheal tube (loss of airway defense mechanism with increased risk of pneumonia) and in selected conditions (COPD exacerbation, acute cardiogenic pulmonary edema, immunosuppressed patients with pulmonary infiltrates and hypoxia) is clearly associated with a better outcome in comparison to conventional invasive ventilation. However, NIV is associated with complications, especially minor complications related to interface. Major complications like aspiration pneumonia, barotrauma and hypotension are infrequent.

Long-term Noninvasive Ventilation in Obesity Hypoventilation Syndrome Without Severe OSA: The Pickwick Randomized Controlled Trial

Noninvasive ventilation (NIV) is an effective form of treatment in obesity hypoventilation syndrome (OHS) with severe OSA. However, there is paucity of evidence in patients with OHS without severe OSA phenotype. Is NIV effective in OHS without severe OSA phenotype? In this multicenter, open-label parallel group clinical trial performed at 16 sites in Spain, we randomly assigned 98 stable ambulatory patients with untreated OHS and apnea-hypopnea index< 30 events/h (ie, no severe OSA) to NIV or lifestyle modification (control group) using simple randomization through an electronic database. The primary end point was hospitalization days per year. Secondary end points included other hospital resource utilization, incident cardiovascular events, mortality, respiratory functional tests, BP, quality of life, sleepiness, and other clinical symptoms. Both investigators and patients were aware of the treatment allocation; however, treating physicians from the routine care team were not aware of patients' enrollment in the clinical trial. The study was stopped early in its eighth year because of difficulty identifying patients with OHS without severe OSA. The analysis was performed according to intention-to-treat and per-protocol principles and by adherence subgroups. Forty-nine patients in the NIV group and 49 in the control group were randomized, and 48 patients in each group were analyzed. During a median follow-up of 4.98 years (interquartile range, 2.98-6.62), the mean hospitalization days per year ± SD was 2.60 ± 5.31 in the control group and 2.71 ± 4.52 in the NIV group (adjusted rate ratio, 1.07; 95%CI, 0.44-2.59; P= .882). NIV therapy, in contrast with the control group, produced significant longitudinal improvement in Paco2, pH, bicarbonate, quality of life (Medical Outcome Survey Short Form 36 physical component), and daytime sleepiness. Moreover, per-protocol analysis showed a statistically significant difference for the time until the first ED visit favoring NIV. In the subgroup with high NIV adherence, the time until the first event of hospital admission, ED visit, and mortality was longer than in the low adherence subgroup. Adverse events were similar between arms. In stable ambulatory patients with OHS without severe OSA, NIV and lifestyle modification had similar long-term hospitalization days per year. A more intensive program aimed at improving NIV adherence may lead to better outcomes. Larger studies are necessary to better determine the long-term benefit of NIV in this subgroup of OHS. ClinicalTrials.gov; No.: NCT01405976; URL: www.clinicaltrials.gov.

The benefits of non-invasive ventilation for Community-Acquired Pneumonia: A meta-analysis.

There is an observed international increase in NIV application as an alternative to endotracheal intubation in non-COPD patients admitted with community acquired pneumonia despite the lack of strong evidence for its use. The aim of this study is the meta-analysis of data from randomised-controlled trials on the effectiveness of non-invasive ventilation versus standard medical care in adults admitted with severe community-acquired pneumonia. Monthly electronic searches on CENTRAL and MEDLINE were performed between September 2017 and October 2019. Only randomized controlled-trials comparing non-invasive ventilation to standard medical care for the treatment of community-acquired pneumonia in adults were eligible for inclusion. The primary outcomes were the rate of endotracheal intubation (ETI) and the proportion of patients meeting the criteria of ETI as defined by the investigators. Secondary outcomes were the ICU and hospital mortality rate. Study eligibility was independently assessed by two investigators. The risk of bias of included studies was assessed using Cochrane's Risk of bias Tool. Four RCTs involving a total of 218 participants were eligible for inclusion. Results from the meta-analysis showed that NIV significantly reduced rate of ETI (RR = 0.46, 95% CI [0.26, 0.79]), the proportion of patients that met the criteria for ETI (RR = 0.28, 95% CI[0.16, 0.49]) and ICU mortality rate (RR = 0.3, 95% CI[0.09, 0.93]). No significant effect on hospital mortality rate was found (RR = 0.44, 95% CI [0.05, 3.67]). The authors rated quality of evidence based on GRADE criteria as 'Moderate' for the rate of intubation and proportion of patients meeting ETI criteria outcomes, but quality of evidence for ICU and hospital mortality rate as 'Low'. This study provides evidence supporting the use of NIV as potential means of avoiding endotracheal intubation and ICU mortality, in patients with acute respiratory failure due to CAP in the critical care setting. However, there is need for further larger international studies.

Non-Invasive Ventilation in Stable Chronic Obstructive Pulmonary Disease

The benefit of non-invasive ventilation (NIV) in stable chronic obstructive pulmonary disease (COPD) remains controversial. However, there is increasingly more evidence of NIV efficiency, especially high-flow NIV. This review presents the old and the new evidence of NIV effectiveness in stable COPD, considering pathophysiological arguments for NIV in COPD. Guidelines, randomized controlled trials (RCTs) and crossover studies included in review and metaanalysis based on patient-reported outcomes (PROs) have been analyzed. The role of NIV in rehabilitation and in palliative care and the role of telemedicine in relation with NIV are still up for debate. Challenges in choosing the right device and the optimal mode of ventilation still exist. There are also discussions on the criteria for patient inclusion and on how to meet them. More studies are needed to determine the ideal candidate for chronic NIV and to explain all the benefits of using NIV.

Not All COPD Patients Benefit from Prophylactic Noninvasive Ventilation After Scheduled Extubation: An Exploratory Study.

BackgroundProphylactic noninvasive ventilation (NIV) after scheduled extubation can benefit patients with chronic respiratory disorders, among which chronic obstructive pulmonary disease (COPD) is a significant example. However, it is not known whether all COPD patients benefit from prophylactic NIV.MethodsWe performed a post hoc analysis of prospectively collected data. COPD patients who successfully completed a spontaneous breathing trial were enrolled. In the prophylactic NIV group, NIV was applied immediately after extubation. In the usual care group, conventional oxygen therapy was used. Patients were followed up to 90 days post-extubation.ResultsAmong patients with PaCO2 > 45 mmHg, 128 and 40 received prophylactic NIV and usual care, respectively. Prophylactic NIV led to lower rates of re-intubation (4% vs 30% at 72 h and 11% vs 35% at 7 days, both p < 0.01) and hospital mortality (18% vs 40%, p < 0.01) than usual care. The proportion of 90-day mortality was also lower in the prophylactic NIV group (log rank test, p = 0.04). Among patients with PaCO2 ≤ 45 mmHg, 32 and 21 received prophylactic NIV and usual care, respectively. In this cohort however, prophylactic NIV neither reduced re-intubation (6% vs 5% at 72 h, p > 0.99, and 9% vs 14% at 7 days, p = 0.67) nor hospital mortality (19% vs 24%, p = 0.74). The proportion of 90-day mortality did not differ between the two groups (log rank test, p = 0.79).ConclusionThis exploratory study shows that prophylactic NIV benefits COPD patients with PaCO2 > 45 mmHg, but it may not benefit those with PaCO2 ≤ 45 mmHg. Further study with a larger sample size is required to confirm this.

Hypercapnic COPD patients and NIV at home: is there any benefit? Using the CAT and BODE index in an effort to prove benefits of NIV in these patients.

IntroductionThe benefits of long-term noninvasive ventilation (NIV) in stable COPD with chronic hypercapnic respiratory failure (CHRF) have been debated for many years due to the conflicting results observed in these patients.Materials and methodsWe investigated the effects of domiciliary NIV in stable hypercapnic COPD patients for a period of 1 year using COPD Assessment Test (CAT), BODE Index, and the number of acute exacerbations. NIV was administered in 57 stable COPD patients with CHRF in the spontaneous/timed mode. Spirometry, 6 minute walk test, Medical Research Council dyspnea scale, arterial blood gases, number of acute exacerbations, BODE Index, and CAT were assessed. Study participants were reassessed in the 1st, 6th, and 12th months after the initial evaluation.ResultsThere was a significant improvement in COPD exacerbations (p<0.001), CAT (p<0.001), PO2 (p<0.001), PCO2 (p<0.001), and Medical Research Council dyspnea scale (p<0.001) in 1 year of follow-up. BODE Index was improved in the first 6 months (5.8±2.2 vs 4.8±2.4, p<0.001), but the improvement was not maintained.ConclusionIn conclusion, domiciliary NIV in stable COPD patients with CHRF has beneficial effect on CAT, arterial blood gases, and number of acute exacerbations in a year of NIV use at home. A significant improvement in BODE Index from baseline to 12 months was found in patients aged >70 years, while for those aged <70, the improvement was not maintained after the sixth month.

P.069 Respiratory dysfunction and sleep disordered breathing in children with Myasthenia Gravis

Background: Myasthenia Gravis ( MG) is an autoimmune disease that affects the neuromuscular junction. It typically presents with fluctuating muscle weakness which can affect respiratory muscles. Data about the prevalence of sleep disordered breathing in children with MG and the benefits of non-invasive ventilation outside the setting of MG crisis has not been studied so far. Methods: Eleven children between 3 and 18 years old with confirmed MG were recruited from the The Hospital for Sick Children Neuromuscular clinic in a prospective observational study. Informed consent was obtained and patients underwent PFTs, MIP/MEP, SNIP, FVC and standard polysomnography testing’s. Results: In our study, we found that 2/11 children had abnormal Apnea Hypopnea index (AHI) and were diagnosed with obstructive sleep apnea (OSA). One of them has juvenile ocular MG with mild to moderate OSA and the second child has congenital MG with mild OSA. CPAP therapy was initiated for both patients. Conclusions: In our cohort, obstructive sleep apnea rate was significantly higher in children with MG than the known prevalence in general pediatric population ( 18% vs 2-3% ). Early diagnosis and management of OSA can have great impact on children’s health and quality of life. A larger study is needed to validate our findings.

Role of Domiciliary Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease Patients Requiring Repeated Admissions with Acute Type II Respiratory Failure: A Prospective Cohort Study.

Background:Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with acute hypercapnic respiratory failure (AHRF) is associated with high mortality and increased risk for further exacerbations and hospitalization. While there is ample evidence regarding the benefit of noninvasive ventilation (NIV) during AECOPD, evidence supporting long-term noninvasive ventilation (LTNIV) for more stable COPD patients is limited.Objective:The aim of this study is to assess the effectiveness of LTNIV in COPD patients requiring frequent hospital admissions and NIV support for AHRF.Materials and Methods:A prospective cohort study including 120 patients having survived an admission requiring NIV support for AHRF due to COPD, with a history of ≥3 similar episodes in the past year. Patients were advised LTNIV (30) with standard treatment, or (90) standard treatment alone. Both groups were followed up for 1 year. Among non-NIV group 10 died, and 8 lost follow-up, whereas two died in NIV group. The primary endpoint was death. Data of remaining 100 patients were analyzed for other objectives-number of readmissions, AHRF, Intensive Care Unit (ICU)/ventilator requirement, dyspnea, quality of life, exercise tolerance, lung function, and arterial blood gases.Results:LTNIV group had 40% reduction in mortality (6.6% vs. 11.1%). There was significant reduction in number of hospital admissions (28.6% vs. 84.7%: P <0.05), ICU admissions (7.1% vs. 56.9%: P = 0.01), ventilator requirement (3.6% vs. 30.6%: P = 0.003), AHRF (7.1% vs. 48.6%: P = 0.000) and improvement in partial arterial CO2 pressure (39.8 ± 2.1 vs. 57.03 ± 3.7 mmHg) and severe respiratory insufficiency score (P < 0.05) among LTNIV group, but no significant change in lung function and exercise tolerance.Conclusion:Patients tolerated LTNIV well and had a better outcome compared to those without NIV. LTNIV may be considered in patients with recurrent AHRF.

Theme 13 Respiratory and nutritional management

Background Regular administration of positive pressure non-invasive ventilation (NIV), typically at night to ameliorate nocturnal hypoventilation, extends survival without halting disease progression (1). Many people with MND need practical support to benefit from NIV treatment beyond that which can be provided by family caregivers. There is a paucity of research describing formal care support in MND in general, and very little knowledge of the work of professionals supporting NIV treatment in any context. Objectives To understand how professional caregivers support NIV treatment in MND. Methods A qualitative approach was used to facilitate exploration and description of formal support of NIV treatment by a variety of health and social care professionals who, as a part of their job, provide support for MND patients using NIV. The semi-structured interview schedule included knowledge of MND symptoms, familiarity with NIV treatment, practical support, expectations, and a critical assessment of NIV treatment and their ability to support NIV treatment. The analysis was essentially explanation building, towards seeing common patterns, and ultimately providing recommendations. Results Seventeen professionals consented, including GPs, community and respiratory physiotherapists, speech and language therapists (SLTs), community nurses and nursing home/care agency staff. GPs, community physiotherapists and SLTs reported very few cases in their practices but had knowledge of NIV treatment, in contrast to community nurses and nursing home/care agency staff, who typically have neither knowledge nor experience until faced with a patient using NIV. Practical support provided by professionals included advice, titrating pressure, assistance for those unable to use the equipment independently, and psychological support. Discussion Attitudes and expectations of NIV differed, with some professionals being concerned about symptom relief, some about functional improvements (such as improved speech), and some with operational issues (such as mask comfort), without considering the worth of NIV as a treatment. Some professionals who are responsible for the daily care of patients using NIV report no education about NIV in advance of meeting such patients, and so typically learn about NIV treatment ‘on-the-job’. Conclusions Professional carers were very disparate in their attitudes and their background training in MND and NIV. There is a need to examine training requirements for nursing home/care agency staff. Furthermore, professionals showed no consensus on the benefits of NIV but were fulfilling their professional duties to administer and sustain it without knowledge or involvement in the decision to commence it. Reference Bourke S, Tomlinson M, Williams T et al Lancet Neurology 2006; 5:140-7.

Evidence-based Utilization of Noninvasive Ventilation and Patient Outcomes.

Strong evidence supports use of noninvasive ventilation (NIV) for patients with respiratory distress from chronic obstructive pulmonary disease and heart failure (strong evidence conditions [SECs]). Despite unclear benefits of NIV for other causes of acute respiratory failure, utilization for conditions with weaker evidence is increasing, despite evidence demonstrating higher mortality for patients who suffer NIV failure (progression from NIV to invasive mechanical ventilation [IMV])) compared with being treated initially with IMV. To determine the association of hospital variation in evidence-based utilization of NIV with patient outcomes. Using the California State Inpatient Database 2011, we identified adult patients who received NIV. Patients were considered to have an SEC for NIV if they had an acute exacerbation of chronic obstructive pulmonary disease or heart failure. We used multivariable hierarchical logistic regression to determine the association between hospital rates of NIV use for SECs and patient risk of NIV failure (need for IMV after NIV). Among 22,706 hospitalizations with NIV as the initial ventilatory strategy, 6,820 (30.0%) had SECs. Patients with SECs had lower risk of NIV failure than patients with weak evidence conditions (8.1 vs. 18.2%, P < 0.0001). Regardless of underlying diagnosis, patients admitted to hospitals with greater use of NIV for SECs had lower risk of NIV failure (Quartile 4 vs. Quartile 1 adjusted odds ratio = 0.62; 95% CI = 0.49-0.80). Even patients without an SEC benefited from admission to hospitals that used NIV more often for patients with SECs (Quartile 4 vs. Quartile 1 adjusted odds ratio for NIV failure = 0.68; 95% CI = 0.52-0.88). Most patients who received NIV did not have conditions with strong supporting evidence for its use with wide institutional variation in patient selection for NIV. Surprisingly, we found that all patients, even those without an SEC, benefited from admission to hospitals with greater evidence-based utilization of NIV, suggesting a "hospital effect" that is synergistic with patient selection.