Home Non-invasive Ventilation Research Articles

Monitoring of Noninvasive Ventilation by Built-in Software of Home Bilevel Ventilators: A Bench Study

Current bilevel positive-pressure ventilators for home noninvasive ventilation (NIV) provide physicians with software that records items important for patient monitoring, such as compliance, tidal volume (Vt), and leaks. However, to our knowledge, the validity of this information has not yet been independently assessed.Testing was done for seven home ventilators on a bench model adapted to simulate NIV and generate unintentional leaks (ie, other than of the mask exhalation valve). Five levels of leaks were simulated using a computer-driven solenoid valve (0-60 L/min) at different levels of inspiratory pressure (15 and 25 cm H(2)O) and at a fixed expiratory pressure (5 cm H(2)O), for a total of 10 conditions. Bench data were compared with results retrieved from ventilator software for leaks and Vt.For assessing leaks, three of the devices tested were highly reliable, with a small bias (0.3-0.9 L/min), narrow limits of agreement (LA), and high correlations (R(2), 0.993-0.997) when comparing ventilator software and bench results; conversely, for four ventilators, bias ranged from -6.0 L/min to -25.9 L/min, exceeding -10 L/min for two devices, with wide LA and lower correlations (R(2), 0.70-0.98). Bias for leaks increased markedly with the importance of leaks in three devices. Vt was underestimated by all devices, and bias (range, 66-236 mL) increased with higher insufflation pressures. Only two devices had a bias < 100 mL, with all testing conditions considered.Physicians monitoring patients who use home ventilation must be aware of differences in the estimation of leaks and Vt by ventilator software. Also, leaks are reported in different ways according to the device used.

Process of Attaining Self-care for Chronic Respiratory Failure Patients Receiving Home Noninvasive Positive Pressure Ventilation Therapy

Process of Attaining Self-care for Chronic Respiratory Failure Patients Receiving Home Noninvasive Positive Pressure Ventilation Therapy

Portable Pulse-Dose Oxygen Concentrators Should Not Be Used With Noninvasive Ventilation

An increasing number of patients, mainly COPD and overlap-syndrome patients, simultaneously use home oxygen therapy and noninvasive ventilation (NIV) at night. Usually the oxygen source is a stationary concentrator. We report a patient who, without a medical recommendation, was using a portable oxygen concentrator during nocturnal NIV. In the laboratory, with the patient, we tested the portable oxygen concentrator's triggering and oxygen delivery, with the supplemental oxygen connected at 3 different positions: near the ventilator, near the exhalation valve, and on the nasal mask port. We also tested the concentrator's triggering capacity by placing the nasal prongs and the nasal mask independently. We tested ventilator inspiratory pressures of 10, 14, and 18 cm H(2)O, and expiratory pressures of 4 and 6 cm H(2)O. The portable oxygen concentrator did not detect the patient's inspiratory effort or deliver the required oxygen flow at any of the tested settings. We recommended that the patient not use the portable oxygen concentrator during nocturnal NIV.

Monitoring high performance data streams in vertical markets: Theory and applications in public safety and healthcare

Over the last several years, monitoring high performance data stream sources has become very important in various vertical markets. For example, in the public safety sector, monitoring and automatically identifying individuals suspected of terrorist or criminal activity without physically interacting with them has become a crucial security function. In the healthcare industry, noninvasive mechanical home ventilation monitoring has allowed patients with chronic respiratory failure to be moved from the hospital to a home setting without jeopardizing quality of life. In order to improve the efficiency of large data stream processing in such applications, we contend that data stream management systems (DSMS) should be introduced into the monitoring infrastructure. We also argue that monitoring tasks should be performed by executing data stream queries defined in Continuous Query Language (CQL), which we have extended with: 1) new operators that allow creation of a sophisticated event-based alerting system through the definition of threshold schemes and threshold activity scheduling, and 2) multimedia support, which allows manipulation of continuous multimedia data streams using a similarity-based join operator which permits correlation of data arriving in multimedia streams with static content stored in a conventional multimedia database. We developed a prototype in order to assess these proposed concepts and verified the effectiveness of our framework in a lab environment.

Cellular transplants in amyotrophic lateral sclerosis patients: an observational study

Cytotherapy is a promising option for neurodegenerative disease treatment. Because of the fatal prognosis and imperative need for effective treatment, amyotrophic lateral sclerosis (ALS) patients request this therapy before its effectiveness has been verified. The increase in clinics offering cytotherapies but providing little scientific information has prompted considerable medical tourism. We present an observational study of Spanish ALS patients receiving cytotherapy, analyzing the experiences arising from the treatment (TX) and considering two progression markers, FVC and ALSFRS-R. Twelve ALS patients with a mean age of 48.6 years (SD 12.8) received cytotherapy 26.9 months (SD 15.8) after clinical onset. ALSFRS-R and FVC at TX were 32.3 (SD 6.8) and 63.4% (SD 15.3), respectively. TX involved transplants of olfactory ensheathing cells in three patients, and autologous mesenchymal stromal cells in the remainder. One patient died 33 months post-TX after surviving for 49 months. Five required mechanical non-invasive home ventilation 7.4 months post-TX. Two required invasive ventilation 13 months post-TX. Five patients needed gastrostomy feeding 23.3 months post-TX. Survival between clinical onset and the study end date was 50 months (SD 17.2). No significant adverse events or changes in the decline of FVC and ALSFRS-R compared with the disease's natural history were observed. Our observations suggest that these therapies do not halt the course of the disease. Cytotherapy cannot yet be considered a curative treatment for ALS.

Noninvasive Ventilation in Chronic Respiratory Failure: Effects on Quality of Life

Background: Noninvasive ventilation (NIV) has been found to be an essential technique to treat chronic respiratory failure (CRF) resulting from restrictive thoracic disorders (RTD). The last decades were characterized by the expansion of NIV to treat patients suffering from various other conditions, such as chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS). Objectives: The aim of this study was to evaluate the effect of NIV on health-related quality of life (HRQoL) of patients with CRF during 2 years and to identify parameters associated with changes in HRQoL. Methods: Ninety-one patients with CRF [35 COPD; 17 RTD; 28 OHS; 11 neuromuscular diseases (NMD)] participated. HRQoL was assessed with the SF-36 questionnaire. Additional measurements included blood gases, pulmonary function tests, dyspnea, daytime sleepiness, exacerbations and hospitalizations. The patients were evaluated every 3–6 months. Results: Improvements in SF-36 physical component summary (PCS, p < 0.0001) and mental component summary (MCS, p < 0.0001) scores in RTD and MCS in OHS (p = 0.01) and COPD (p = 0.003) were observed by the third month. PCS in OHS and COPD patients improved by the sixth month (p = 0.003 and p < 0.0001, respectively). NMD patients did not present improvements in HRQoL. Improvements in HRQoL were associated with improvements in PaO₂ and dyspnea in COPD patients, and with total hours of daily ventilator use, improvement in dyspnea, pressure support and expiratory positive airway pressure in RTD patients. Conclusion: Home NIV is consistently effective in improving HRQoL and physiological parameters in patients with CRF. Randomized trials to identify subgroups of COPD responders are justified by our results.

Home noninvasive ventilation in COPD

Educational aims To explain the rationales for home noninvasive ventilation (NIV) in chronic obstructive pulmonary disease (COPD) patients. To review available evidence on the use of home NIV in COPD patients. To review the current consensus on the indications for home NIV in COPD patients. To describe recent evidence in support of home NIV in a selected group of severe COPD patients. To outline future research directions in this area. Summary NIV is now considered the standard care for COPD patients with hypercapnic exacerbations of their disease. There are theoretical benefits of long-term NIV in COPD patients, but evidence from randomised controlled trials (RCTs) is conflicting and inconclusive. This article will address the following issues: • What are the physiological and clinical rationales for the use of home NIV in COPD patients? • What is the available evidence on the use of home NIV in COPD patients? • What are the limitations of previous studies performed in this area? • Recent advances in home NIV. • Future directions.

A Noninvasive Method to Identify Ineffective Triggering in Patients with Noninvasive Pressure Support Ventilation

Background: Ineffective inspiratory triggering efforts are a major cause of poor patient-ventilator interactions during mechanical ventilation, but their routine identification requires the insertion of an esophageal catheter. Objectives: We developed a mathematical analysis of ventilatory tracings recorded under noninvasive pressure ventilation in order to identify ineffective triggering efforts and their consequences without recording esophageal pressure. Methods: We assessed 2,183 cycles from 44 pressure support tracings in 14 children with cystic fibrosis treated by noninvasive home ventilation. Airway pressure, flow and esophageal pressure time series were visually analyzed and manually counted. Airway pressure versus time and flow versus time were then analyzed using a dedicated algorithm written by us. Esophageal pressure was only used for validation. Results: A mathematical treatment of flow time series allowed us to draw phase portraits that had specific periodic trajectories for triggered ventilatory cycles and ineffective triggering efforts. From flow and pressure tracings, our algorithm correctly identified 100% of triggered cycles and 53/56 (94.6%) of ineffective triggering efforts. Ineffective triggering was associated with a significant reduction in minute ventilation, inspiratory flows and a significant increase in inspiratory efforts. Conclusions: A noninvasive analysis of flow and airway pressure can reliably identify ineffective triggering efforts during noninvasive pressure support ventilation. This approach may be a valuable tool for evaluating patient-ventilator interactions and their consequences during long-term recordings.

Prognosefaktoren bei Patienten mit COPD mit chronisch-hyperkapnischer respiratorischer Insuffizienz und außerklinischer Beatmungstherapie

The prevalence of patients with severe COPD and chronic hypercapnic respiratory failure (CHRF) receiving non-invasive home ventilation has greatly increased. With regard to disease severity, a multidimensional assessment seems indicated. Base excess (BE), in particular, reflects the long-term metabolic response to chronic hypercapnia and thus constitutes a promising, easily accessible, integrative marker of CHRF. Infact, BE as well as nutritional status and lung hyperinflation have been identified as independent predictors of long-term survival. In addition and in a review with the literature, a broad panel of indices including frequent comorbidities are helpful for assessment and monitoring purposes of patients with CHRF. Accordingly, in view of the patients' individual risk profile, the decision about the initiation of NIV should probably not rely solely on symptoms and chronic persistent hypercapnia but include a spectrum of factors that specifically reflect disease severity. Owing to the physiologically positive effects of NIV and according to retrospective data, patients with COPD and recurrent hypercapnic respiratory decompensation and patients with prolonged mechanical ventilation and/or difficult weaning could also be considered for long-term non-invasive ventilation. This, however, has to be corroborated in future prospective trials.

Le suivi pratique des patients sous ventilation non invasive au long cours

Efficacy and tolerance of home non-invasive ventilation (NIV) must be assessed by using objective criteria (clinical evaluation, arterial blood gases, oxymetry, and research of side effects such as air leaks, skin problems, etc). In this article, we describe a procedure for long-term follow-up of home NIV. We also suggest an algorithm using available polygraphic tools to ascertain causes of NIV failure, in order to correct them.

Patients’ with ALS and caregivers’ experiences of non-invasive home ventilation

The purpose of this study was to describe the patients’ with ALS and their caregivers’ experiences of non-invasive positive-pressure ventilation. In-depth interviews with seven patients and eight caregivers were analyzed using a qualitative content analysis method. Three main themes emerged: “Getting to know the ventilator”, “Embracing the ventilator” and “Being on a ventilator on a 20–24-h basis”. The patients reported improved sleep and improved activity level but also contradictory emotions as to starting on the ventilator. The ability to stay at home close to the family was mentioned. Findings for the caregivers revealed an initial period of stress and interrupted sleep followed by a period of harmony and relief from stress. When the patient was on the ventilator 20–24 h, the findings indicate an extensive involvement in the care of the patient, as well as dealing with several kinds of technical situations with the ventilator devices causing the caregivers another period of stress. The caregivers reve...

Influence of long-term home noninvasive positive pressure ventilation on respiratory muscle strength in patients with stable severe chronic obstructive pulmonary disease

Objective To study the influence of long-term home noninvasive positive pressure ventilation (HNPPV) on respiratory muscle strength in patients with stable severe chronic obstructive pulmonary disease (COPD).Methods Sixty-four patients with stable severe COPD discharged from Huabei Oil-field Hospital,Renqiu,Hebei were divided into two groups,one (n=24) with HNPPV plus conventional therapy,and the other (n=40) with conventional therapy plus long-term oxygen therapy as controls.All parameters were followed-up for one-year and compared for the two groups,including maximal iuspiratory pressure (MIP),transdiaphragmatic pressure (Pdi),maximal transdiaphragmatic pressure (Pdimax),ratio of Pdi/Pdimax,arterial partial pressure of carbon dioxide (PaCO2),forced expiratory volume in one second (FEV1),6-min walking distance (6MWD),mortality and re-hospitalization rate.Results Age,gender,course of the disease,body mass index (BMI),arterial PaCO2,PaO2,MIP,Pdi,Pdiraax,ratio of Pdi/ Pdimax,FEV1,ratio of FEV1/FVC%,6MWD and re-hospitalization rate of the patients between the two groups were all comparable (P>0.05).In one-year follow-up,PaCO2averaged (52±8)mm Hg,MIP (64±7) cm H2O,Pdi (33±5) cm H2O,Pdimax (101±9) cm H2O,Pdi/Pdimax (0.31±0.04),FEV1 (35±4) %,FEV1/FVC% (44±4) %,6MWD (272±26) m and (2.6 ± 0.8) admissions per year in the HNPPV group,significantly different from those in the control group [ (57 ± 6) mm Hg,(59 ± 6) cm H2O,(31±4) cm H2O,(84±7) cm H2O,(0.35±0.05),(33±3)%,(41±4)%,(212±28) m,and (3.7±0.8) admissions per year] (P 0.05).Conclusions Long-term use of HNPPV for patients with stable severe COPD could efficiently improve their respiratory muscle strength and endurance,thus improving their pulmonary ventilation and treatment efficcacy. Key words: Continuous positive airway pressure ventilation; Pulmonary disease,chronic obstructive; Respiratory muscule

Home Non-Invasive Mechanical Ventilation and Long-Term Oxygen Therapy in Stable Hypercapnic Chronic Obstructive Pulmonary Disease Patients: Comparison of Costs

Background: A cost analysis of nocturnal non-invasive ventilation (NNV) in stable chronic obstructive pulmonary disease (COPD) patients would be helpful in decision making, when the balance between the increased demand and the availability of resources should be checked. Objectives: Based on data from the Italian trial in stable hypercapnic COPD patients, this study compares the cost of care associated with the use of NNV when added to the usual long-term oxygen therapy (LTOT) with the cost of care of LTOT regimen alone. Methods: Cost was calculated in 77 of 90 patients included into that trial. Analysis included drug therapy, hospitalisations due to acute exacerbation, oxygen and ventilator equipments. An estimation of charges was made according to the national sources of cost for drugs and hospital admissions and the actualised reimbursement for the home care provided to both oxygen and ventilator users. The cost/day comparison was made between the individual patients in the 2 groups (NNV + LTOT, n = 35; LTOT, n = 42). Results: The mean cost of drugs and oxygen was similar in both groups, whereas the cost of hospitalisation tended to be lower in NNV + LTOT compared to LTOT alone (8.25 ±10.29 vs. 12.50 ± 20.28 EUR/patient/day, p < 0.05). Inclusion of the ventilator equipment increased the total cost to 23.73 EUR/day in the NNV + LTOT compared to 21.42 EUR/day in the LTOT group (not significant). Conclusions: The present report suggests that long-term management with addition of non-invasive ventilation does not increase costs compared with the usual LTOT regimen: the hospital-related costs were reduced when using the ventilator in these hypercapnic COPD patients.

Performance of ventilators for noninvasive positive-pressure ventilation in children

The aim of the present study was to evaluate the performance characteristics of all the ventilators proposed for home noninvasive positive-pressure ventilation in children in France. The ventilators (one volume-targeted, 12 pressure-targeted and four dual) were evaluated on a bench which simulated six different paediatric ventilatory patterns. For each ventilator, the quality of the inspiratory and expiratory trigger and the ability to reach and maintain the preset pressures and volumes were evaluated with the six patient profiles. The performance of the ventilators showed great variability, and depended upon the type of trigger (flow or pressure), type of circuit and patient profile. Differences were observed between the preset and measured airway pressure and between the tidal volume measured by the ventilator and on the bench. Leaks were associated with an inability to detect the patient's inspiratory effort or autotriggering. No single ventilator was able to adequately ventilate the six paediatric profiles. Only a few ventilators were able to ventilate the profiles simulating the youngest patients. A systematic paediatric bench evaluation is recommended for every ventilator proposed for home ventilation, in order to detect any dysfunction and guide the choice of the appropriate ventilator for a specific patient.

Noninvasive home ventilation for chronic obstructive pulmonary disease: indications, utility and outcome

Despite its widespread use, the role of noninvasive home mechanical ventilation for the management of severe chronic obstructive pulmonary disease and chronic hypercapnic respiratory failure is still controversial. The majority of randomized controlled trials show methodological weaknesses, including issues of patient selection, insufficient pressure support and poor adherence to therapy. Data from short-term trials, while assuring effective ventilation, are encouraging by demonstrating physiological improvements, in line with benefits regarding symptoms and quality of life. The role of home mechanical ventilation for long-term survival is, however, still unclear. Possible indications of home mechanical ventilation, physiological concepts underlying the effects of noninvasive ventilation and their impact on clinically important long-term outcomes are reported. Due to systemic involvement, the decision to undertake home mechanical ventilation should probably not be based on symptomatic chronic hypercapnia alone, but on a broader spectrum of factors. In particular, patients with repeated hypercapnic decompensation are at high risk for death and obvious candidates for home mechanical ventilation. Beyond restoration of chemosensitivity, changes in breathing pattern and a reduction of mechanical load are likely mechanisms of home mechanical ventilation, inducing symptom relief and improving functional reserve. To fully utilize its potential, high pressure levels are required. Future prospective controlled studies should take into account these experiences.

Ventilatory support and pharmacological treatment of patients with central apnoea or hypoventilation during sleep: FIGURE 1.

The concept of central sleep apnoea or hypoventilation encompasses hypercapnic central hypoventilation, such as obesity hypoventilation syndrome and eucapnic or hypocapnic central sleep apnoea.Among subjects with eucapnic or hypocapnic central sleep apnoea, several therapeutic options are available for those with Cheyne–Stokes respiration (CSR). CSR is frequent in patients with New York Heart Association stage III and IV chronic heart failure, and in various neurological disorders. In these patients, treatment modalities include optimising cardiac condition and drugs, such as theophylline, acetazolamide and/or oxygen. Ventilatory support, such as nasal continuous positive airway pressure (CPAP), bi-level pressure support, or adaptive servo-ventilation (ASV), has been shown to improve CSR in patients with cardiac failure; however, convincing evidence that nasal CPAP improves life expectancy in these patients is lacking. Nevertheless, the treatment of associated obstructive sleep-disordered breathing is indicatedper se, as it may improve cardiac function.There is currently no proof that bi-level ventilation is superior to nasal CPAP. The few available studies that have focused on ASV have shown satisfactory control of CSR in cardiac failure patients. While ASV is not a first-line treatment choice, it appears to be superior to oxygen, CPAP and bi-level pressure ventilation in controlling the apnoea/hypopnea index and probably sleep fragmentation. As yet there are no data on mortality and, as such, firm conclusions cannot be drawn as to the role of ASV in the management of cardiac failure patients suffering from CSR.Obesity-related hypoventilation has increased dramatically over recent decades due to the epidemic increase in obesity in the developed countries. Obesity hypoventilation syndrome predisposes to the development of pulmonary hypertension and cor pulmonale. Noninvasive home ventilation is increasingly applied in obese patients with hypercapnic respiratory failure, however, initial mechanical ventilatory support can be reduced to nasal continuous positive airway pressure in only a subset of these individuals.

Impact of noninvasive home ventilation on long-term survival in chronic hypercapnic COPD: a prospective observational study

The long-term benefit from noninvasive ventilation (NIV) in chronic hypercapnic chronic obstructive pulmonary disease (COPD) remains uncertain. Within a prospective observational design, we compared the long-term survival of 140 patients with severe persistent hypercapnic COPD (FEV(1) 28.7 +/- 8.7% predicted; PaCO(2) 60.1 +/- 9.2 mmHg) with (n = 99) or without (n = 41) NIV. End-point was all-cause mortality, determined up to 4 years by Kaplan-Meier analysis. Additionally, Cox's proportional hazards regression and stratification by risk factors was performed. Patients were characterised by anthropometric and functional parameters, comorbidities and medical therapy. Adherence in patients with NIV was high (88.9%), daily ventilator use being 6.4 +/- 2.6 h/day and inspiratory pressures 21.0 +/- 4.0 cmH(2)O. One- and 2-year survival rates were 87.7% and 71.8%, respectively, in patients with NIV vs. 56.7% and 42.0% in patients without NIV. Survival rates were significantly higher in patients with NIV compared to those without this therapy (p = 0.001; hazard ratio 0.380; 95% confidence interval 0.138-0.606). The difference between groups was still significant after adjustment for differences in baseline characteristics. Moreover, stratification by risk factors revealed beneficial effects, particularly in patients with high base excess (BE; > 8.9 mmol/l), low pH (< 7.41), FEV(1) (< 27.5%) haemoglobin (< 13.8 g/dl) or large hyperinflation (residual volume-to-total lung capacity > 189% predicted) upon inclusion (p < 0.05 each). In patients with severe chronic hypercapnic COPD receiving NIV at high inspiratory pressure levels and showing high adherence to this therapy, long-term survival was significantly higher than in non-ventilated patients. Patients displaying more severe disease according to known risk factors seemed to benefit most from long-term NIV.

Predictors of Survival in COPD Patients With Chronic Hypercapnic Respiratory Failure Receiving Noninvasive Home Ventilation

Patients with COPD and chronic hypercapnic respiratory failure (CHRF) are at high risk, and noninvasive ventilation at home is increasingly being used. Knowledge of prognostic parameters under these conditions is limited but may be clinically helpful and highlight the role of noninvasive ventilation. In 188 patients with COPD (mean +/- SD FEV1, 31.0 +/- 9.6% of predicted; PaCo2, 56.3 +/- 9.4 mm Hg) discharged from the hospital receiving NIV between July 1994 and July 2004, the prognostic value of body mass index (BMI), lung function, laboratory parameters, and blood gas levels was assessed by univariate and multivariate Cox regression analyses. Moreover, the impact of changes in risk factors on mortality assessed 6.7 +/- 2.8 months after the initiation of noninvasive ventilation was evaluated. Overall, the mortality rate during follow-up (duration, 32.2 +/- 24.3 months) was 44.7%, with 1-year, 2-year, and 5-year survival rates of 84.0%, 65.3%, and 26.4%. Deaths resulted predominantly from respiratory causes (73.8%). Univariate regression analyses revealed age, BMI, hemoglobin, FEV1, specific airway resistance, residual volume (RV)/total lung capacity (TLC), pH, and base excess (BE) to be associated with prognosis (p < 0.01 each), whereas multivariate analysis identified only age, BMI, RV/TLC, and BE as independent predictors (p < 0.05). In patients at risk (BMI < 25 km/m2, RV/TLC >or= 73%, or BE >or= 9 mmol/L), changes in these predictors were also associated with survival. In patients with COPD and CHRF, nutritional status, hyperinflation, and BE, which turned out to be reliable and consistent markers in CHRF, were independent prognostic factors for mortality. These data favor a multidimensional approach in these patients, including the use of noninvasive ventilation.

Effect of sleep on patient/ventilator asynchrony in patients undergoing chronic non-invasive mechanical ventilation

Patients who require home non-invasive ventilation (NIV) during sleep normally have the ventilation settings adjusted empirically during daytime wakefulness. However, patient-ventilator asynchrony may occur during sleep. To detect the incidence of ineffective efforts (IE) during the sleep compared to wakefulness, we studied 48 patients already enrolled in a long-term home NIV programme. We evaluated arterial blood gases, breathing pattern during spontaneous breathing (SB) and ventilation during wakefulness. In addition, we assessed the breathing pattern and oxygen gas exchange during night-time NIV. Daytime NIV significantly improved blood gases compared to SB (PaO2 NIV 10.2 +/- 1.95 kPa vs PaO2 SB 8 +/- 1.37, p < 0.001; PaCO2 NIV 5.75 +/- 1.08 kPa, vs PaCO2 SB 6.5 +/- 1.25, p < 0.001). The IE index was higher during sleep compared to wakefulness (48 +/- 39.5 events/h versus 0 +/- 0). The IE index was correlated with the time spent with SaO2 < 90% (r = 0.39, p < 0.01), but not with ventilator parameters, underlying disease, ventilation mode or type of mask. Eight patients had an IE index >100 events/h; these patients had a faster respiratory rate, required a higher level of inspiratory assistance and had poor gas exchange during sleep. We conclude that IE to breath are common during nocturnal NIV and that they may be associated with desaturations even in patients who are considered compliant and effectively treated.

Paediatric home ventilatory support: The Auckland experience

To examine the trend over time, describe the disease categories treated, intervention success and outcomes of the children treated at home with continuous positive airway pressure (CPAP), non-invasive ventilation (NIV) and ventilation via tracheostomy (invasive ventilatory support, IVS) by the Respiratory Service at the Starship Children's Hospital in Auckland. A retrospective review was undertaken of the Respiratory Service records from November 1991 to February 2004. Home CPAP, NIV or IVS was initiated in 160 children (89 boys, median age 6 years) in the study period. Sixty-nine (46 boys) remain on support and are still actively managed by the Starship Respiratory Service, of whom 46% live outside the Greater Auckland Region. Despite 42% of children being less than 5 years of age at initiation of therapy, institution of support failed in only 11%. The majority received treatment by non-invasive mask interface (68% (n = 108) CPAP, 29% (n = 47) NIV), with only 3% (n = 5) supported via tracheostomy. The numbers and complexity of support rose over the 12 years. Respiratory support was discontinued in 57% of cases, after a median of 12.5 months (range 3-52 months); in two-thirds, support was no longer required due to an improvement in the medical condition. The most common indication for support in current patients is respiratory parenchymal or airway disease followed by neuromuscular disease. Obesity is not a common indication. This review documents the increasing trend in children receiving respiratory support at home. Future planning and resources are needed to address this growing need.