Implementation Of Noninvasive Ventilation Research Articles

NIV@Home: a pilot randomized controlled trial of in-home noninvasive ventilation initiation compared to a single-day admission model.

Objective: Noninvasive ventilation (NIV) is the primary treatment for respiratory insufficiency in neuromuscular disease. NIV implementation is usually conducted within hospitals; however, in-home implementation with intensive follow-up is an effective alternative. This pilot study aimed to assess model feasibility, acceptability, and NIV usage at 12-weeks after a single visit in-home implementation of NIV with remote monitoring follow-up (NIV@Home) compared to an in-hospital day admission NIV initiation plus planned polysomnography (Usual care). Methods: A single-blinded randomized controlled trial (www.anzctr.org.au ACTRN12620000682943) of adults with neuromuscular disease referred for NIV implementation. Participants were stratified by disease (MND or Other diagnoses) and bulbar symptoms before randomization to NIV@Home or Usual care, with follow-up at 12-weeks. The primary outcome was NIV usage. Secondary outcomes included feasibility, health-related quality of life, symptoms, carer burden, and NIV experience (semi-structured qualitative interviews). Results: Twenty-three participants (MND bulbar = 9, MND non-bulbar = 11, Other = 3) were randomized (NIV@Home = 9). No statistical differences were observed in the percentage of MND participants using NIV for >4 hours/day (NIV@Home = 33% vs. Usual care = 60%, p=0.370), average use (NIV@Home = 2.4 [1.5-9.3] vs. 5.3 [1.8-7.0] hours/day, p=0.568), or secondary outcomes. In-home NIV implementation was feasible and safe but took more therapist time (NIV@Home = 278 [270-305] vs. 172 [130-200] minutes, p<0.001). Participants in the NIV@Home group reported substantial advantages to receiving care in home. Conclusion: In-home NIV implementation is feasible and acceptable to people with MND but requires more therapist time. Larger studies are required to determine whether there are clinically important differences between this model of NIV initiation and a traditional hospital-based model.

Noninvasive ventilation for weaning from mechanical ventilation: A literature review.

The implementation of noninvasive ventilation as a weaning strategy from mechanical ventilation has been steadily rising in recent years. Unlike mechanical ventilation, noninvasive ventilation is thought to preserve diaphragmatic muscle strength, ensuring a quicker and more effective healing process. This review article aims to highlight this topic by examining past studies that investigated noninvasive ventilation as a weaning strategy, and by comparing its performance to other methods. Additionally, we reviewed the available literature in utilizing this strategy in certain subgroups of the population.&#x0D; Based on our review, we conclude that noninvasive ventilation reduces the risks of reintubation, minimizes the requirement for antibiotics, lowers the incidence of ventilator-associated pneumonia and leads to decreased length of intensive care unit stay.&#x0D; However, regarding post-extubation respiratory, and mortality rates, the results were mixed.&#x0D;

Respiratory Health, Sleep Dysfunction, and Mental Health in Children and Adolescents With a Neuromuscular Disorder: A Descriptive Qualitative Study

Objectives: To explore how respiratory health and sleep problems affect mental health in children and adolescents with neuromuscular disorders (NMDs).Methods: A qualitative descriptive study was carried out with content analysis of in-depth interviews conducted with children with NMDs and their parents. Data were collected during semi-structured interviews with children with NMDs and their parents. A total of 14 families were recruited (17 parents and 7 children and adolescents with NMD aged 5–17 years). Each interview was conducted with 1–3 family member(s).Results: Engagement in community activities, meaningful relationships, feeling well, and achieving independence each contributed positively to children’s mental health. Additional challenges to mental health during periods of poor respiratory and/or sleep health included: 1) challenges to behavioral regulation, 2) changes to mood, and 3) challenges to thinking. Parents and children reported nurturing and coping self-management strategies when their physical and mental health were dually challenged in addition to medical management strategies such as non-invasive ventilation (NIV).Conclusions: This study supports the notion that changes in mental health may indicate poor physical health in children with NMDs. Treating respiratory and sleep problems, such as by early NIV implementation, may improve the mental health of children with NMDs and thus support their overall wellbeing and health outcomes.

Non-Invasive Ventilation as a Therapy Option for Acute Exacerbations of Chronic Obstructive Pulmonary Disease and Acute Cardiopulmonary Oedema in Emergency Medical Services.

In this observational prospective multicenter study conducted between October 2016 and October 2018, we tested the hypothesis that the use of prehospital non-invasive ventilation (phNIV) to treat patients with acute respiratory insufficiency (ARI) caused by severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and acute cardiopulmonary oedema (ACPE) is effective, time-efficient and safe. The data were collected at four different physician response units and three admitting hospitals in a German EMS system. Patients with respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease and acute cardiopulmonary oedema were enrolled. A total of 545 patients were eligible for the final analysis. Patients were treated with oxygen supplementation, non-invasive ventilation or invasive mechanical ventilation. The primary outcomes were defined as changes in the clinical parameters and the in-hospital course. The secondary outcomes included time efficiency, peri-interventional complications, treatment failure rate, and side-effects. Oxygenation under phNIV improved equally to endotracheal intubation (ETI), and more effectively in comparison to standard oxygen therapy (SOT) (paO2 SOT vs. non-invasive ventilation (NIV) vs. ETI: 82 mmHg vs. 125 mmHg vs. 135 mmHg, p-value SOT vs. NIV < 0.0001). In a matched subgroup analysis phNIV was accompanied by a reduced time of mechanical ventilation (phNIV: 1.8 d vs. ETI: 4.2 d) and a shortened length of stay at the intensive care unit (3.4 d vs. 5.8 d). The data support the hypothesis that the treatment of severe AECOPD/ACPE-induced ARI using prehospital NIV is effective, time efficient and safe. Compared to ETI, a matched comparison supports the hypothesis that prehospital implementation of NIV may provide benefits for an in-hospital course.

P132 Research in the time of COVID-19: Recruitment to a clinical trial comparing models of NIV implementation in people with MND

Abstract Introduction A pilot randomised controlled trial (RCT) examining the feasibility of a new model of non-invasive ventilation (NIV) implementation was due to commence in early 2020. Based on previous research, it was anticipated that 100% of people with motor neurone disease (MND) would be eligible, 60% would consent to participate and 20 people would be randomised in five months. The aim of this report is to describe the impact of COVID-19 pandemic contingencies on trial recruitment. Methods Report of project progress, participant screening and recruitment. Results First reports of COVID-19 coincided with study commencement and changed usual healthcare delivery. Lockdowns meant telehealth substituted for face-to-face assessment, respiratory function testing was limited and/or patients were reluctant to seek medical treatment. This modified pathway impacted evaluation of diagnosis, timing of need for NIV and procedural safety, with patients then referred specifically for a single-day hospital NIV implementation to enable face-to-face multidisciplinary assessment to aid decisions. Of 81 potential participants screened in an 8-month period, 64% were ineligible for the RCT. Despite this shift in eligibility rate, 16 people with MND have been recruited as of May 2021. Conclusion The current climate has amplified the significance of this research trial; people with MND have had reduced access to face-to-face services globally and clinicians have had to quickly adapt to a changing landscape of telemedicine and remote monitoring of patients. This trial’s screening data suggest that COVID-19 hasn’t stopped people with MND being implemented on NIV, but it has altered assessment pathways.

OUTCOMES OF PATIENTS HOSPITALIZED DUE TO ACUTE EXACERBATION OF COPD AND REQUIRING VENTILATION SUPPORT

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) with respiratory failure has been associated with higher mortality and morbidities. Implementation of Non-invasive ventilation (NIV) in an early stage of AECOPD with acute respiratory failure has been found to reduce the intubation rate and improve the outcomes. IMV comes in use when the patient cannot tolerate NIV or has worsening respiratory failure despite NIV or has other comorbidities. We hypothesized to see trends and temporal changes in outcomes of AECOPD hospitalizations and factors associated with poor outcomes among those who received ventilation support. METHODS: We extracted data from the Nationwide Inpatient Sample (NIS) for the years 2007-2018 for adult hospitalizations due to AECOPD by using International Classification of Diseases (9th/10th Editions) Clinical Modification diagnosis codes (ICD-9-CM/ICD-10-CM) diagnosis codes and ventilation (IMV and NIV) by procedural codes. Primary objective is to study the trends of discharge disposition (in-hospital mortality and discharge to facilities) and predictors of poor outcomes among those who required ventilation. Cochran Armitage trend test and multivariate survey logistic regression models were used to analyze the data using SAS 9.4 software. RESULTS: We extracted a total of 5,673,467 hospitalizations due to acute exacerbation of COPD from 2007-2018, out of which 455,848 (8.0%) required either IMV or NIV. During the study period, overall, in-hospital mortality has reduced (1.8% in 2007 to 0.4% in 2018; ptrend<0.001) which was largely attributed to decline in in-hospital mortality among those who received NIV (6.3% in 2007 to 2.0% in 2018; ptrend<0.001) and IMV (26.6% in 2007 to 16.7% in 2018; ptrend<0.001). We observed similar declining trends for discharge to facilities. Additionally, among those who received NIV or IMV, age above 65, females (OR 1.1; 95%CI 1.1-1.1; p 0.03), Caucasian (OR 1.5; 95%CI 1.4-1.6; p<0.01), urban-non teaching hospitals (OR 1.2; 95%CI 1.1-1.2; p<0.01), IMV (OR 5.6; 95%CI 5.2-6.0; p<0.01), sepsis (OR 3.5,95%CI 3.3-3.9; p<0.01), pneumonia, CHF, renal failure were associated with higher odds of in-hospital mortality. CONCLUSIONS: Over the years, improved outcomes among AECOPD patients were attributed to significant decline in in-hospital mortality and discharge to facilities among those who received NIV and IMV. Additionally, we also identified several demographic and hospital level characteristics associated with poor outcomes among AECOPD patients requiring ventilatory support. CLINICAL IMPLICATIONS: Our study highlights the outcomes trends of AECOPD patients who required ventilatory support in the last decade. Although outcomes have been improved, still several modifiable factors are associated with higher mortality and morbidity which our study has highlighted. Better risk stratification and strategies are required to further improve the outcomes in these complex patient population. DISCLOSURES: No relevant relationships by Faizan Malik, source=Web Response No relevant relationships by MARIO MEKHAIL, source=Web Response No relevant relationships by Achint Patel, source=Web Response No relevant relationships by Kinjalben Patel, source=Web Response No relevant relationships by Aditi Patil, source=Web Response No relevant relationships by Abdur Raheem, source=Web Response No relevant relationships by Harshil Shah, source=Web Response No relevant relationships by Shiv Shah, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response No relevant relationships by vimala thambi, source=Web Response

Measuring Adherence to Long-Term Noninvasive Ventilation.

Obtaining benefits from long-term noninvasive ventilation (NIV) relies on achieving adequate adherence to treatment. Reported adherence to NIV is variable and could be influenced by high-volume users and attrition of nonusers and those who die. This observational study aimed to describe patterns of use and adherence rates in new unselected users of NIV. All adults (> 18 y old) commencing long-term NIV were consecutively enrolled and followed for 6 months. Ventilator data were manually downloaded from devices and usage (minutes per day) was collected. Subjects were categorized into adherent users (≥ 4 h/d) and nonadherent users (< 4 h/d). Data were obtained from 86 subjects. Most (65%) had motor neuron disease, and most commenced NIV in an out-patient setting (72%). At one month after NIV implementation, overall average daily use was 302.1 min/d and categorical adherence was 57%. At 6 months or prior to death, overall average daily use increased (388.7 min/d), but categorical adherence was similar (62%). The majority of subjects (84%) remained in the same adherence category from their first month to their sixth month of use or death. Individuals with motor neuron disease demonstrated significantly lower rates of adherence compared to the rest of the cohort at 1 month (48% vs 73%, P = .03). In those who died within the study period (n = 19, all with motor neuron disease), this difference persisted to death (42% at death vs 73% at 6 months, P = .032). Average daily usage may conceal true prevalence of adherence or nonadherence to NIV within a population. Reporting both average daily use data and categorical adherence rates (using a threshold of 4 h/d) may improve transparency of reported outcomes from clinical trials and identifies a therapeutic target for home mechanical ventilation services for quality improvement.

Management of respiratory distress following prehospital implementation of noninvasive ventilation in a physician-staffed emergency medical service: a single-center retrospective study

BackgroundNoninvasive ventilation (NIV) is recognized as first line ventilatory support for the management of acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. We aimed to study the prehospital management of patients in acute respiratory distress with an indication for NIV and whether they received it or not.MethodsThis retrospective study included patients ≥18 years old who were cared for acute respiratory distress in a prehospital setting. Indications for NIV were oxygen saturation (SpO2) <90% and/or respiratory rate (RR) >25/min with a presumptive diagnosis of APE or COPD exacerbation. Study population characteristics, initial and at hospital vital signs, presumptive and definitive diagnosis were analyzed. For patients who received NIV, dyspnea level was evaluated with a dyspnea verbal ordinal scale (D-VOS, 0-10) and arterial blood gas (ABG) values were obtained at hospital arrival.ResultsAmong the 187 consecutive patients included in the study, most (n = 105, 56%) had experienced APE or COPD exacerbation, and 56 (30%) received NIV. In comparison with patients without NIV, those treated with NIV had a higher initial RR (35 ± 8/min vs 29 ± 10/min, p < 0.0001) and a lower SpO2 (79 ± 10 vs 88 ± 11, p < 0.0001). The level of dyspnea was significantly reduced for patients treated with NIV (on-scene D-VOS 8.4 ± 1.7 vs 4.4 ± 1.8 at admission, p < 0.0001). Among the 131 patients not treated with NIV, 41 (31%) had an indication. In the latter group, initial SpO2 was 80 ± 10% in the NIV group versus 86 ± 11% in the non-NIV group (p = 0.0006). NIV was interrupted in 9 (16%) patients due to either discomfort (n = 5), technical problem (n = 2), persistent desaturation (n = 1), or vomiting (n = 1).ConclusionsThe results of this study contribute to a better understanding of the prehospital management of patients who present with acute respiratory distress and an indication for NIV. NIV was started on clinically more severe patients, even if predefined criteria to start NIV were present. NIV allows to improve vital signs and D-VOS in those patients. A prospective study could further elucidate why patients with a suspected diagnosis of APE and COPD are not treated with NIV, as well as the clinical impact of the different strategies.Trial registrationThe study was approved by our institutional ethical committee (CER-VD 2020-01363).

Critical Breaths in Transit: A Review of Non-invasive Ventilation (NIV) for Neonatal and Pediatric Patients During Transportation.

Respiratory illnesses are a leading cause of death for children worldwide, with the majority of these cases occurring from preterm birth complications or acute respiratory infections. Appropriate respiratory intervention must be provided quickly to lower the chances of death or permanent harm. As a result, respiratory support given in prehospital and interfacility transport can substantially improve health outcomes for these patients, particularly in areas where transportation time to appropriate facilities is lengthy. Existing literature supports the use of non-invasive ventilation (NIV), such as nasal or bilevel continuous positive airway pressure, as a safe form of respiratory support for children under 18 years old in certain transportation settings. This mini review summarizes the literature on pediatric NIV in transport and highlights significant gaps that future researchers should address. In particular, we identify the need to: solidify clinical guidelines for the selection of eligible pediatric patients for transport on NIV; explore the range of factors influencing successful NIV implementation during transportation; and apply appropriate best practices in low and middle income countries.

Effect of noninvasive ventilation on intubation risk in prehospital patients with acute cardiogenic pulmonary edema: a retrospective study.

The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate. We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality. A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901). In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.

Post-extubation non-invasive ventilation in the pediatric intensive care unit: a multicenter study.

Extubation failure is a complication that increases morbidity and mortality. Noninvasive ventilation (NIV) has demonstrated to be effective as ventilatory support therapy. To determine the rate of postextubation NIV success and the factors associated with procedural failure or success. Design: observational, retrospective, analytical, and multicenter study. All patients who required post-extubation NIV during 2014 and 2015 were included. Rescue NIV was defined as the implementation of NIV for acute respiratory failure; elective NIV was described as its implementation for prophylaxis. NIV failure was defined as the need for orotracheal intubation within the first 48 hours. The characteristics of failure and success and the types of NIV were compared, and the equipment used was assessed. Rescue NIV was required in 112 children; elective NIV, in 143. The rates of success were 68.8% and 72.7%, respectively. Mortality was higher among patients in whom rescue NIV failed compared to those with successful NIV. A longer length of stay and more days of invasive mechanical ventilation prior to extubation were observed in the elective NIV group. The most common diagnosis was acute lower respiratory tract infection in previously healthy children. The use of post-extubation NIV may be a useful tool to prevent reintubation with invasive mechanical ventilation. Immunocompromised patients and those with neurological history had a higher rate of failure. Patients with failure tolerated less hours of NIV and had a longer length of stay in the pediatric intensive care unit.

Accuracy of Patient Perception of Supine Sleep.

For clinicians involved in investigating and treating sleep disorders, understanding the accuracy of patient recall of supine sleep would allow informed comparisons between polysomnography (PSG) and patient-reported sleep in patients with supine-predominant obstructive sleep apnea. This study aims to assess the accuracy of patient perception of supine sleep. Prospective observational cohort study, assessing patient perception of total sleep and supine sleep, including duration. Data were analyzed utilizing descriptive statistics, bias-plot (Bland-Altman) analysis, and Spearman correlation (rs) to analyze relationships among continuous data. Total number of patients who underwent PSG was 518, with data from 368 of these patients analyzed. Most of these patients underwent diagnostic PSG (49.2%). Patients were excluded because of missing or incomplete data (n = 133) or immobility (n = 17). Some patients (n = 97, 26%) did not perceive supine sleep, with 34 (35% of those with unperceived supine sleep or 9% of whole group) of these having more than 60 minutes of PSG supine sleep (range 0-305.5 minutes). All "unsure" patients (n = 8, 2.2%) had significant supine sleep recorded (31.5-257.5 minutes). For the presence of any PSG supine sleep, questioning had a sensitivity of 77.9%, specificity 72.7% with positive predictive value of 96.7% and negative predictive value of 24.5%. There was a significant correlation (rs = 0.63, P < .0001) between perceived and PSG supine sleep, but wide limits of agreement (-246.9 to 194.2 minutes). In patients undergoing in-laboratory PSG, the perception of supine sleep predicts the presence of PSG supine sleep. However, questioning patients has a poor negative predictive value and patient estimates of supine sleep duration are inaccurate.

Understanding the use of NIV in ALS: results of an international ALS specialist survey

Objective: To identify common practices of noninvasive ventilation (NIV) use among ALS specialists and how they follow respiratory status in their patients. Methods: A 25-item questionnaire on NIV indications/initiation was sent via SurveyMonkey® to ALS specialists identified through membership in NEALS (114 sites in the US) and ENCALS (39 sites in Europe). Descriptive statistics and Cochran–Mantel–Haenszel test for general association were performed. Results: In their initial evaluation, US and European specialists (n = 186) use upright forced vital capacity (FVC) most (92.8% vs 91.1%; p = 0.752). Upright FVC results are most important for US respondents when deciding to prescribe NIV; European respondents consider symptoms of orthopnea and/or dyspnea as most important. European respondents use overnight pulse oximetry (69.8% vs 7.9%; p < 0.001) and arterial blood gas analyses (62.8% vs 3.2%; p < 0.001) more than US respondents. Insurance regulations/national health care coverage impact NIV initiation more in the US than in Europe (70.0% vs 47.5%; p = 0.025). When asked if insurance/other financial constraints affects when they prescribe NIV, more US respondents answered positively (77.2% vs 15.4%; p < 0.001). In patients with no respiratory symptoms, most US specialists (68.3%) initiated NIV at VC <50% predicted; European responses showed greater variability. Conclusions: Given the impact of NIV on respiratory function and the importance of respiratory function to quality of life and survival, understanding differences that influence NIV prescribing is critical. This information may inform future study design and identify areas warranting additional research to develop best practices for NIV implementation.

Non-invasive ventilation in emergency departments in public hospitals in Catalonia. The VENUR-CAT study

ObjectivesTo know the implementation and characteristics of non-invasive ventilation (NIV) in the Emergency Departments (EDs) of public hospitals in Catalonia (Spain) and analyze possible differences based on the typology, degree of activity and the availability of an Intensive Care Unit (ICU) in the hospital. DesignA non-interventional, descriptive study was carried out, using a structured questionnaire divided into 3 sections: 1) professional experience and training; 2) devices used; and 3) clinical scenarios and the use of NIV. SettingPersons responsible for public EDs in Catalonia. ResultsFifty-two of the 54 public EDs in Catalonia responded (96.3%). Fifty-one perform NIV, which is mainly initiated by emergency care physicians (78.5%); 66.7% maintain the patient in the ED until discharge; and in 43.1% of the cases the length of stay is >24h. Of the EDs, 39.2% have their own protocol, 35.3% of which are established by consensus with other departments (more frequently in non-county hospitals [p=0.012], and centers with an ICU [p=0.014]), while 25.5% have no protocol, and 43.1% register the activity. Training represents the greatest difficulty for the implementation of NIV, but 19.6% do not provide specific training. When support is needed, the main physician of reference is the intensivist (35.3%) (more frequently in non-county hospitals [p=0.012], and centers with an ICU [p=0.002]). ConclusionsIn most EDs in Catalonia, NIV is performed by emergency care physicians. Areas needing improvement include drainage of patients once NIV has been started, the promotion of protocols, registry of activity, and training of the healthcare professionals.

Ventilación no invasiva en los servicios de urgencias hospitalarios públicos de Cataluña. Estudio VENUR-CAT

ObjectivesTo know the implementation and characteristics of non-invasive ventilation (NIV) in the Emergency Departments (EDs) of public hospitals in Catalonia (Spain) and analyze possible differences based on the typology, degree of activity and the availability of an Intensive Care Unit (ICU) in the hospital. DesignA non-interventional, descriptive study was carried out, using a structured questionnaire divided into 3sections: 1) professional experience and training; 2) devices used; and 3) clinical scenarios and the use of NIV. SettingPersons responsible for public EDs in Catalonia. ResultsFifty-two of the 54 public EDs in Catalonia responded (96.3%). Fifty-one perform NIV, which is mainly initiated by emergency care physicians (78.5%); 66.7% maintain the patient in the ED until discharge; and in 43.1% of the cases the length of stay is>24h. Of the EDs, 39.2% have their own protocol, 35.3% of which are established by consensus with other departments (more frequently in non-county hospitals [P=.012], and centers with an ICU [P=.014]), while 25.5% have no protocol, and 43.1% register the activity. Training represents the greatest difficulty for the implementation of NIV, but 19.6% do not provide specific training. When support is needed, the main physician of reference is the intensivist (35.3%) (more frequently in non-county hospitals [P=.012], and centers with an ICU [P=.002]). ConclusionsIn most EDs in Catalonia, NIV is performed by emergency care physicians. Areas needing improvement include drainage of patients once NIV has been started, the promotion of protocols, registry of activity, and training of the healthcare professionals.

Exploring the feasibility of a music-assisted relaxation intervention to assist with the initiation of non-invasive ventilation in people with Motor Neuron Disease

Background: Transitioning to non-invasive ventilation (NIV) can cause anxiety in people with Motor Neuron Disease (MND), which may reduce adherence rates. Music therapy has demonstrated positive effects with mechanical (invasive) ventilation.Method: This feasibility study examined the effects of music-assisted relaxation (MAR) on NIV adherence, anxiety, and quality of life for people with MND. Data were collected at baseline, 7-days post, and 3-months post NIV implementation.Results: Of 18 consenting participants, 15 chose the MAR condition. Results suggested that supporting NIV transition within the first 7 days may be advantageous for long-term adherence. No effects were found for anxiety or quality of life. Limitations included small sample size, lack of an adequate control, and possible ceiling effects on the instruments used. Qualitative data indicated most participants considered the relaxing and distracting effects of MAR were useful.Conclusions: In this small sample, we found some demand for and acceptability of a music-based intervention in this setting. Participants reported differing experiences of using MAR, and there were technical and logistical issues regarding timely and accessible provision of a MAR intervention within the treatment trajectory of NIV implementation. Conflicting quantitative and qualitative data support the need for mixed method research in this area.

Severe hypercapnic respiratory failure in acute exacerbation of COPD: significance of ventilation and extracorporal CO2 removal

In acute exacerbations of COPD with acute hypercapnic respiratory failure and a pH 7.25 - 7.35, the initiation of non-invasive ventilation is the gold standard. However, absolute and relative contraindications have to be taken into account. The implementation of non-invasive ventilation in case of a severe respiratory acidosis necessitates a skilled therapeutic team and a close monitoring in order to avoid or perceive a NIV failure in time. In this case, the intubation and invasive mechanical ventilation is recommended. Ventilator settings have to aim at the prevention of an overinflation and increase of intrinsic PEEP. If severe hypercapnia and respiratory acidosis cannot be managed by mechanical ventilation, extracorporeal CO2 removal (ECCO2R) is a new treatment option. There are some reports about its use in awake patients in order to avoid an intubation. However, its general and primary use without optimizing medical therapy and mechanical ventilation is not indicated. ECCO2R is an experimental therapy in COPD with acute hypercapnic respiratory failure, its significance is still ambiguous. Therefore, it should only be applied in individual situations by a specialist team trained in its use.

Management of Acute Respiratory Failure in Patients With Hematological Malignancy.

Acute respiratory failure (ARF) is the leading cause of intensive care unit admission in patients with hematologic malignancies and is associated with a high mortality. The main causes of ARF are bacterial and opportunistic pulmonary infections and noninfectious lung disorders. Management consists of a systematic clinical evaluation aimed at identifying the most likely cause, which in turn determines the best first-line empirical treatments. The need for mechanical ventilation is a major determinant of prognosis. Beneficial outcomes have been demonstrated with early use of noninvasive ventilation (NIV) in selected patients with hematologic malignancies. However, most of these studies did not control the time between onset of ARF to NIV implementation nor accounted for the etiology of ARF or the presence of associated organ dysfunction at the time of NIV initiation. Moreover, the benefits demonstrated with NIV in these patients were derived from studies with high mortality rates of intubated patients. Additional studies are therefore warranted to determine the appropriate patients with hematologic malignancy and ARF who may benefit from prophylactic or curative NIV.

Non-invasive ventilation in the emergency department for patients in type II respiratory failure due to COPD exacerbations

IntroductionAcute chronic obstructive pulmonary disease (COPD) exacerbations can cause respiratory failure and may require non-invasive ventilation (NIV). There is a paucity of studies examining their NIV implementation within the emergency department (ED). Aim of the studyThe aims were (i) to establish whether NIV was beneficial for patients using arterial blood gas analysis (ABG), (ii) to observe whether current ED practice met the guidelines of obtaining ABG measurements within 15 minutes of arrival and commencement of NIV within 1 hour of clinical indication and (iii) to examine which healthcare professionals (HCPs) initiated NIV. MethodsA retrospective observational study reviewing all patients commenced on NIV in the ED due to COPD exacerbations was undertaken. ResultsA total of 48 patients were included and the majority received NIV within 1 hour (n = 36, 75%) as recommended by the guidelines. Over 50% of the patients in the study had ABG analysis within 15 minutes and 89% (n = 43) within 30 minutes and statistically significant improvements were noted in respiratory rate, oxygen saturation and ABGs from baseline to repeat measurements undertaken 58 minutes post NIV initiation (p < 0.001). The largest healthcare group to initiate NIV was the nursing team (50% n = 24) with the majority of emergency nurses being experienced nurses [band 6 (n = 17)]. ConclusionFrom this small single centre study, early ABG analyses and NIV initiation were beneficial to COPD patients presenting in respiratory failure with the majority receiving treatment within the recommended guidelines.

Improved survival with an ambulatory model of non-invasive ventilation implementation in motor neuron disease

Non-invasive ventilation (NIV) increases survival and quality of life in motor neuron disease (MND). NIV implementation historically occurred during a multi-day inpatient admission at this institution; however, increased demand led to prolonged waiting times. The aim of this study was to evaluate the introduction of an ambulatory model of NIV implementation. A prospective cohort study was performed. Inclusion criteria were referral for NIV implementation six months pre- or post-commencement of the Day Admission model. This model involved a 4-h stay to commence ventilation with follow-up in-laboratory polysomnography titration and outpatient attendance. Outcome measures included waiting time, hospital length of stay, adverse events and polysomnography data. Results indicated that after changing to the Day Admission model the median waiting time fell from 30 to 13.5 days (p < 0.04) and adverse events declined (4/17 pre- (three deaths, one acute admission) vs. 0/12 post-). Survival was also prolonged (median (IQR) 278 (51–512) days pre- vs 580 (306–1355) days post-introduction of the Day Admission model; hazard ratio 0.41, p = 0.04). Daytime PaCO2 was no different. In conclusion, reduced waiting time to commence ventilation and improved survival were observed following introduction of an ambulatory model of NIV implementation in people with MND, with no change in the effectiveness of ventilation.