Initiation Of Non-invasive Ventilation Research Articles

Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study)

BackgroundThe objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV).MethodsThirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients’ level of comfort. NIV failure was considered to be a requirement for endotracheal intubation.ResultsA total of 457 patients were included, with a median age of 3.3 months (IQR 1.3–16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230–1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009–1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS.ConclusionsSedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.

Effect of early initiation of noninvasive ventilation in patients transported by emergency medical service for acute heart failure

Background While the indication for noninvasive ventilation (NIV) in severely hypoxemic patients with acute heart failure (AHF) is often indicated and may improve clinical course, the benefit of early initiation before patient arrival to the emergency department (ED) remains unknown. Objective This study aimed to assess the impact of early initiation of NIV during emergency medical service (EMS) transportation on outcomes in patients with AHF. Design A secondary retrospective analysis of the EAHFE (Epidemiology of AHF in EDs) registry. Setting Fifty-three Spanish EDs. Participants Patients with AHF transported by EMS physician-staffed ambulances who were treated with NIV at any time during of their emergency care were included and categorized into two groups based on the place of NIV initiation: prehospital (EMS group) or ED (ED group). Outcome measures Primary outcome was the composite of in-hospital mortality and 30-day postdischarge death, readmission to hospital or return visit to the ED due to AHF. Secondary outcomes included 30-day all-cause mortality after the index event (ED admission) and the different component of the composite primary endpoint considered individually. Multivariate logistic regressions were employed for analysis. Results Out of 2406 patients transported by EMS, 487 received NIV (EMS group: 31%; EMS group: 69%). Mean age was 79 years, 48% were women. The EMS group, characterized by younger age, more coronary artery disease, and less atrial fibrillation, received more prehospital treatments. The adjusted odds ratio (aOR) for composite endpoint was 0.66 (95% CI: 0.42–1.05). The aOR for secondary endpoints were 0.74 (95% CI: 0.38–1.45) for in-hospital mortality, 0.74 (95% CI: 0.40–1.37) for 30-day mortality, 0.70 (95% CI: 0.41–1.21) for 30-day postdischarge ED reconsultation, 0.80 (95% CI: 0.44–1.44) for 30-day postdischarge rehospitalization, and 0.72 (95% CI: 0.25–2.04) for 30-day postdischarge death. Conclusion In this ancillary analysis, prehospital initiation of NIV in patients with AHF was not associated with a significant reduction in short-term outcomes. The large confidence intervals, however, may preclude significant conclusion, and all point estimates consistently pointed toward a potential benefit from early NIV initiation.

Perioperative Management in Neuromuscular Diseases: A Narrative Review.

Patients with neuromuscular diseases are particularly vulnerable in the perioperative period to the development of pulmonary and cardiac complications, or medication side effects. These risks could include hypoventilation, aspiration pneumonia, exacerbation of underlying cardiomyopathy, arrhythmias, adrenal insufficiency, prolonged neuromuscular blockade, issues related to thermoregulation, rhabdomyolysis, malignant hyperthermia, or prolonged mechanical ventilation. Interventions at each of the perioperative stages can be implemented to mitigate these risks. A careful pre-operative evaluation may help identify risk factors so that appropriate interventions are initiated, including cardiology consultation, pulmonary function tests, initiation of noninvasive ventilation, or implementation of preventive measures. Important intraoperative issues include positioning, airway and anesthetic management, and adequate ventilation. The postoperative period may require correction of electrolyte abnormalities, control of secretions with medications, manual or mechanical cough assistance, avoiding the risk of reintubation, judicious pain control, and appropriate medication management. The aim of this review is to increase awareness of the particular surgical challenges in this vulnerable population, and guide the clinician on the various evaluations and interventions that may result in a favorable surgical outcome.

Factors Associated With Change in S3-NIV Score Over Time in People With Chronic Respiratory Failure Treated With Long-Term Home Noninvasive Ventilation

IntroductionMonitoring changes in symptoms over time during long-term nocturnal home non-invasive ventilation (NIV) using patient-reported outcome measures is crucial. This study aimed to identify factors associated with changes in the S3-NIV total score, its two domains (“respiratory symptoms” and “sleep and NIV-related side effects”) and individual item responses. MethodsWe conducted a retrospective, longitudinal data analysis of a cohort of adults with chronic respiratory failure treated with NIV. Data were obtained from a French homecare provider. Multivariate linear and multinomial ordinal mixed effect models were used to identify factors associated with changes in S3-NIV scores over time. ResultsMedian follow-up was 2 years for 2135 participants. Each participant completed a median of five S3-NIV questionnaires; totaling 11,359 analyzed questionnaires. Type of respiratory condition, sex, age and time since NIV initiation were associated with change in S3-NIV score over time. NIV adherence was not associated with total S3-NIV score but high adherence was associated with more severe respiratory symptoms and an improvement in sleep and NIV-related side effects during the follow-up. Intensity of pressure support was associated with a lower total S3-NIV score and more side effects. Face masks and supplemental oxygen were associated with a lower S3-NIV total score. ConclusionChanges in S3-NIV scores over time are associated with the individual's characteristics and NIV settings. Analysis of the two domains and individual items of the S3-NIV could increase understanding of the difficulties experienced by people on NIV.

Remote pulmonary function testing allows for early identification of need for non-invasive ventilation in a subset of persons with ALS

The traditional ALS multidisciplinary clinical practice of quarterly respiratory assessment may leave some individuals in danger of developing untreated respiratory insufficiency between visits or beginning non-invasive ventilation (NIV) later than would be optimal. Remote, or home-based, pulmonary function testing (rPFT) allows patients with ALS to perform regular respiratory testing at more frequent intervals in the home. The aim of this study was to determine the clinical benefit of weekly rPFT compared to standard, quarterly in-clinic respiratory assessments: the number of individuals with earlier identification of NIV need, the magnitude of this advance notice, and the individual factors predicting benefit. Participants with ALS (n = 39) completed rPFT training via telemedicine and then completed one year of weekly self-guided assessments in the home. Over this period, 17 individuals exhibited remotely-measured FVC dropping below 50% of predicted, the value often used for recommendation of NIV initiation. In 13 individuals with clinical detection of this event, the median and range of advance notice of need for NIV was 53 (−61–294) days. Prescription of NIV occurred for 21 individuals on the study, six of whom began NIV as a result of remote testing, prior to indication of need as determined by in-person assessments. Weekly home assessments appeared to be of greatest clinical value in a subset of patients with low baseline respiratory test values and rapid respiratory decline. This has potential implications for clinical management of ALS as well as the conduct of clinical trials that rely on respiratory endpoints.

Optimal timing for intubation in patients on non‐invasive ventilation: A retrospective cohort study

AbstractBackground and AimsThe timing of transition from non‐invasive ventilation (NIV) to invasive ventilation in the intensive care unit (ICU) is uncertain due to a lack of clinical evidence. This study aimed to identify the optimal timing of intubation in patients with respiratory failure managed with NIVs.MethodsA single‐center observational study was conducted in Tokyo, Japan. Patients in the ICU managed with NIV between 2013 and 2022 were screened. The primary outcome was 28‐day invasive ventilator‐free days. Statistical analyses used locally estimated scatter plot smoothing (LOESS) and generalized linear mixed models to estimate the association between the timing of transition and prolonged intubation duration.ResultsDuring the study period, 139 of 589 adult ICU patients receiving NIV transitioned to invasive ventilation. The LOESS curve indicated the longest 28‐day ventilator‐free days around 24 h after NIV initiation, after which the primary outcome decreased linearly. Late intubation after 24 h of NIV initiation was associated with fewer 28‐day ventilator‐free days (adjusted mean difference: −0.22 days [95% confidence interval: −0.31, −0.13]).ConclusionWe identified a non‐linear association between the timing of intubation and 28‐day invasive ventilator‐free days. The critical 24‐h time window for patients on NIV was associated with longer 28‐day invasive ventilator‐free days.

Nutritional and neurological status of amyotrophic lateral sclerosis patients with an early initiation of non-invasive ventilation: Associated factors and impact on evolution of the disease

Nutritional and neurological status of amyotrophic lateral sclerosis patients with an early initiation of non-invasive ventilation: Associated factors and impact on evolution of the disease

Management of severe acute pulmonary oedema, from expert guidelines to bedside strategies: multidisciplinary survey involving 1048 physicians

Abstract Introduction Current recommendations regarding the management of severe acute pulmonary oedema (APE) have low levels of recommendation and/or evidence (LOR/E) that may lead to high heterogeneity in clinical practice 1–3. We hypothesized that practice may diverge from guidelines and differ according to medical specialty and level of expertise. The objective of this survey was to evaluate the clinical management of 4 phenotypes of APE by physicians of 3 specialties and their divergence from guidelines. Methods Four vignettes were designed by a scientific committee representing the French scientific societies of cardiology, emergency medicine, and intensive care (Table 1). In addition, 20 experts in the field of APE care were enrolled. Target participants and designated experts were French physicians of the 3 specialties. From 06/2022 to 09/2022, the vignettes were submitted to the physicians and experts using an open online survey. Results Among the 1048 respondents, 781 completed the 4 cases whereas all 20 experts completed the whole survey (Table 1). Accordance with international guidelines was heterogenous (Table 2). Compliance with SpO2<90% threshold for O2 administration (LOE/R: I-C 1): 22% of physicians and 53% of experts were in accordance with the guidelines. Initiation of non-invasive ventilation (NIV) for respiratory distress (LOE/R: IIa-B 1): concordance was 54% and 93%, respectively. Intubation for progressive respiratory failure despite O2 or NIV (LOE/R: I-C 1): in case of pre-hospital NSTEMI worsening despite NIV and medications, compliance was 55% among physicians and 85% among experts. In case of STEMI with worsening respiratory failure, compliance was respectively 44% and 70%. Intravenous (iv) loop diuretics indications and choice of a loop diuretic (LOE/R: I-C 1): 91% of physicians and 95% of experts were in accordance. For the systolic blood pressure>110 mmHg threshold for iv vasodilators (LOE/R: IIb-C 1) and iv nitrates during NSTEMI with signs of APE (LOE/R: I-C 2): concordance was respectively 8% and 96% among physicians, 32% and 100% among experts. For reperfusion strategies, 20% of physicians and experts acted according to the guidelines. For early PCI within 24h of NSTEMI (LOE/R: I-A 2) and immediate strategy (< 2 hours) for very high-risk NSTEMI (LOE/R: I-C 2): concordance was respectively 62% and 12% among physicians, 80% and 10% among experts. Except for indications of mechanical ventilation and NSTEMI early invasive strategy, results were homogenous among medical specialties (Table 2). Conclusion Our data show that therapeutic strategies regarding classical clinical cases of severe APE often diverge from guidelines with expected differences between specialties. The low level of evidence fuelling the Guidelines may explain these heterogeneities 4. There is a need for more clinical investigation to fill the current gap in evidence and strengthen future guidelines that may reduce heterogeneity in care.Table 1Table 2

Health trajectories before initiation of non-invasive ventilation for chronic obstructive pulmonary disease: a French nationwide database analysis.

Chronic obstructive pulmonary disease (COPD) is the most common indication for long-term domiciliary non-invasive ventilation (NIV) but there is uncertainty in data supporting current guidelines. This study described health trajectories before initiation of at-home NIV in people with COPD, and compared mortality outcomes between groups with different pre-NIV health trajectories. Data were from the French national health insurance reimbursement system database for individuals with COPD aged ≥40 years and ≥1 reimbursement for NIV between 1 January 2015 and 31 December 2019. Common health trajectories were determined using time sequence analysis through K-clustering (TAK analysis). Data from 54,545 individuals were analysed; the population was elderly (median age 70 years) with multiple comorbidities. Four clusters were generated. Cluster 1 (n=35,975/54,545; 66%) had NIV initiated in ambulatory settings or after the first acute event/exacerbation. Cluster 2 (6653/54,545; 12%) started NIV after ≥2 severe exacerbations in the previous 6 months. Cluster 3 (11,375/54,545; 21%) started NIV after frequent severe COPD-related exacerbations in the previous year. Cluster 4 (652/54,545; 1%) started NIV after many long-lasting severe exacerbations. The four clusters differed in age, sex, comorbidities, pre-NIV investigations, and prescriber/location of NIV initiation. Mortality differed significantly between clusters: highest in Cluster 4 and lowest in Cluster1. The significant heterogeneity in clinical initiation of NIV probably reflects the current lack of strong evidence and guideline recommendations. Knowledge about the characteristics and outcomes in different clusters should be used to address inequities and facilitate more consistent and personalised use domiciliary NIV in COPD. JLP and SB are supported by the French National Research Agency in the framework of the "Investissements d'avenir" program (ANR-15-IDEX-02) and the "e-health and integrated care and trajectories medicine and MIAI artificial intelligence (ANR-19-P3IA-0003)" Chairs of excellence from the Grenoble Alpes University Foundation. This work was supported by ResMed.

The utility of diaphragm ultrasound thickening indices for assessing respiratory decompensation in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) leads to diaphragmatic weakness at some point during its course, which is a major cause of respiratory insufficiency. The aim of this study was to evaluate ultrasound-based measures for assessing the diaphragmatic competency and the need for ventilatory support. Twenty-six subjects with ALS and 12 healthy controls were enrolled. All participants underwent B-mode diaphragm ultrasound (DUS). Diaphragm thickness and thickening indices were recorded. In the subjects with ALS, further assessments included functional scales and spirometry. We investigated the diagnostic accuracy of DUS thickening indices in predicting diaphragmatic dysfunction and the correlation between clinical, spirometric, and DUS data. Significant relationships were found between forced vital capacity and all diaphragmatic thickening indices. Similarly, all diaphragmatic thickening indices correlated with both Milano Torino staging and disease progression rate. Only thickening fraction (TFdi) correlated with score on the revised ALS Functional Rating Scale (r = 0.459, P = .024). TFdi had better accuracy in predicting diaphragmatic dysfunction (area under the curve [AUC] = 0.839, 95% confidence interval [CI] 0.643 to 0.953) and the need for initiation of noninvasive ventilation (NIV) (AUC = 0.989, 95% CI 0.847 to 1.000) compared with the other indices. A TFdi cut-off point of 0.50 was a sensitive threshold to consider NIV. DUS successfully identifies diaphragmatic dysfunction in ALS, being a valuable accessory modality for investigating respiratory symptoms. TFdi was found to be the most useful DUS index, which encourages further investigation.

Clinical epidemiology of amyotrophic lateral sclerosis in Liguria, Italy: a ten year follow up study

Objective This article presents an updated analysis of the LIGALS register, a prospective study conducted over a ten-year period (2009-2018) in Liguria, Italy, aimed at evaluating the incidence, prevalence, clinical presentation, and management of amyotrophic lateral sclerosis (ALS). Methods We calculated the mean annual crude incidence rate of ALS, assessed the point prevalence of ALS on January 1, 2018, and analyzed demographic factors, clinical characteristics, and clinical management strategies. Data analysis included Cox regression analysis to identify predictors of survival. Results The mean annual crude incidence rate of ALS was 3.16/100,000 per year (CI 95%) while the point prevalence of ALS on January 1, 2018, was 9.31/100,000 population (CI 95%). Among the patients, 6.5% were familial ALS, while 93.5% were sporadic cases. Clinical management strategies, including percutaneous endoscopic gastrostomy (PEG) and noninvasive ventilation (NIV), were employed. The study observed a stable frequency of NIV initiation and PEG placement over time, with a growing trend toward earlier PEG positioning. The mean survival from symptom onset was 39 months, whereas from diagnosis, it was 26 months. Cox regression analysis identified several predictors of survival, including gender, age at onset and diagnosis, site of onset, diagnostic category, phenotype, and diagnostic delay. Conclusions This comprehensive analysis provides valuable insights into the long-term trends in ALS epidemiology and clinical management in Liguria, Italy. It underscores the importance of continued research efforts in understanding and addressing the challenges posed by ALS, particularly in terms of early diagnosis and optimizing clinical interventions to improve patient outcomes.

Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India.

Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported. In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively. The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Noninvasive respiratory assistance as aid for respiratory care in neuromuscular disorders.

Chronic respiratory failure is a common complication of neuromuscular disease. The use of noninvasive ventilation and mechanically assisted cough can reduce symptoms of hypoventilation, slow lung function decline, improve sleep quality, and in some cases prolong survival in patients with neuromuscular disease. In this article, we review indications for the initiation of noninvasive ventilation and mechanically assisted cough as well as provide recommendations for settings and titration. We discuss the evidence supporting the use of noninvasive ventilation as an adjunct to rehabilitation in patients with neuromuscular disease. Lastly, we review the ethical considerations that are relevant to decisions regarding initiation and cessation of noninvasive ventilation. While noninvasive ventilation and mechanically assisted cough have become standards of care in many forms of neuromuscular disease, most current recommendations are based on expert opinion rather than much-needed data from prospective clinical trials and we emphasize topics requiring future research.

Effect of Intensity of Home Noninvasive Ventilation in Individuals With Neuromuscular and Chest Wall Disorders: A Systematic Review and Meta-Analysis of Individual Participant Data

IntroductionHome noninvasive ventilation (NIV), targeting a reduction of carbon dioxide with a combination of sufficient inspiratory support and backup-rate improves outcomes in patients with chronic obstructive pulmonary disease. The aim of this systematic review with individual participant data (IPD) meta-analysis was to evaluate the effects of intensity of home NIV on respiratory outcomes in individuals with slowly progressive neuromuscular (NMD) or chest-wall disorders (CWD). MethodsControlled, non-controlled and cohort studies indexed between January-2000 and December-2020 were sought from Medline, Embase and the Cochrane Central Register. Outcomes were diurnal PaCO2, PaO2, daily NIV usage, and interface type (PROSPERO-CRD 42021245121). NIV intensity was defined according to the Z-score of the product of pressure support (or tidal volume) and backup-rate. Results16 eligible studies were identified; we obtained IPD for 7 studies (176 participants: 113-NMD; 63-CWD). The reduction in PaCO2 was greater with higher baseline PaCO2. NIV intensity per se was not associated with improved PaCO2 except in individuals with CWD and the most severe baseline hypercapnia. Similar results were found for PaO2. Daily NIV usage was associated with improvement in gas exchange but not with NIV intensity. No association between NIV intensity and interface type was found. ConclusionFollowing home NIV initiation in NMD or CWD patients, no relationship was observed between NIV intensity and PaCO2, except in individuals with the most severe CWD. The amount of daily NIV usage, rather than intensity, is key to improving hypoventilation in this population during the first few months after introduction of therapy.

Limitations of the apnea-hypopnea index in children and young adults with neuromuscular disorders

There are no validated criteria to initiate noninvasive ventilation (NIV) in children and young adults with neuromuscular disease (NMD). In order to analyze NIV initiation criteria, we reviewed the polysomnography (PSG) criteria that led to the initiation of NIV in 61 consecutive patients with NMD, median age 4.1 (0.8–21) years, who had a PSG during their routine care. NIV was initiated on abnormal PSG data (apnea-hypopnea index (AHI) > 10 events/h and/or a transcutaneous carbon dioxide pressure > 50 mmHg and/or a pulse oximetry 〈 90%, both during at least 2% sleep time or 〉 5 consecutive minutes) in 11 (18%) patients. Six of these 11 patients had an AHI ≤ 10 events/h and would not have been ventilated if only AHI was retained. However, one of these 6 patients had isolated nocturnal hypoxemia, 3 isolated nocturnal hypercapnia and 2 abnormal respiratory events. Six (10%) patients with a normal PSG were started on NIV on clinical criteria. Our results show the limitation of the AHI when taken as the unique PSG criterion for NIV initiation in young patients with NMD and underline the need to include also abnormalities of overnight gas exchange into the NIV decision-making process.

Lowering PCO2 With Noninvasive Ventilation Is Associated With Improved Survival in Chronic Hypercapnic Respiratory Failure.

Chronic hypercapnic respiratory failure is associated with high mortality. Although previous work has demonstrated a mortality improvement with high-intensity noninvasive ventilation in COPD, it is unclear whether a PCO2 reduction strategy is associated with improved outcomes in other populations of chronic hypercapnia. The objective of this study was to investigate the association between PCO2 reduction (by using transcutaneous PCO2 as an estimate for PaCO2 and survival in a broad population of individuals treated with noninvasive ventilation for chronic hypercapnia. We hypothesized that reductions in PCO2 would be associated with improved survival. Therefore, we performed a cohort study of all the subjects evaluated from February 2012 to January 2021 for noninvasive ventilation initiation and/or optimization due to chronic hypercapnia at a home ventilation clinic in an academic center. We used multivariable Cox proportional hazard models with time-varying coefficients and PCO2 as a time-varying covariate to test the association between PCO2 and all-cause mortality and when adjusting for known cofounders. The mean ± SD age of 337 subjects was 57 ± 16 years, 37% women, and 85% white. In a univariate analysis, survival probability increased with reductions in PCO2 to < 50 mm Hg after 90 d, and these remained significant after adjusting for age, sex, race, body mass index, diagnosis, Charlson comorbidity index, and baseline PCO2 . In the multivariable analysis, the subjects who had a PaCO2 < 50 mm Hg had a reduced mortality risk of 94% between 90 and 179 d (hazard ratio [HR] 0.06, 95% CI 0.01-0.50), 69% between 180 and 364 d (HR 0.31, 95% CI 0.12-0.79), and 73% for 365-730 d (HR 0.27, 95% CI 0.13-0.56). Reduction in PCO2 from baseline for subjects with chronic hypercapnia treated with noninvasive ventilation was associated with improved survival. Management strategies should target the greatest attainable reductions in PCO2 .

Pediatric outpatient non-invasive ventilation program: Reflections on the first experience from the Middle East.

Long-term noninvasive ventilation (NIV) is being progressively used in children. The current guidelines recommend NIV initiation in the hospital during overnight polysomnography (PSG) titration study. Due to the logistic, socioeconomic, and financial difficulties including bed availability, an outpatient program for NIV initiation and patients/parents counseling to prevent delay and provide cost-effective care has been commissioned. Hence, this study reports on the clinical outcome of our program as it represents the first reported experience from the middle east. A retrospective review of electronic medical charts was conducted for all patients with PSG-confirmed sleep-related breathing disorders (SRBD) who were evaluated and treated in the NIV clinic in the pediatric pulmonary clinic at Sidra Medicine from January 2020 to November 2021. Patients' data included demographics, PSG results, and NIV clinic records. The results show that twenty-eight patients (17 male, 11 female) were included during the study period. The patients' median age at NIV initiation was 11±5.17 years. The median BMI was 32.72±15.91 kg/m2. The most common diagnosis was morbid obesity in 9 (32%) of the patients. The identified SRBD based on the diagnostic PSG were obstructive sleep apnea in 21 patients, hypoventilation in 3 patients, mixed apnea in 3 patients, and central apnea in 1 patient. The median total Apnea-Hypopnea Index (AHI) was 12.7 (0.7-153.9) events per hour. The main reason for the initial NIV clinic visit was NIV initiation in 19 patients. Upon follow-up, six patients were successfully weaned off NIV support by the treating pulmonologist. Five patients refused to use NIV at home. Fifteen out of the remaining seventeen patients used NIV ≥ 4 hours per night (subjective adherence: 88%). Twelve patients used the NIV for ≥ 24 nights per month (70.6%). All parents reported that the clinic experience was beneficial and helped them to be more comfortable with applying the NIV machine at home. In conclusion, pediatric NIV outpatient programs are achievable and beneficial, especially in developing countries. Pediatric NIV clinics managed by a specialized and experienced team play important role in the initiation and follow-up of NIV support. They provide alternative pathways for the care of pediatric patients, education, and support of their families, and decrease the load on intensive care and sleep laboratory units. Studies about cost-effectiveness are needed to evaluate the impact of implementing outpatient NIV programs on sleep laboratories and hospital admission rates.

Predictors of Noninvasive Ventilation Failure in the Post-Extubation Period: A Systematic Review and Meta-Analysis.

To identify factors associated with failure of noninvasive ventilation (NIV) in the post-extubation period. We searched Embase Classic +, MEDLINE, and the Cochrane Database of Systematic Reviews from inception to February 28, 2022. We included English language studies that provided predictors of post-extubation NIV failure necessitating reintubation. Two authors conducted data abstraction and risk-of-bias assessments independently. We used a random-effects model to pool binary and continuous data and summarized estimates of effect using odds ratios (ORs) mean difference (MD), respectively. We used the Quality in Prognosis Studies tool to assess risk of bias and the Grading of Recommendations, Assessment, Development and Evaluations to assess certainty. We included 25 studies ( n = 2,327). Illness-related factors associated with increased odds of post-extubation NIV failure were higher critical illness severity (OR, 3.56; 95% CI, 1.96-6.45; high certainty) and a diagnosis of pneumonia (OR, 6.16; 95% CI, 2.59-14.66; moderate certainty). Clinical and biochemical factors associated with moderate certainty of increased risk of NIV failure post-extubation include higher respiratory rate (MD, 1.54; 95% CI, 0.61-2.47), higher heart rate (MD, 4.46; 95% CI, 1.67-7.25), lower Pa o2 :F io2 (MD, -30.78; 95% CI, -50.02 to -11.54) 1-hour after NIV initiation, and higher rapid shallow breathing index (MD, 15.21; 95% CI, 12.04-18.38) prior to NIV start. Elevated body mass index was the only patient-related factor that may be associated with a protective effect (OR, 0.21; 95% CI, 0.09-0.52; moderate certainty) on post-extubation NIV failure. We identified several prognostic factors before and 1 hour after NIV initiation associated with increased risk of NIV failure in the post-extubation period. Well-designed prospective studies are required to confirm the prognostic importance of these factors to help further guide clinical decision-making.

An exposed/unexposed cohort study assessing the effectiveness, the safety and the survival of patients established on home non-invasive ventilation after 80 years old

BackgroundLittle is known about the use of long-term non-invasive ventilation (NIV) in the elderly. We aimed to assess if the effectiveness of long-term NIV of patients ≥ 80 years (older) was not greatly inferior to that of patients < 75 years (younger). MethodsThis retrospective exposed/unexposed cohort study included all patients established on long-term NIV treated at Rouen University Hospital between 2017 and 2019. Follow-up data were collected at the first visit following NIV initiation. The primary outcome was daytime PaCO2 with a non-inferiority margin of 50% of the improvement of PaCO2 for older patients compared to younger patients. ResultsWe included 55 older patients and 88 younger patients. After adjustment on the baseline PaCO2, the mean daytime PaCO2 was reduced by 0.95 (95% CI: 0.67; 1.23) kPa in older patients compared to1.03 (95% CI: 0.81; 1.24) kPa in younger patients for a ratio of improvements estimated at 0.95/1.03 = 0.93 (95% CI: 0.59; 1.27, one-sided p = 0.007 for non-inferiority to 0.50). Median (interquartile range) daily use was 6 (4; 8.1) hours in older versus 7.3 (5; 8.4) hours in younger patients. No significant differences were seen in the quality of sleep and NIV safety. The 24-months survival was 63.6% in older and 87.2% in younger patients. Conclusionseffectiveness and safety seemed acceptable in older patients, with a life expectancy long enough to expect a mid-term benefit, suggesting that initiation of long-term NIV should not be refused only based on age. Prospective studies are needed.

Practical Guide to Management of Long-term Noninvasive Ventilation for Adults with Chronic Neuromuscular Disease.

Recent technological advances in respiratory support and monitoring have dramatically enhanced the utility of long-term noninvasive ventilation. Improvements in quality of life and prolonged survival at home have been demonstrated for several common chronic neuromuscular diseases. Many adults with progressive neuromuscular respiratory disease can now comfortably maintain normal ventilation at home to near total respiratory muscle paralysis without needing a tracheostomy. However, current practice in many communities falls short of that potential. Mastery of the new technology calls for detailed awareness of the respiratory cycle, expert knowledge of mechanical devices, facial interfaces, quantitative monitoring tools for home ventilation, and a willingness to stay current in a rapidly expanding body of clinical research. The depth and breadth of the expertise required to manage home assisted ventilation is giving rise to a new focused medical subspecialty in chronic respiratory failure at the interface between pulmonology, critical care, and sleep medicine. For clinicians seeking pragmatic "how to" guidance, this primer presents a comprehensive, physician-directed management approach to long-term noninvasive ventilation of adults with chronic neuromuscular respiratory disease. Bilevel devices, portable ventilators, ventilation modalities, terminology, and monitoring strategies are reviewed in detail. Building on that knowledge base, we present a step-by-step guide to initiation, refinement, and maintenance of home noninvasive ventilation that is tailored to patient-centered goals of therapy. The "quantitative" approach recommended here fully incorporates routine monitoring of home assisted ventilation using technologies that have only recently become widely available including cloud-based device telemonitoring and noninvasive measurements of blood gases. Strategies for troubleshooting and problem solving are included.