Initiation Of Non-invasive Ventilation Research Articles

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 (NIV). Improved quality of life and prolonged survival 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, and 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 has given 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 NIV of adults with chronic neuromuscular respiratory disease. Bi-level 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 NIV tailored to patient-centered goals of therapy. The quantitative approach recommended incorporates routine monitoring of home 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.

Outpatient Utilization of the RAM Cannula for Nasal Noninvasive Ventilation in Children.

The RAM cannula® consists of nasal prongs that can be used to administer oxygen, continuous, and bilevel positive airway pressure therapies. Studies have reported the efficacy and utility of the RAM cannula in inpatients requiring noninvasive ventilation (NIV); however, there is limited literature on the use of the RAM cannula to provide NIV in the outpatient setting. This study aimed to describe the clinical features and outcomes of children who used NIV via RAM cannula in the outpatient setting. Retrospective review. We conducted a retrospective review of children treated with outpatient NIV via RAM cannula at our institution between January 2010 and March 2023. The analyzed data included age, diagnoses, indications for NIV, duration of RAM cannula use, complications, and outcomes at 6 months. We identified 20 patients who used outpatient NIV via RAM cannula during the study period. The median age at initiation of NIV via RAM cannula was 5.8 months (IQR 2.4-9.9 months). Indications for NIV included sleep-related hypoventilation (15%), restrictive lung disease (25%), obstructive sleep apnea (45%), and chronic respiratory failure (50%), with 6 patients having ⩾2 indications for NIV. RAM cannula was utilized for inability to tolerate conventional NIV interfaces (80%), to alleviate dyspnea (60%), and to avoid tracheostomy (55%). Patients used NIV via RAM cannula for a median duration of 7.7 months (IQR 3.7-20.6 months). Patient outcomes included ongoing usage of RAM cannula (55%), changing to conventional NIV interfaces (15%) or oxygen (10%), weaning off respiratory support (5%), and death (15%). There were no complications related to using the RAM cannula. Our study demonstrates the utility of outpatient NIV via RAM cannula in children with a variety of diagnoses until clinical improvement or tolerance of conventional interfaces, and for avoidance of tracheostomy.

Respiratory support strategies in the prevention of bronchopulmonary dysplasia: A single center quality improvement initiative.

Bronchopulmonary dysplasia (BPD) continues to be a significant morbidity affecting very preterm infants, despite multiple advancements in therapies to treat respiratory distress syndrome and prevent BPD. Local quality improvement (QI) efforts have shown promise in reducing unit or system-wide rates of BPD. In preterm infants born between 23- and 32-weeks' gestation, our aim was to decrease the rate of BPD at 36 weeks corrected gestational age from 43% to 28% by January 2019. Directed by a multidisciplinary respiratory QI team, we gradually implemented the following interventions to reach our aim: (1) early initiation of non-invasive ventilation in the delivery room, (2) initiation of caffeine prior to 24 h of life, (3) administration of early selective surfactant per a well-defined guideline, (4) continuation of non-invasive ventilation until 32 and 0/7 weeks corrected gestational age (CGA), and (5) a revision of the early selective surfactant guideline. Outcome measures included rates of BPD, and process measures included compliance with the above interventions. A total of 509 infants with an average gestational age of 29 1/7 weeks and birth weight of 1,254 (SD±401) grams were included. The rate of BPD in our unit decreased from a baseline of 43% to 19% from the start of the project in October 2016 until the first quarter of 2022 (p < 0.00001). The greatest reductions in BPD rates were seen after the initiation of the guideline to extend non-invasive ventilation until 32 0/7 weeks CGA. The rate of severe BPD decreased from 22% to 9%. In preterm infants born between 23- and 32-weeks' gestation, our local QI interventions to reduce rates of BPD were associated with a reduction in rates by 56%. Increased use of antenatal steroids and higher birth weights post- vs. pre-intervention may have contributed to this successes.

At-home noninvasive ventilation initiation with telemonitoring in amyotrophic lateral sclerosis patients: a retrospective study.

Noninvasive ventilation (NIV) improves survival and quality of life in amyotrophic lateral sclerosis (ALS) patients. NIV initiation is mostly conducted at hospital, but a recurrent lack of hospital beds led to the necessity of exploring an at-home initiation process. Here, we report data from our NIV initiation cohort of ALS patients. Could our at-home NIV initiation process with telemonitoring in ALS patients be an efficient solution for adherence and nocturnal hypoxaemia correction? We performed a retrospective analysis of data collected from 265 ALS patients treated at the Bordeaux ALS Centre for whom NIV initiation was carried out between September 2017 and June 2021, with two modalities: at-home initiation or in-hospital initiation. The primary outcome was adherence to NIV at 30 days. The secondary outcome was at-home NIV initiation process efficiency of nocturnal hypoxaemia correction. At 30 days, NIV adherence (mean >4 h·day-1) was 66% of the total population, 70% of the at-home NIV initiation subgroup and 52% of the in-hospital NIV initiation subgroup. Nocturnal hypoxaemia correction was observed in 79% of adherent patients in the at-home NIV initiation subgroup. Mean delay of NIV prescription and at-home NIV initiation was 8.7 days (+/-6.5) versus 29.5 days in hospital. Our study shows that our at-home NIV initiation process in ALS patients is a good option to provide rapid access to NIV with good adherence and efficiency. Further literature on the benefits of at-home NIV initiation is welcomed, especially to evaluate long-term efficiency and global cost analysis.

Improving the delivery of acute NIV at Kings Mill Hospital: A closed loop quality improvement project.

The British Thoracic Society (BTS) Acute Non-Invasive Ventilation (NIV) standards state all patients who require acute NIV should be initiated on NIV within two hours of hospital admission. The delivery of acute NIV is a time critical intervention as prompt application of acute NIV substantially reduces mortality for patients with acute hypercapnic respiratory failure. This audit aimed to assess the number of patients for whom there is a delay in the initiation of acute NIV. We also assessed the outcome of admission for patients started on acute NIV. Data was collected on patients admitted to Kings Mill Hospital for acute NIV between 1/2/2019 and 31/3/2019. Awareness and knowledge of acute NIV was highlighted as an area for improvement. E-learning packages on 'Acute NIV' were designed and sent to medical-staff. The audit was repeated for patients admitted for acute NIV between 1/2/2020 and 31/3/2020 and analysed using chi-square tests. 25 patients were included in the initial audit and 30 patients in the re-audit. Prior to intervention 31% of patients had a delay in the initiation of acute NIV, which increased to 77% post-intervention (p <0.0001). Prior to intervention there was a mortality rate of 17% and a mortality rate of 13% post-intervention (p >0.05). Further work is required to ensure the sustained delivery of acute NIV to BTS standards, however variable achievements in the targets does not seem to have a significant adverse effect on patient outcomes.

Expanded central role of the respiratory physiotherapists in the community setting.

The development of community hubs through the Slaintecare initiative will rely on respiratory physiotherapists and clinical nurse specialists for the management of chronic respiratory diseases. The role of the respiratory physiotherapist has evolved dramatically over the last decade. We review the increasing scope of practice of the physiotherapist and the evidence base for same. We pay particular attention to the role of the physiotherapist in areas such as pulmonary rehabilitation, sputum clearance, neuromuscular disease, chronic respiratory failure, ambulatory oxygen assessments and dysfunctional breathing. We give an in depth review of sputum clearance techniques. We also address areas of potential future expansion for the role of the physiotherapist such as prescription and initiation of non-invasive ventilation.

P125 The effect of glucocorticoids on rate of lung function decline in Duchenne Muscular Dystrophy patients receiving Non-Invasive Ventilation

Abstract Background Duchenne Muscular Dystrophy (DMD) causes progressive muscle weakness as a result of a mutation in the X-linked gene dystrophin. Recently glucocorticoid treatment has delayed deterioration in muscle strength prolonging survival. When respiratory failure develops, Non-invasive ventilation (NIV) is used to improve symptoms and prolong life. Recent research suggests the use of glucocorticoids with concomitant NIV may be associated with accelerated lung function decline. Methods To evaluate this we conducted a retrospective analysis of serial lung function data in patients with DMD across two healthcare campuses in Melbourne, Australia. A database of all patients with a coded diagnosis of DMD was collated from 1980-2010. Patient records were examined to collect data on age, lung function (FEV1/FVC/FER), glucocorticoid use (y/n), daily glucocorticoid dose, date of NIV initiation, FVC at NIV commencement, date of death (where applicable) and concomitant diagnosis of scoliosis or cardiomyopathy. This data was analysed to see if a trend for accelerated lung function decline with the use of NIV was observed. Progress to date A total of 356 patients were identified of which 36 had transitioned to the Austin Hospital adult Ventilation Service with available serial lung function data. There was no statistical difference in mean rate of decline in lung function post NIV initation (n=26, p=0.527) with glucocorticoid treatment. Intended outcome and impact Our inital results are in line with the previously observed rates of decline in lung function from other studies and do not indicate a negative synergistic effect on NIV with glucorticoid therapy.

Noninvasive Ventilation Automated Technologies: A Bench Evaluation of Device Responses to Sleep-Related Respiratory Events.

Noninvasive ventilation (NIV) is the reference standard treatment for most situations of chronic respiratory failure. NIV settings must be titrated to both preserve upper-airway patency and control hypoventilation. Automatic adjustment of pressure support (PS) and expiratory positive airway pressure (EPAP) may facilitate the initiation and follow-up of domiciliary NIV. However, whether the automatic-adjustment algorithms embedded into current devices accurately detect, respond to, and score common sleep-related respiratory events remains unclear. A bench was set up to simulate central hypopnea (CH), central apnea (CA), obstructive hypopnea (OH), and obstructive apnea (OA). Four home ventilators were evaluated, with their dedicated modes for automatic PS and EPAP adjustment. All 4 devices increased PS during CH, CA, and OH. However, PS adjustment varied widely in magnitude, with tidal volumes within 100 ± 20% of the target being provided by only 3 devices for CH, one for CA, and one for OH. Two devices increased EPAP for OH and 3 for OA, including one that also increased EPAP for CA. Only 2 devices scored residual hypopnea after simulated CA, and only one scored a residual event after OH. One device scored no event. Current NIV devices differed markedly in their responses to, and reporting of, standardized sleep-related respiratory events. Further improvements in embedded NIV algorithms are needed to allow more widespread out-of-laboratory initiation and follow-up of NIV.

USING THE RATIO OF OXYGEN SATURATION (ROX) INDEX TO PREDICT TREATMENT OUTCOME FOR HIGH-FLOW NASAL CANNULA AND/OR NONINVASIVE VENTILATION IN PATIENTS WITH COPD EXACERBATIONS

USING THE RATIO OF OXYGEN SATURATION (ROX) INDEX TO PREDICT TREATMENT OUTCOME FOR HIGH-FLOW NASAL CANNULA AND/OR NONINVASIVE VENTILATION IN PATIENTS WITH COPD EXACERBATIONS

Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India.

Noninvasive ventilation (NIV) is an established first-line treatment of acute respiratory failure both in emergency departments (ED) and intensive care unit (ICU) settings. It is however not always successful. Prospective, observational study was done among patients above 18 years presenting with acute respiratory failure initiated on NIV. Patients were placed in one of two groups covering successful NIV treatment and NIV failure. Two groups were compared on four variables: initial respiratory rate (RR), initial high-sensitivity C-reactive protein (hs-CRP), PaO2/FiO2 ratio (p/f ratio), and heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score at the end of 1 hour of initiation of NIV. A total of 104 patients fulfilling the inclusion criteria were included in the study, of which 55 (52.88%) were exclusively treated with NIV (NIV success group), and 49 (47.11%) required endotracheal intubation and mechanical ventilation (NIV failure group). Noninvasive ventilation failure group had a higher mean initial RR compared with NIV success group (40.65 ± 3.88 vs 31.98 ± 3.15, p <0.001). Mean initial PaO2/FiO2 ratio was also significantly lower in the NIV failure group (184.57 ± 50.33 vs 277.29 ± 34.70, p <0.001). Odds ratio for successful NIV treatment with a high initial RR was 0.503 (95% confidence interval (CI), 0.390-0.649) and with a higher initial PaO2/FiO2 ratio was 1.053 (95% CI: 1.032-1.071 and with a HACOR score of >5 at the end of 1 hour of initiation of NIV was highly associated with NIV failure (p <0.001). A high initial level of hs-CRP was 0.949 (95% CI: 0.927-0.970). Noninvasive ventilation failure could be predicted with information available at presentation in ED, and unnecessary delay in endotracheal intubation could possibly be prevented. Mathen PG, Kumar KPG, Mohan N, Sreekrishnan TP, Nair SB, Krishnan AK, et al. Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India. Indian J Crit Care Med 2022;26(10):1115-1119.

The Impact of Non-Invasive Ventilation on Sleep Quality in COPD Patients.

Background: Non-invasive ventilation (NIV) has been shown to be the most appropriate therapy for COPD patients with chronic respiratory failure. While physiological parameters and long-term outcome frequently serve as primary outcomes, very few studies have primarily addressed the impact of NIV initiation on sleep quality in COPD. Methods: This single-center prospective cohort study comprised NIV-naïve patients with COPD. All patients underwent polysomnographic evaluation both at baseline and at 3 months follow-up, accompanied by the assessment of health-related quality of life (HRQL) using the Severe Respiratory Insufficiency Questionnaire (SRI) and the Epworth Sleepiness Scale (ESS). A subgroup evaluation was performed to address the impact of comorbid obstructive sleep apnea syndrome (OSAS). Results: Forty-six patients were enrolled and twenty-five patients completed the follow-up period (66.7 ± 7.4 years). NIV resulted in an increase in slow-wave sleep (+2% (−3.5/7.5), p = 0.465) and rapid eye movement sleep (+2.2% (−1.0/5.4), p = 0.174), although no statistical significance could be detected. ESS (−1.7(−3.6/0.1), p = 0.066) also showed a positive trend. Significant improvements in the Respiratory Disturbance Index (RDI) (−12.6(−23.7/−1.5), p = 0.027), lung function parameters, transcutaneous PCO2 and the SRI summary scale (4.5(0.9/8), p = 0.016) were observed. Conclusion: NIV therapy does not decrease sleep quality and is even capable of improving HRQL, transcutaneous PaCO2, daytime sleepiness and RDI, and the latter especially holds true for patients with comorbid OSAS.

Role of prognostic scores in predicting in-hospital mortality and failure of non-invasive ventilation in adults with COVID-19

We tested the prognostic performance of different scores for the identification of subjects with acute respiratory failure by COVID-19, at risk of in-hospital mortality and NIV failure. We conducted a retrospective study, in the Medical High-Dependency Unit of the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring non-invasive ventilation (NIV) between March 2020 and January 2021. Clinical parameters, the HACOR score (Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory Rate) and ROX index ((SpO2/FiO2)/respiratory rate) were collected 3 (-3) and 1 day (-1) before the NIV initiation, the first day of treatment (Day0) and after 1 (+1), 2 (+2), 5 (+5), 8 (+8) and 11 (+11) of treatment. The primary outcomes were in-hospital mortality and NIV failure. We included 135 subjects, mean age 69±13 years, 69% male. Patients, who needed mechanical ventilation, showed a higher HACOR score (Day0: 6 [5-7] vs 6 [6-7], p=.057; Day+2: 6 [6-6] vs 6 [4-6], p=.013) and a lower ROX index (Day0: 4.2±2.3 vs 5.1±2.3, p=.055; Day+2: 4.4±1.2.vs 5.5±1.3, p=.001) than those with successful NIV. An HACOR score >5 was more frequent among nonsurvivors (Day0: 82% vs 58%; Day2: 82% vs 48%, all p<0.01) and it was associated with in-hospital mortality (Day0: RR 5.88, 95%CI 2.01-17.22; Day2: RR 4.33, 95%CI 1.64-11.41) independent to age and Charlson index. In conclusion, in subjects treated with NIV for ARF caused by COVID19, respiratory parameters collected after the beginning of NIV allowed to identify those at risk of an adverse outcome. An HACOR score >5 was independently associated with increased mortality rate.

Early Initiation of non-invasive ventilation at home improves survival and reduces healthcare costs in COPD patients with chronic hypercapnic respiratory failure: A retrospective cohort study

BackgroundWhile non-invasive ventilation at home (NIVH) is gaining wider acceptance as a treatment option for chronic obstructive pulmonary disease with chronic respiratory failure (COPD-CRF), uncertainty remains about the optimal time to begin NIVH, whether a specific phenotype of COPD-CRF predicts improved outcomes, and how NIVH affects healthcare costs. Materials and methodsUsing 100% research identifiable fee-for-service Medicare claims from 2016 through 2020, we designed an observational, retrospective, cohort study to determine how NIVH use in COPD-CRF patients stratified by CRF phenotype and by timing of initiation affected mortality, healthcare utilization, and total healthcare costs compared to a matched control group. ResultsIn hypercapnic COPD-CRF patients starting NIVH within the first week following diagnosis, risk of death was reduced by 43% (HR, 0.57; 95% CI 0.51–0.63, p < .0001), those starting 8–15 days following diagnosis had mortality reduction of 31% (HR, 0.69; 95% CI 0.62–0.77, p < .0001), and those starting 16–30 days following diagnosis showed mortality reduction of 16% (HR 0.84, CI 0.073-0.096, p < .01) compared to controls. Medicare spending was also associated with timing of NIVH initiation in hypercapnic COPD-CRF. Those beginning treatment 0–7 days and 0–15 days following diagnosis had a $5484 and a $3412 reduction in Medicare expenditures respectively the next year. NIVH was not associated with improved clinical outcomes or decreased Medicare spending in COPD-CRF patients who were not hypercapnic. ConclusionIn this study, early initiation of NIVH for hypercapnic COPD-CRF patients was associated with reductions in the risk of death and in total Medicare spending.