Noninvasive Ventilation In Management Research Articles

A practical peer-led approach to improving knowledge of settings and confidence with non-invasive ventilation management

A practical peer-led approach to improving knowledge of settings and confidence with non-invasive ventilation management

Mask interfaces and devices for home noninvasive ventilation in children.

Home noninvasive ventilation (NIV), including continuous (CPAP) and bilevel (BPAP) positive airway pressure, is increasingly used in children worldwide. In this narrative review, we present a comprehensive summary of the equipment available for home NIV in pediatrics, excluding neonates. NIV may be challenging in young children, as the majority of the equipment has been developed for adults. Regarding the interfaces, only a few masks have been specifically developed for young children in recent years, while older children may benefit from a large variety of interfaces. Even though much progress has been made, skin injuries are still present, and need to be managed rapidly. Several studies addressed the management of the side effects, but recent studies are lacking regarding orofacial anomalies. No recent study reported the available interfaces for young children and the strategies for an optimal mask fit. Regarding the devices, an adapted NIV device to pediatrics that allows an adequate patient's breathing detection should guarantee optimal ventilatory efficiency and monitoring of NIV. A close follow-up and regular monitoring should be mandatory to rule out the potential issues, optimize NIV therapy and ascertain the efficacy of NIV. However, studies are lacking to guide the choice of devices in young children and the optimal management of home NIV in pediatrics. We summarized the characteristics of the different interfaces available for young children and the limitations of NIV devices. We finally addressed potential areas for future research on long-term home NIV in children.

Comparative study between high flow nasal cannula, high velocity nasal insufllation and noninvasive ventilation in management of acute respiratory failure

Comparative study between high flow nasal cannula, high velocity nasal insufllation and noninvasive ventilation in management of acute respiratory failure

COMPARISON OF AVERAGE VOLUME ASSURED PRESSURE SUPPORT (AVAPS) AND BILEVEL POSITIVE AIRWAY PRESSURE (BIPAP) MODES IN THE MANAGEMENT OF COPD PATIENTS WITH ACUTE HYPERCAPNIC RESPIRATORY FAILURE

To know the efcasy of AVAPS Modes of non invasive ventilation in management of COPD patients with type 2 Respiratory failure.To compare improvement in clinical parameters, biochemical parameters, patient tolerance between AVAPS and Conventional BIPAPA mode of ventilation

Atuação profissional no serviço hospitalar de fisioterapia diante das infecções por coronavírus

ABSTRACT During the COVID-19 pandemic, we observed an important growth of demands on healthcare providers. Delimited attributions for each position are important, aiming less burden and better care effectiveness. Physical therapists play a fundamental role in the care of patients with COVID-19 complications. This research analyzed physical therapist’s role and knowledge about COVID-19 during the pandemic in a public hospital. This is a mixed cross-sectional study, with a quantitative descriptive and qualitative exploratory method, carried out in a public hospital in Goiânia. The physical therapists filled out an anamnesis form and a questionnaire with pre-structured questions about the attributions of physical therapy in the hospital environment. The population was composed of 13 professionals. Most considered oxygen therapy implementation (100%), INVASIVE and non-invasive ventilation management (100%), participation in orotracheal intubation (92.3%), airway aspiration (100%), extubation (92.3%), measurement of the orotracheal tube cuff pressure (92.3%), and replacement the mechanical ventilator filter (92.3%) as physical therapy assignments. Most professionals (46.15%) considered that these patients’ mobilization must frequently be carried out. regarding COVID-19 AND their role in the pandemic. Confusion is still present regarding procedures related to the respiratory area in the hospital environment.

COVID-19 advanced respiratory care educational training programme for healthcare workers in Lesotho: an observational study

ObjectiveTo develop and implement a ‘low-dose, high-frequency’ (LDHF) advanced respiratory care training programme for COVID-19 care in Lesotho.DesignProspective pretraining–post-training evaluation.SettingLesotho has limited capacity in advanced respiratory care.ParticipantsPhysicians and nurses.InterventionsDue to...

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

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

Noninvasive Ventilation in Amyotrophic Lateral Sclerosis.

Amyotrophic lateral sclerosis is a progressive neurodegenerative disease involving upper and lower motor neurons and has limited treatment options. The weakness progresses to involve the diaphragms, resulting in respiratory failure and death. Home noninvasive ventilation has been shown to improve survival and quality of life, especially in those with intact bulbar function. Once initiated, close monitoring with nocturnal oximetry, remote downloads from the home noninvasive ventilation machine, and measurement of serum bicarbonate should be conducted. Additionally, transcutaneous CO2 monitoring can be considered if available. This article discusses the indications, timing, initiation, and management of noninvasive ventilation in amyotrophic lateral sclerosis.

Indications for Non-Invasive Ventilation in Respiratory Failure.

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

The Oral Secretion Scale and Prognostic Factors for Survival in Subjects With Amyotrophic Lateral Sclerosis.

Noninvasive ventilation (NIV) can be tolerated in patients with amyotrophic lateral sclerosis (ALS), unless bulbar impairment becomes severe. Excessive oral secretions may result in NIV intolerance and insufficient ventilation. To assess the reliability of the Oral Secretion Scale (OSS) for predicting the tolerance of NIV, when to initiate hospice or transition to tracheostomy, and prognostic factors for survival of users of NIV. A validated OSS was developed to measure oral secretions in correlation with the ability to swallow saliva and clear the upper airway: OSS score of 4 = normal (automatic swallow); OSS score of 3 = infrequent secretions (automatic swallow decreased); OSS score of 2 = occasional drooling and/or pooling (conscious swallow required); OSS score of 1 = severe, frequent drooling and/or pooling (conscious swallow difficult); OSS score of 0 = most severe, constant drooling/pooling (conscious swallow impossible). A total of 137 subjects were followed up prospectively during ongoing patient visits from NIV initiation until death or tracheostomy. Survival was calculated by using Kaplan-Meier analysis. OSS scores when NIV became intolerable were determined. Uni- and/or multivariate Cox-regression analyses showed prognostic factors that affect survival. The median months of survival from NIV initiation were the following: 11 (95% CI 7.3-14.0), 5 (95% CI 3.1-6.1), and 1 (95% CI 1.1-1.5) stratified by OSS scores of 4, 3-2, and 1, respectively; and 21 (95% CI 8.6-33.2), 8 (95% CI 3.4-11.5), 6 (95% CI 4.2-8.2), and 2 (95% CI 1.5-2.7) stratified by 24, 17-23, 4-16, and <4 h/d of NIV use, respectively. Survival was significantly (P < .001) longer with an OSS score of 4 than an OSS score of 1 at NIV initiation; and significantly (P < .001) longer when NIV used 24 h/d than <24 h/d. In the subjects unable to tolerate NIV, ≥80% had OSS score of 1 or 0. Univariate and multivariate analyses hazard ratio 4.91, 95% CI 2.98-8.09, P < .001, and hazard ratio 4.60, 95% CI 2.66-7.96, P < .001), respectively, showed hours per day of NIV use was a significant factor associated with survival. The subjects with an OSS score of 4 tolerated NIV and survived significantly longer than subjects with an OSS score of <4. An OSS score of 1 signaled NIV intolerance and the need for hospice or transition to planned tracheostomy. Use of OSS can help guide NIV management decisions.

Assisted ventilation in motor neurone disease during inpatient palliative care: barriers and utilisation

ObjectivesAn increasing number of patients with motor neuron disease (MND) in the UK and Ireland use assisted ventilation, and a small proportion of these use long-term tracheostomy ventilation (TV).1 2...

The development of oxygen and non-invasive ventilation pathways in an adult cystic fibrosis centre

Purpose: Cystic Fibrosis (CF) is a genetically inherited condition affecting more than 10,000 people in the United Kingdom. A progressive cycle of infection and lung damage occurs. Worsening lung function results in hypoventilation and ultimately leads to respiratory failure that may require supplementary oxygen and/or mechanical support such as Non-Invasive Ventilation (NIV). Guidelines support the use of NIV for nocturnal hypoventilation, hypercapnic respiratory failure and as a bridge to transplant. At the time of development, there were no published guidelines on the use of oxygen therapy in CF and no published pathways on the set up and management of supplementary oxygen or NIV in CF. This special interest report documents the development of separate oxygen and NIV pathways through interdisciplinary working in an adult CF centre.

Practical implementation of noninvasive ventilation in Amyotrophic Lateral Sclerosis: lessons learned from a clinical case series.

PurposeNoninvasive ventilation (NIV) may improve survival and quality of life in Amyotrophic Lateral Sclerosis (ALS) patients. There is a surprising paucity of practical guidelines for office-based implementation and management of NIV outside of tertiary ALS centers. We saw the need for a clinical protocol to allow feasible and consistent NIV management in this patient population.MethodsWe created a clinical protocol for office-based initiation of NIV implemented on consecutive ALS patients referred from our regional ALS multidisciplinary clinic. The protocol provided initial empiric settings using a bilevel device in volume-assured pressure support mode. A respiratory therapist (RT) initiated NIV in an office setting and made adjustments according to patient tolerance and therapy targets outlined in the protocol. Later setting changes were performed at patient or provider request. We evaluated patient adherence and efficacy via device download at 30 days and 1 year.ResultsWe present data from a case series of the first 14 consecutive patients initiated on NIV over a 20-month period. Our protocol underwent iterative modification based on clinical experience and patient feedback. Early challenges included the significant time and resource burden required to coordinate device downloads and patient follow-up. Early 30-day NIV adherence was variable (median 20 out of 30 days), while 1-year NIV adherence was excellent (median 27.5 out of 30 days).ConclusionsOur RT-driven clinical NIV protocol was feasible but labor intensive. Achieving real-world adherence of NIV in our ALS patients required iterative protocol adjustment, significant RT provider time, and tele-based follow-up.

Evaluation of diaphragmatic dysfunction after surgical treatment of type A aortic dissection by ultrasound: incidence, risk factors and influence on outcomes

Objective To study the incidence, possible risk factors, and influence on patient outcomes of diaphragmatic dysfunction in patients after surgical treatment of type A aortic dissection using ultrasound. Methods Patients who received replacement of hemiarch or total arch with concomitant procedures concerning aortic pathology, and an elephant trunk procedure for the descending aorta were prospectively enrolled in this study from February to May 2017. After surgery, they were transferred to the cardiac surgical intensive care unit. They were divided into two groups based on diaphragmatic excursion: diaphragmatic dysfunction (DD) group and diaphragmatic function normal (DN) grouBilateral diaphragmatic excursions were evaluated using ultrasound during spontaneous breathing trial by T-tube. The differences in demographic characteristics, operation-related variables and outcomes were compared between the two groups. Results A total of 42 patients were enrolled in this study, and 32 of them suffered from diaphragmatic dysfunctions. Compared with DN group, the excursion of the influenced diaphragm in DD group was significantly reduced[(0.450±0.331)cm vs. (1.801±0.616)cm, P<0.01], while the excursion of the non-influenced diaphragm was not reduced[(2.013±0.655)cm vs. (1.801±0.616)cm, P=0.254]. Diaphragmatic thickness was comparable [(0.184±0.028)cm vs. (0.189±0.028)cm, P=0.559 ] between the two groups while thickening fraction was significantly reduced in DD group[(4.67%±3.63)% vs. (23.58%±10.69)%, P<0.01]. Meanwhile, respiratory rate was significantly higher in DD group as compared to DN group [(24.13±4.98)times/min vs. (20.50±3.17)times/min, P=0.037]. Patients in DD group showed longer cross-clamp duration[(121.78±27.75)min vs. (93.10±18.84)min, P=0.004] and longer cardiopulmonary bypass duration [(208.09±32.78)min vs. (182.70±24.38)min, P=0.03] than patients in DN grouFurthermore, binary logistic analysis indicated that longer cross-clamp duration was the potential risk factor for diaphragmatic dysfunction after type A aortic dissection surgery. Mechanical ventilation duration was longer in DD group than in DN group (88 h vs. 37 h, P=0.194) but without statistical significance. The usage of noninvasive ventilation was significantly increased in DD group as compared to DN group (46.88% vs. 10%, P=0.036). Other outcomes such as post-operative complications, mortality, ICU length of stay were comparable between the two groups. Conclusions Diaphragmatic dysfunction was very common after surgical treatment of type A aortic dissection. Longer duration of cross-clamp was considered as a potential risk factor of diaphragmatic dysfunction. A sequential management of noninvasive ventilation after extubation was feasible for diaphragmatic dysfunction after surgical treatment of type A aortic dissection. Key words: Diaphragm; Ultrasound; Type A aortic dissection

Noninvasive ventilation utilization in the Kingdom of Saudi Arabia: Results of a national survey.

INTRODUCTION:Noninvasive ventilation (NIV) has been extensively used globally and is often administered as the first-line treatment. Currently, data regarding the utilization of NIV in the Kingdom of Saudi Arabia (KSA) is scarce. The present study aimed to assess and quantify the utilization of NIV in clinical practice across the KSA and investigate obstacles that may cause NIV underutilization.METHODS:A web-based survey composed of a 31-item, self-administered questionnaire was developed and validated. The questionnaire was designed to obtain general information about each hospital, availability of NIV practice, use of NIV, and obstacles that can hinder NIV use in clinical settings; the survey was sent to senior respiratory therapists (RTs) of 76 hospitals. Descriptive statistics were used to analyze the data.RESULTS:Sixty-one hospitals (80.3%) responded to the survey (47 governmental and 14 private). NIV was available in all hospitals and all the Intensive Care Units. The majority of RTs (85%) reported having a good experience with NIV, with a confidence rate of 60%; however, only 22% of the RTs had received formal training. Although NIV setup was the sole responsibility of RTs, only 69% participated in NIV management. Moreover, 72% of hospitals had an NIV setup protocol in place. However, 50% of them lacked a protocol for NIV failure. NIV protocols for specific indications were present in 64% of the hospitals: 47.2% for monitoring and 42% for weaning. The perceived efficiency of NIV practice was low in the medical wards, with a <49% success rate in 39% of the hospitals. Shortage of staff and lack of formal training were the most common reasons for NIV underutilization.CONCLUSION:The efficiency of NIV in the KSA was low. The RTs expressed moderate confidence in administering NIV. Lack of appropriate exposure and formal training could have negative impacts on NIV practice.

Impact of a Noninvasive Ventilation Protocol in Hospitalized Children With Acute Respiratory Failure.

Noninvasive ventilation (NIV) has proven to be useful in the management of children with acute respiratory failure as a result of acute lower respiratory infection. Despite this, evidence addressing the initiation and/or discontinuation criteria of NIV in children remains limited. The objective of this study was to evaluate the usefulness and clinical impact of an NIV protocol in hospitalized children with acute respiratory failure because of acute lower respiratory infection. A randomized controlled clinical trial was carried out among subjects admitted during the winter season at Hospital Josefina Martinez between May and October of 2013. Inclusion criteria were age 3 months to 2 y, diagnosis of acute lower respiratory infection and requiring NIV according to a Modified Wood Scale score of ≥ 4 points. Subjects were randomized to NIV management according to medical criteria (control group) or to protocolized management of NIV (protocol group). Hours of NIV, hospital stay, and supplemental oxygen use after discontinuation of NIV, severity changes after NIV initiation, respiratory symptoms, and proportion of intubations were considered as events of interest. A total of 23 subjects were analyzed in the control group and 24 were analyzed in the protocol group. Hours of hospital stay, NIV, and supplemental oxygen post-NIV were not significantly different between groups (P = .70, .69, and .68, respectively). There were also no differences in intubation rate (3 of 29 for the control group and 2 of 31 for the protocol group). For the total sample there was a statistically significant decrease in the Modified Wood Scale score after 1 h of NIV (P < .001). A similar result was observed when performing a stratified intragroup analysis. We observed that the implementation of an NIV management protocol that integrates initiation and discontinuation criteria for NIV is feasible. However, its use showed no advantages over a non-protocolized strategy.

Noninvasive Respiratory Support in Infants and Children.

CPAP and noninvasive ventilation (NIV) offer an alternative to intubation and mechanical ventilation in the treatment of acute and chronic respiratory disorders commonly encountered in infants and children. There are many distinct challenges associated with the application, management, and safety of CPAP and NIV in the pediatric population. This review attempts to identify indications, contraindications, management strategies, and safety measures associated with the application of CPAP or NIV delivery in children. More recently, high-flow nasal cannula (HFNC) has emerged as an alternative to CPAP and NIV. Evidence related to the use of CPAP, NIV, and HFNC is included in this review.

Unplanned Extubation and Subsequent Trial of Noninvasive Ventilation in the Neonatal Intensive Care Unit

Unplanned extubation (UE) occurs as an infrequent complication of mechanical ventilation in the neonatal intensive care unit (NICU). Following UE, a trial of noninvasive ventilation (NIV) may be considered if a neonate is showing adequate respiratory effort. This study investigated the success and failure rate of NIV management of neonates experiencing UE. Retrospective single-center study of neonates experiencing UE in the NICU over a 9-year period. Reintubation within 12 hours of a trial of NIV following UE was defined as treatment failure. Short-term respiratory outcomes were analyzed for all infants plus the incidence of bronchopulmonary dysplasia for preterm infants born less than 32 weeks' gestation. A total of 43 patients were included. Of those, 30 infants were trialed on NIV following UE. Baseline demographics were similar between both the groups except for the oxygen requirement before UE. The NIV was successful in 20 and failed in 10 infants. Infants who failed a trial of the NIV were reintubated between 0.45 and 5.25 hours following UE. Respiratory outcomes in very preterm infants did not differ between groups. A trial of NIV may be considered as a treatment option in preterm and term newborns experiencing UE in the NICU.

P108 Acute Niv Practices At A District General Hospital And The Impact Of Regular Electronic Feedback On Patient Outcome

Background Non-invasive ventilation (NIV) has become the standard of care for management of acute type 2 respiratory failure. There is evidence that junior doctors receive inadequate training and confidence in the use of NIV is low. National audits have shown consistent shortcomings in NIV management. Aims To assess initiation of acute NIV in a District General Hospital setting, to provide prompt structured feedback to doctors initiating NIV and to assess whether feedback leads to improvement. Methods A total of 72 acute NIV initiations were prospectively assessed between January and June 2014. Data from patient records was collected using a structured pro-forma to assess nine parameters (described below). A feedback email with total score out of nine along with brief written feedback was sent to all doctors initiating NIV. Results Performance was reported for each of the nine criteria; documented indication for NIV (94%); documented NIV start time (90%); BTS recommended NIV pressures achieved (61%); ABG immediately prior to therapy (93%); ABG performed at 1–2 h (75%) and at 4–6 h (79%); documented ceiling of treatment (70%) and discussion with patient/relatives (67%); improvement in pH at 6 h (58%). Use of correct pressures led to an improvement in pH in 68% compared to 43% when inadequate pressures were used (p Scores steadily improved over the first 3 months however fell at the beginning of April, coinciding with the rotation of junior doctors, rising again towards the end of the study period. Conclusion Better adherence with BTS guidelines led to improvements in patient outcomes. Structured feedback led to improvement in NIV initiation scores.

The Changing Landscape of Adult Home Noninvasive Ventilation Technology, Use, and Reimbursement in the United States

There has been an exponential increase in the use of home noninvasive ventilation (NIV). Despite growing use, there is a paucity of evidence-based guidelines and practice standards in the United States to assist clinicians in the initiation and ongoing management of home NIV. Consequently, home NIV practices are being influenced by complicated local reimbursement policies and coding. This article aims to provide a practice management perspective for clinicians providing home NIV, including Local Coverage Determination reimbursement criteria for respiratory assist devices, Durable Medical Equipment coding, and Current Procedural Terminology coding to optimize clinical care and minimize lost revenue. It highlights the need for further research and development of evidence-based clinical practice standards to ensure best practice policies are in place for this rapidly evolving patient population.