Non-invasive Ventilation Set-up Research Articles

P005 A two-night randomised controlled cross-over trial of AVAPS AE auto-titrating bi-level ventilation vs standard in-lab titration in patients with motor neurone disease commencing overnight ventilatory support

Abstract Introduction Sleep disordered breathing in motor neurone disease (MND) is heterogeneous. Auto-adjusting AVAPS-AE mode of non-invasive ventilation (NIV) could simplify NIV setup and use in MND. This pilot study assessed NIV titration and longer-term outcomes with AVAPS AE auto-pressure support versus standard S/T mode NIV titration in patients with MND. Methods 10 MND patients commencing NIV consented to a 2 consecutive night randomised controlled cross-over trial of auto-titrating AVAPS-AE versus standard S/T mode NIV titrated according to current clinical practice. Patients underwent in-laboratory polysomnography (PSG) on both nights before continuing on the second allocated mode of NIV. Results 8 patients completed both cross-over nights and 9 subsequently continued on home NIV (4 on S/T and 5 on AVAPS-AE mode). Compared to baseline, both S/T and AVAPS-AE modes significantly reduced apnea hypopnea index (AHI; mean [95%CI] 14.8 [6.8-22.8] to 1.2 [0-2.7] and 3.6 [0-7.1] /h respectively), with no significant differences between modes on other PSG outcomes. Maximum EPAP (15.4 [13.4-17.4] vs 8.3 [4.9-11.6] cmH2O, p=0.003) and pressure support levels (16.3 [11.2-21.3] vs 6.6 [5.9-7.4] cmH2O, p=0.003) were higher with AVAPS-AE versus S/T mode respectively, although average pressure support levels were not different. Over 6 months of follow-up, average daily use was similar in both treatment groups (AVAPS-AE 7.3 [3.2-11.3]; S/T mode 7.8 [3.5-12] h/day). Conclusion Automated AVAPS-AE mode of BiPAP support appears to achieve similar control of sleep disordered breathing when compared to standard S/T mode, and to be well tolerated and used in patients with MND.

Cost-effectiveness of outpatient versus inpatient non-invasive ventilation setup in obesity hypoventilation syndrome: the OPIP trial

BackgroundCurrent guidelines recommend that patients with obesity hypoventilation syndrome (OHS) are electively admitted for inpatient initiation of home non-invasive ventilation (NIV). We hypothesised that outpatient NIV setup would be more...

The role of noninvasive ventilation in the management of type II respiratory failure in patients with myotonic dystrophy.

Type 1 myotonic dystrophy (DM1) causes sleep disordered breathing and respiratory failure due to a combination of obstructive sleep apnoea, reduced central drive and respiratory muscle weakness. Noninvasive ventilation (NIV) is commonly used for treating respiratory failure in neuromuscular disease; however, there have been few studies assessing the role of NIV in DM1. The aim of this retrospective service evaluation was to investigate the impact of NIV adherence on hypercapnia and symptoms of hypoventilation in patients with DM1. Data on capillary carbon dioxide tension (PCO2), lung function, adherence to NIV and symptoms of hypoventilation were obtained from the records of 40 patients with DM1. Mean capillary PCO2 significantly reduced from 6.81±1.17 kPa during supervised inpatient set-up to 5.93±0.82 kPa after NIV set-up (p<0.001). NIV adherence reduced from 7.8 (range: 1.0–11.0) h per 24 h during supervised inpatient set-up to 2.9 (0–10.4) h per 24 h in the community. Overall 72% of patients used NIV <5 h per 24 h during follow-up, including 11% who discontinued NIV completely. There was no correlation between adherence to NIV and changes in capillary PCO2. Patients who reported symptomatic benefit (50%) had higher adherence than those who did not feel benefit (p<0.05). In conclusion, in patients with myotonic dystrophy with Type II respiratory failure maintaining adherence is challenging.

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.

Neural respiratory drive and cardiac function in patients with obesity hypoventilation syndrome following initiation of non-invasive ventilation.

Chronic hypercapnic respiratory failure (HRF) in obesity hypoventilation syndrome (OHS) is commonly treated using non-invasive ventilation (NIV). We hypothesised that treatment of OHS would improve neural respiratory drive index (NRDI) and cardiac function. Fourteen patients (8 females) with OHS, who were admitted for initiation of domiciliary NIV, were prospectively studied. Patients had (mean ± SD): age (53±10 years), body mass index (BMI) (50.1±10.8 kg/m2), and pCO2 (7.3±0.9 kPa). NRDI was assessed by surface electromyogram of the parasternal intercostals. Cardiac function was assessed by transthoracic echocardiography (TTE). All measurements were performed at baseline, 6 weeks, and 3 months. NRDI improved on day one following NIV set-up comparing to baseline (484.2±214.8 vs. 316.5±106.5 AU) and this improvement was maintained at 6 weeks (369.1±173.2 AU) and at 3 months (351.2±167.1 AU) (P=0.004). No significant differences were identified in terms of cardiac function between baseline and 3 months [tricuspid annular plane systolic excursion (TAPSE) (24.6±5.8 vs. 23.0±4.0 mm, P=0.317); systolic pulmonary artery (PA) pressures (36.7±15.2 vs. 44.5±23.9 mmHg, P=0.163]. NIV improves NRDI in patients with OHS, while the cardiac function over a three-month period remains unchanged.

Medium-term cost-effectiveness of an automated non-invasive ventilation outpatient set-up versus a standard fixed level non-invasive ventilation inpatient set-up in obese patients with chronic respiratory failure: a protocol description

IntroductionObesity is an escalating issue, with an accompanying increase in referrals of patients with obesity-related respiratory failure. Currently, these patients are electively admitted to hospital for initiation of non-invasive ventilation...

P175 Home Mechanical Ventilation (HMV): an expanding service in acute hospitals

Background HMV/domiciliary non-invasive ventilation (NIV) is being increasingly used to treat chronic ventilatory failure, particularly due to obesity and neuromuscular conditions. In patients attending an acute hospital, most domiciliary NIVs are set up at the end of an acute episode of admission with hypercapnic acidotic respiratory failure but over time, as more at-risk patients come under surveillance for respiratory failure, we hypothesised that a unit supervising domiciliary NIV/HMV is expected to do more elective set-ups. Methods Comparison of the volume of new domiciliary NIV set-ups and the elective NIV set-up rate over three 12-month periods: Apr 2005-Mar 2006 (period 1), Apr 2011-Mar 2012 (period 2) and Apr 2012-Mar 2013 (period 3) in a dedicated 11-bedded ward-based NIV unit (established: Aug 2004) in a 1000-bedded central England teaching hospital trust, providing domiciliary NIV support to over 260 patients with over 392 under surveillance for respiratory failure. Results The volume more than doubled from 19 new domiciliary NIV set-ups in period 1 to 39 new domiciliary NIV set-ups in period 2; to 64 set- ups in period 3. The elective domiciliary NIV set-up rate increased from 7/19 (36.8%) to 19/39 (48.7%) to 30/64 (46.9%) for periods 1, 2 and 3 respectively [[Figure 1][1]]. Discussion We have previously shown that the elective set-up rate for new HMV has gone up in our unit. In this survey we have shown that this increase in 'elective set-up rate' is associated with a consistent increase in volume of HMV set-ups. This is most likely to be due to an increased number of people at risk of respiratory failure coming under the unit's surveillance. HMV is well known to improve quality of life and reduce unscheduled care utilisation when started at the appropriate timepoint in chronic ventilatory failure through surveillance. Comparison of data between centres supervising domiciliary NIV/HMV, e.g 'elective set-up rates', is warranted in this rapidly evolving field.