Ward-based Non-invasive Ventilation Research Articles

Ward-Based Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure Unrelated to Chronic Obstructive Pulmonary Disease.

Background The use of ward-based noninvasive ventilation (NIV) for acute hypercapnic respiratory failure (AHRF) unrelated to chronic obstructive pulmonary disease (COPD) remains controversial. This study evaluated the outcomes and failure rates associated with NIV application in the ward-based setting for patients with AHRF unrelated to COPD. Methods A multicentre, retrospective cohort study of patients with AHRF unrelated to COPD was conducted. COPD was not the main reason for hospital admission, treated with ward-based NIV between February 2004 and December 2018. All AHRF patients were eligible; exclusion criteria comprised COPD patients, age < 18 years, pre-NIV pH < 7.35, or a lack of pre-NIV blood gas. In-hospital mortality was the primary outcome; univariable and multivariable models were constructed. The obesity-related AHRF group included patients with AHRF due to obesity hypoventilation syndrome (OHS), and the non-obesity-related AHRF group included patients with AHRF due to pneumonia, bronchiectasis, neuromuscular disease, or fluid overload. Results In total, 479 patients were included in the analysis; 80.2% of patients survived to hospital discharge. Obesity-related AHRF was the indication for NIV in 39.2% of all episodes and was the aetiology with the highest rate of survival to hospital discharge (93.1%). In the multivariable analysis, factors associated with a higher risk of in-hospital mortality were increased age (odds ratio, 95% CI: 1.034, 1.017–1.051, P < 0.001) and pneumonia on admission (5.313, 2.326–12.131, P < 0.001). In the obesity-related AHRF group, pre-NIV pH < 7.15 was associated with significantly increased in-hospital mortality (7.800, 1.843–33.013, P=0.005); however, a pre-NIV pH 7.15–7.25 was not associated with increased in-hospital mortality (2.035, 0.523–7.915, P=0.305). Conclusion Pre-NIV pH and age have been identified as important predictors of surviving ward-based NIV treatment. Moreover, these data support the use of NIV in ward-based settings for obesity-related AHRF patients with pre-NIV pH thresholds down to 7.15. However, future controlled trials are required to confirm the effectiveness of NIV use outside critical care settings for obesity-related AHRF.

Late presentation of acute hypercapnic respiratory failure carries a high mortality risk in COPD patients treated with ward-based NIV.

Non-invasive ventilation (NIV) is recommended for treatment of acute hypercapnic respiratory failure (AHRF) refractory to medical management in patients with COPD. This study investigated the relationship between time from hospital presentation to diagnosis of AHRF and in-hospital mortality. Retrospective analysis of hospitalised COPD patients treated with a first episode of ward-based NIV for AHRF at a large UK teaching hospital between 2004 and 2017. Data collected prospectively as part of NIV service evaluation. Multivariable logistic regression performed to identify predictors of in-hospital mortality. In total, 547 unique patients were studied comprising 245 males (44.8%), median age 70.6 years, median FEV1% predicted 34%. Overall in-hospital mortality was 19% (n = 104); median survival was 1.7 years. In univariate analysis, a longer time between hospital presentation to diagnosis of AHRF was associated with in-hospital mortality (median [IQR]: 8.7 [0.7-75.8] hours vs. 1.9 [0.3-13.6] hours, p < 0.0001). In multivariable logistic regression, significant predictors of in-hospital mortality were AHRF >24 h after hospital presentation (odds ratio [95% CI]: 2.29 [1.33-3.95], p = 0.003), pneumonia on admission (1.81 [1.07-3.08], p = 0.027), increased age (1.10 [1.07-1.14], p < 0.001) and NIV as ceiling of treatment (5.86 [2.87-11.94], p < 0.001). Hospitalised COPD patients with late presentation of AHRF, requiring acute ward-based NIV, may have increased in-hospital mortality. These patients may benefit from closer monitoring and earlier specialist respiratory review.

Temporal trends in survival following ward-based NIV for acute hypercapnic respiratory failure in patients with COPD.

Non-invasive ventilation (NIV) is recommended for treatment of acute hypercapnic respiratory failure (AHRF) in acute exacerbations of COPD. National UK audit data suggests that mortality rates are rising in COPD patients treated with NIV. To investigate temporal trends in in-hospital mortality in COPD patients undergoing a first episode of ward-based NIV for AHRF. Retrospective study of hospitalised COPD patients treated with a first episode of ward-based NIV at a large UK teaching hospital between 2004 and 2017. Patients were split into two cohorts based on year of admission, 2004-2010 (Cohort 1) and 2013-2017 (Cohort 2), to facilitate comparison of patient characteristics. In total, 547 unique patients were studied. There was no difference in in-hospital mortality rate between the time periods studied (17.6% vs 20.5%, P=.378). In Cohort 2 there were more females, a higher rate of co-morbid bronchiectasis and pneumonia on admission and more severe acidosis, hypercapnia and hypoxia. More patients in Cohort 2 had NIV as the ceiling of treatment. Patients in Cohort 2 experienced a longer time from AHRF diagnosis to application of NIV, higher maximum inspiratory positive airway pressure, lower maximum oxygen and shorter duration of NIV. Finally, patients in Cohort 2 experienced a shorter hospital length of stay (LOS), with no differences observed in rate of transfer to critical care or intubation. In-hospital mortality remained stable and LOS decreased over time, despite greater comorbidity and more severe AHRF in COPD patients treated for the first time with ward-based NIV.

Ward-Based Non-Invasive Ventilation in Acute Exacerbations of COPD: A Narrative Review of Current Practice and Outcomes in the UK.

Non-invasive ventilation (NIV) is frequently used as a treatment for acute hypercapnic respiratory failure (AHRF) in hospitalised patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In the UK, many patients with AHRF secondary to AECOPD are treated with ward-based NIV, rather than being treated in critical care. NIV has been increasingly used as an alternative to invasive ventilation and as a ceiling of treatment in patients with a ‘do not intubate’ order. This narrative review describes the evidence base for ward-based NIV in the context of AECOPD and summarises current practice and clinical outcomes in the UK.

Early ward-based acute noninvasive ventilation: a paper that changed practice.

The landmark YONIV trial addressed key practical questions surrounding the early use of ward-based noninvasive ventilation, which is now an established evidence-based treatment for acute hypercapnic respiratory failure http://ow.ly/BDC530iWhne

Nutritional Risk Screening 2002 as a Predictor of Outcome During General Ward-Based Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease with Respiratory Failure.

BackgroundNoninvasive ventilation (NIV) may reduce the need for intubation and mortality associated with chronic obstructive pulmonary disease (COPD) with type II respiratory failure. Early and simple predictors of NIV outcome could improve clinical management. This study aimed to assess whether nutritional risk screening 2002 (NRS2002) is a useful outcome predictor in COPD patients with type II respiratory failure treated by noninvasive positive pressure ventilation (NIPPV).Material/MethodsThis prospective observational study enrolled COPD patients with type II respiratory failure who accepted NIPPV. Patients were submitted to NRS2002 evaluation upon admission. Biochemical tests were performed the next day and blood gas analysis was carried out prior to NIPPV treatment and 4 hours thereafter. Patients were divided into NRS2002 score ≥3 and NRS2002 score <3 groups and NIV failure rates were compared between both groups.ResultsOf the 233 patients, 71 (30.5%) were not successfully treated by NIPPV. The failure rate was significantly higher in the NRS2002 score ≥3 group (35.23%) in comparison with patients with NRS2002 score <3 (15.79%) (p<0.05). Multivariate analysis indicated that PaCO2 (OR 1.25, 95%CI 1.172–1.671, p<0.05) prior to NIPPV treatment and NRS2002 score ≥3 (OR 1.76, 95%CI 1.303–2.374, p<0.05) were independent predictive factors for NIPPV treatment failure.ConclusionsNRS2002 score ≥3 and PaCO2 values at admission may predict unsuccessful NIPPV treatment of COPD patients with type II respiratory failure and help to adjust therapeutic strategies. NRS2002 is a noninvasive and simple method for predicting NIPPV treatment outcome.

Utility of respiratory ward-based NIV in acidotic hypercapnic respiratory failure.

We sought to elicit predictors of in-hospital mortality for first and subsequent admissions with acidotic hypercapnic respiratory failure (AHRF) in a cohort of chronic obstructive pulmonary disease patients who have undergone ward-based non-invasive ventilation (NIV), and identify features associated with long-term survival. Analysis of prospectively collected data at a single centre on patients undergoing NIV for AHRF between 2004 and 2009. Predictors of in-hospital mortality and intubation were sought by logistic regression and predictors of long-term survival by Cox regression. Initial pH exhibited a threshold effect for in-hospital mortality at pH 7.15. This relationship remained in patients undergoing their first episode of AHRF. In both first and subsequent admissions, a pH threshold of 7.25 at 4 h was associated with better prognosis (P = 0.02 and P = 0.04 respectively). In second or subsequent episodes of AHRF, mortality was lower and predicted only by age (P = 0.002) on multivariate analysis. NIV could be used on medical wards for patients with pH 7.16 or greater on their first admission, although more conservative values should continue to be used for those with a second or subsequent episodes of AHRF.

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.

P221 Temporal Trends in Severity and In-Hospital Mortality in Acute Hypercapnic Respiratory Failure (AHRF) at a Respiratory Ward-Based Non-Invasive Ventilation (NIV) Unit

IntroductionUse of NIV for AHRF in COPD, obesity related morbidity, chest wall and neuro muscular conditions have increased significantly over the past decade – there has been a documented 462%increase...

P224 Why Are We Failing in the UK in Non-Invasive Ventilation (NIV) and Acute Exacerbations of COPD (AECOPD)? Review of Our Local Practise

Introduction and Objectives Ward based NIV is proven treatment in AECOPD with type II respiratory failure with pH 7.25– 7.35.(1) Increasingly this modality is being used out with the trial evidence. The RCP audit of real world practise showed concerning results: failure or delay to deliver NIV and increaced mortality in NIV-treated patients compared to equally severe patients managed without NIV (26% vs 14%).(2) In light of these factors we reviewed our NIV use across our hospital. Did our local service need improvement? Methods We audited 4 months of emergency department admissiond in late 2011 to 2012, ward based NIV care in February-March 2011 and February-March 2012 using the BTS audit tool and critical care admissions for AECOPD from January 2010 to Decemeber 2011. Emergency Department NIV was only considered in 78% of possible patients and only given in 37%. Significant delays were seen in starting NIV; median 357 minutes (range 138–1366). Ward-based NIV In 2011 overall mortality was 33%, however patients with pH 7.25–7.35 mortality was 11%, matching the landmark trial outcomes.(1) If pH was <7.25 mortality was 80%. In 2012 oxygen toxicity contributed to acidosis is 33% of patients and overall mortality was 40%. Critical Care Department (CCD) Time to respiratory support was a median of 4 hours. 31% of patients required invasive ventilation, this was higher if consolidation was present on CXR (p=0.005). Overall mortality was 20%, significantly higher if pH<7.25 at any time at 35% (p=0.02) and if CXR consolidation was present (25% vs 12.5). Conclusions Unfortunately NIV is not commenced in all appropriate patients, delays are common place and NIV is being used in severely ill and very acidotic patients with high mortality outcomes. Driven by national audit data, this detailed analysis of our practise has allowed us to drive local changes to improve our service including: 24/7 NIV nurse; early involvement with CCD in appropraite patients with pH<7.25 and re-education of staff across the Trust.

P220 Evolving Set-Up Practises at a Respiratory Ward-Based Non-Invasive Ventilation (NIV) Unit

IntroductionNIV for acute hypercapnic respiratory failure (AHRF) in COPD, obesity related morbidity, chest wall and neuromuscular conditions has become widespread in the UK over the past decade. In terms of...

S70 Non-invasive ventilation (NIV) in Chronic Obstructive Pulmonary Disease (COPD) exacerbations with acute hypercapnic respiratory failure (AHRF) with pH

Introduction Recent British guidelines on NIV suggest patients with AHRF and pH Methods Analysis of initial ABG (pre-commencement of NIV) for AHRF secondary to COPD between 1 August 2004 and 31 December 2009 was performed. NIV was undertaken in a dedicated unit on a respiratory ward. The admission episodes were stratified by initial pH ranges (predictor variable) and in-hospital mortality was recorded (outcome variable). Results Out of 728 (505 unique patients) admissions with COPD requiring NIV for AHRF, 282 admissions had a pH Conclusion Mortality in the group with pH 7.20–7.25 was similar to the group with pH 7.26–7.30, suggesting that NIV on a dedicated respiratory ward can manage COPD patients with AHRF and pH 7.26 to pH >7.20 for ward-based NIV in COPD exacerbations with AHRF. This has important resource implications, given that more patients could be managed in a ward-based dedicated NIV unit rather than the utilising ITU beds in the UK National Health Service.

Ward-based non-invasive ventilation for hypercapnic exacerbations of COPD: a 'real-life' perspective

Non-invasive ventilation (NIV) has revolutionized the management of hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD). However, most published data have evaluated highly selected patients within the context of randomized controlled trials. We wished to evaluate the outcomes of ward-based NIV in 'real-life' patients admitted to hospital with a hypercapnic exacerbation of COPD. Retrospective data (gender, age, baseline pH, PaCO(2) and values after 1 and 4 h of NIV, and outcomes) were evaluated for all patients receiving NIV in the respiratory unit of Aberdeen Royal Infirmary from January 2006 to December 2009. Data were analysed in three groups: as a whole, in those with baseline pH >or=7.25 and baseline pH <7.25. Data were available for all 392 patients commenced on ward-based NIV [45% male, mean age (range) 71 years (42-89)] with mean baseline pH of 7.24 and PaCO(2) of 10.1 kPa; respective values improved significantly (P <0.0001) following 1 and 4 h of NIV and treatment was considered successful in 66%. In those with baseline pH <7.25 and >or=7.25, the success rates of NIV were 58 and 72%, respectively. In hypercapnic exacerbations of COPD, ward-based NIV is useful in the 'real-life' setting with physiological parameters improving after only a short treatment period, while two-thirds of all patients were discharged from hospital. Further data are required to help determine factors other than pH which influence the outcome of NIV.

Impact of the opening of a ward-based noninvasive ventilation unit on critical care

Noninvasive ventilation (NIV) is now the accepted first-line treatment for acidotic exacerbations of chronic obstructive pulmonary disease (COPD). Many hospitals perform NIV in a ward-based unit outside the ICU. Patients are still admitted to the ICU when failure of NIV may lead to mechanical ventilation, or for bed resource reasons. The impact of the opening of a ward-based NIV unit at University Hospital Aintree in July 2004 is described.