Practical Insight to Monitor Home NIV in COPD Patients

High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation in patients at very high risk for extubating failure: A systematic review of randomized controlled trials

BACKGROUND

Mechanical ventilation is commonly used for managing respiratory failure in chronic obstructive pulmonary disease (COPD) patients, but weaning patients off ventilator support can be challenging and associated with complications. While many patients respond well to Non-invasive ventilation (NIV), a significant proportion may not respond as favourably. We aimed to assess whether high-flow nasal cannula (HFNC) is equally effective as NIV in reducing extubation failure among previously intubated COPD patients.

METHODS

This systematic review was carried out in line with PRISMA guidelines We searched PubMed, Scopus, Web of Science, and Cochrane library from inception until February 15, 2023. Randomized Clinical Trials (RCTs) of adults at high risk for extubating failure were included. We examined the use of HFNC as the intervention and NIV as the comparator. Our outcome of interest included, reintubation rate, length of hospital or intensive care unit (ICU) stay, adverse events, and time to reintubation. The Cochrane risk-of-bias tool was used for randomized trials to assess risk of bias.

RESULTS

We identified 348 citations, 11 of which were included, representing 2,666 patients. The trials indicate that HFNC is comparable to NIV in preventing reintubation after extubating in COPD patients. In comparison to NIV, HFNC also produced improved tolerance, comfort, and less complications such as airway care interventions. NIV with active humification may be more effective that HFNC in avoiding reintubation in patients who are at extremely high risk for extubating failure.

CONCLUSION

The inconclusive nature of emerging evidence highlights the need for additional studies to establish the efficacy and suitability of HFNC as an alternative to NIV for previously intubated COPD patients. Clinicians should consider the available options and individualize their approach based on patient characteristics. Future research should focus on addressing these gaps in knowledge to guide clinical decision-making and optimize outcomes for this patient population.

Validity and reliability of the Dutch version of the S3-NIV questionnaire to evaluate long-term noninvasive ventilation

OBJECTIVES

Noninvasive ventilation (NIV) is an effective treatment for chronic respiratory failure (CRF). Patient-centered outcomes need to be evaluated regularly and the S3-NIV questionnaire seems an applicable tool. We translated this short, self-administered questionnaire into a Dutch version and tested its construct validity and reliability.

METHODS

An observational study was conducted, including 127 stable long-term NIV users with CRF or complex sleep related breathing disorders due to different underlying diseases: chronic obstructive pulmonary disease (25%), slowly progressive neuromuscular disorders (35%), rapidly progressive neuromuscular disorders (12%) and 'other disorders' (28%) including complex sleep apnea and obesity hypoventilation syndrome. Construct validity and reliability were tested.

RESULTS

The Dutch version of the questionnaire was obtained after a translation and back-translation process. Internal consistency of the total score was good (Cronbach's α coefficient of 0.78) as well as for the 'respiratory symptoms' subdomain and the 'sleep and side effects' subdomain (Cronbach's α coefficient of 0.78 and 0.69, respectively). The reproducibility was excellent with an intraclass correlation of 0.89 (95% CI 0.87-0.93). Construct validity was good for the 'respiratory symptoms' subdomain.

CONCLUSION

The Dutch S3-NIV questionnaire is a reliable and valid tool to evaluate symptoms, sleep, and NIV related side effects in long-term NIV users.

Home NIV treatment quality in patients with chronic respiratory failure having participated to the French nationwide telemonitoring experimental program (The TELVENT study)

BACKGROUND

The ETAPES program is a national telemedicine experiment conducted in France between 2018 and 2023 to investigate whether home non-invasive ventilation (NIV) telemonitoring improves healthcare pathways in patients with chronic respiratory failure (CRF) and impacts healthcare organization. The program provides a combination of therapeutic education and NIV telemonitoring with data processed by an algorithm generating alerts. The TELVENT study objective was to analyze the evolution of ventilation quality in patients included in the ETAPES program.

METHODS

Multicentric cohort study on patients undergoing long-term NIV included in the ETAPES program between September 2018 and December 2020 and who did not refuse the use of their data for this research. Data were obtained from homecare provider databases. The primary endpoint was to attain successful NIV treatment, which was determined by a combination of daily NIV usage for > 4 h per day, low leaks, and a low apnea-hypopnea index (AHI) identified by the NIV device. Respiratory disability was assessed using the DIRECT questionnaire.

RESULTS

329 patients were included in the study of which 145 had COPD and 83 had started NIV and ETAPES within one-month delay. Approximately 25% of patients did not achieve the criteria for successful NIV at ETAPES entry. The proportion of patients with successful NIV treatment increased to 86.8% at six months (p = 0.003, Cochran-Armitage trend test) regardless of NIV history and continued to increase at 12 months in newly equipped NIV patients (93.8%, at month 12, p = 0.0026 for trend test). Over time, a significant increase in NIV use and compliance was observed, while AHI significantly decreased in the overall population. No significant decrease was observed for non-intentional leaks. Approximately 4.9 alerts were generated per patient per 6 months. Their number and type (low NIV use, high AHI or leaks) differed among patients based on their NIV history. Respiratory disability score decreased over time compared with baseline.

CONCLUSION

The TELVENT study highlights the importance of remote NIV monitoring to rapidly identify patients with unsuccessful ventilation. The combination of remote monitoring and therapeutic education may improve the quality of home NIV, especially in the first months of treatment.

“The Devices Themselves Aren’t the Problem”—Views of Patients and Their Relatives on Medical Technical Aid Supply in Home Mechanical Ventilation: An Explorative Qualitative Study

(1) The supply of medical technical aids and the instructions on using them is critical for home-mechanically ventilated patients and their relatives. However, limited evidence exists on the needs-based nature of this care. (2) Aim: To gain insights into users’ views on this form of care, to identify key challenges, and to derive empirically sound preliminary recommendations for its future design. (3) Methods: An explorative qualitative interview study was performed in Germany. Semi-structured interviews were conducted with home-mechanically ventilated patients and their relatives. Patients were selected through purposive sampling. Interviews were audio-recorded, transcribed, and analysed using a content analysis approach. (3) Results: 27 patients and 9 relatives were interviewed. From their point of view, ventilation-specific equipment is generally reliable and is seen as a belonging of the patient. However, if the patient lacks competence in using the technology or if information or instructions are neglected, ambiguous and unsafe situations easily arise. (4) Conclusions: The present study is one of the first to provide insights into technical aid supply in home-mechanical ventilation from the users’ point of view. It highlights the need for continuous professional support and for evidence-based educational strategies that promote safety among the users of technical aids in home care.

An overview of noninvasive ventilation in cystic fibrosis

Noninvasive ventilation (NIV) use was initially reported in cystic fibrosis (CF) in 1991 as a bridge to lung transplantation, and over the decades, the use of NIV has increased in the CF population. Individuals with CF are prone to various physiologic changes as lung function worsens, and they benefit from NIV for advanced lung disease. As life expectancy in CF has been increasing due to advances such as highly effective modulator therapy, people with CF may also benefit from NIV for other diagnosis beyond advanced lung disease. NIV can improve gas exchange, quality of sleep, exercise tolerance, and augment airway clearance in CF. CF providers can readily become comfortable with this therapeutic modality. In this review, we will summarize the physiologic basis for NIV use in CF, describe indications for initiation, and discuss how to order and monitor patients on NIV. We will discuss aspects unique to people with CF and the use of NIV, as well as suggestions on how to reduce risks such as infection. We hope that this serves as a resource for CF providers, in particular those who do not have dedicated training in sleep medicine as we all continue to care for the CF patient population.

Assistive technologies for home NIV in patients with COPD: feasibility and positive experience with remote-monitoring and volume-assured auto-EPAP NIV mode

Background

Outcomes for patients with chronic obstructive pulmonary disease (COPD) with persistent hypercapnic respiratory failure are improved by long-term home non-invasive ventilation (NIV). Provision of home-NIV presents clinical and service challenges. The aim of this study was to evaluate outcomes of home-NIV in hypercapnic patients with COPD who had been set-up at our centre using remote-monitoring and iVAPS-autoEPAP NIV mode (Lumis device, ResMed).

Methods

Retrospective analysis of a data set of 46 patients with COPD who commenced remote-monitored home-NIV (AirView, ResMed) between February 2017 and January 2018. Events including time to readmission or death at 12 months were compared with a retrospectively identified cohort of 27 patients with hypercapnic COPD who had not been referred for consideration of home-NIV.

Results

The median time to readmission or death was significantly prolonged in patients who commenced home-NIV (median 160 days, 95% CI 69.38 to 250.63) versus the comparison cohort (66 days, 95% CI 21.9 to 110.1; p<0.01). Average time to hospital readmission was 221 days (95% CI, 47.77 to 394.23) and 70 days (95% CI, 55.31 to 84.69; p<0.05), respectively. Median decrease in bicarbonate level of 4.9 mmol/L (p<0.0151) and daytime partial pressure of carbon dioxide 2.2 kPa (p<0.032) in home-NIV patients with no required increase in nurse home visits is compatible with effectiveness of this service model. Median reduction of 14 occupied bed days per annum was observed per patient who continued home-NIV throughout the study period (N=32).

Conclusion

These findings demonstrate the feasibility and provide initial utility data for a technology-assisted service model for the provision of home-NIV therapy for patients with COPD.

Butorphanol versus Propofol in Patients Undergoing Noninvasive Ventilation: A Prospective Observational Study

Background

The present study aimed to explore sedation management in agitated patients who suffered from acute respiratory failure (ARF) and were treated with noninvasive ventilation (NIV).

Patients and Methods

We divided 118 patients undergoing NIV treatment with butorphanol or propofol into two groups: group B (n = 57, butorphanol was initiated at the rate of 0.12 µg/kg/min as a continuous intravenous infusion and then titrated by 0.06 µg/kg/min every half an hour, group P (n = 61, propofol was initiated at the rate of 5 µg/kg/min as a continuous intravenous infusion and then titrated by 1.5 µg/kg/min every half an hour). Score of Sedation Agitation Scale (SAS) in the two groups was maintained between 3 and 4. Medications including sedative, analgesic, and antipsychotic, NIV intolerance score, SAS score, visual analog scale (VAS), medication use and adverse events were recorded repeatedly.

Results

Patients receiving butorphanol required significantly less total amount of fentanyl than patients receiving propofol during NIV to maintain the target VAS [0 (0–0) µg vs 150 (50–200) µg, P< 0.005]. Hemodynamic stability during NIV showed it was better kept in patients treated with butorphanol.

Conclusion

Butorphanol not only decreased the requirements of fentanyl but also enhanced hemodynamic stability in agitated patients suffering from ARF receiving NIV.

Trial Registration

Registered at http://www.chictr.org.cn/ (ChiCTR1800015534).

Titration and follow-up for home noninvasive positive pressure ventilation in chronic obstructive pulmonary disease: The potential role of tele-monitoring and the Internet of things

INTRODUCTION

Home noninvasive positive pressure ventilation (NIPPV) has become a well-established treatment for stable hypercapnic chronic obstructive pulmonary disease (COPD) patients. There are still other challenges including appropriate titration of ventilator parameters, adequacy of follow-up, monitoring, and management at home to ensure effectiveness and security, and to improve quality of life. The Internet of Things (IoT) is the name given to the network of devices and other "things" with built-in sensors, software, electronics, and network connectivity, which can communicate these objects over wireless networks and then send data to a cloud platform. Reliable tele-monitoring and transmission of clinical parameters from home to hospitals have prompted the development of IoT-based home NIPPV.

OBJECTIVES

This review provides an overview of titration and follow-up of home NIPPV and focuses on different technologies, modalities, managements, and cost-effectiveness used in IoT-based tele-monitoring of home mechanical ventilation.

DATA SOURCE

Literature search of Web of Science, PubMed, and EMBASE was made to find relevant articles about tele-monitoring and the IoT in home mechanical ventilation over the last 15 years. We used the following search terms: NIPPV, COPD, home mechanical ventilation, telemedicine, tele-monitoring, and management.

CONCLUSION

IoT-based management of home NIPPV, such as home titration and follow-up with the use of tele-monitoring, are emerging and yielding positive findings. However, clear conclusions based on RCT of tele-monitoring in COPD patients with NIPPV at home are only a few and large-scale multicenter studies are required for replication and further validation.

Telemedicine in COPD: An Overview by Topics

COPD is a major cause of morbidity and mortality worldwide and carries a huge and growing economic and social burden. Telemedicine might allow the care of patients with limited access to health services and improve their self-management. During the COVID-19 pandemic, patient's safety represents one of the main reasons why we might use these tools to manage our patients. The authors conducted a literature search in MEDLINE database. The retrieval form of the Medical Subject Headings (Mesh) was ((Telemedicine OR Tele-rehabilitation OR Telemonitoring OR mHealth OR Ehealth OR Telehealth) AND COPD). We only included systematic reviews, reviews, meta-analysis, clinical trials and randomized-control trials, in the English language, with the selected search items in title or abstract, and published from January 1st 2015 to 31st May 2020 (n = 56). There was a positive tendency toward benefits in tele-rehabilitation, health-education and self-management, early detection of COPD exacerbations, psychosocial support and smoking cessation, but the heterogeneity of clinical trials and reviews limits the extent to which this value can be understood. Telemonitoring interventions and cost-effectiveness had contradictory results. The literature on teleconsultation was scarce during this period. The non-inferiority tendency of telemedicine programmes comparing to conventional COPD management seems an opportunity to deliver quality healthcare to COPD patients, with a guarantee of patient's safety, especially during the COVID-19 outbreak.

High-flow nasal cannula oxygen therapy versus non-invasive ventilation for chronic obstructive pulmonary disease patients after extubation: a multicenter, randomized controlled trial

Background

High-flow nasal cannula (HFNC) oxygen therapy is being increasingly used to prevent post-extubation hypoxemic respiratory failure and reintubation. However, evidence to support the use of HFNC in chronic obstructive pulmonary disease (COPD) patients with hypercapnic respiratory failure after extubation is limited. This study was conducted to test if HFNC is non-inferior to non-invasive ventilation (NIV) in preventing post-extubation treatment failure in COPD patients previously intubated for hypercapnic respiratory failure.

Methods

COPD patients with hypercapnic respiratory failure who were already receiving invasive ventilation were randomized to HFNC or NIV at extubation at two large tertiary academic teaching hospitals. The primary endpoint was treatment failure, defined as either resumption of invasive ventilation or switching to the other study treatment modality (NIV for patients in the NFNC group or vice versa).

Results

Ninety-six patients were randomly assigned to the HFNC group or NIV group. After secondary exclusion, 44 patients in the HFNC group and 42 patients in the NIV group were included in the analysis. The treatment failure rate in the HFNC group was 22.7% and 28.6% in the NIV group—risk difference of − 5.8% (95% CI, − 23.8–12.4%, p = 0.535), which was significantly lower than the non-inferior margin of 9%. Analysis of the causes of treatment failure showed that treatment intolerance in the HFNC group was significantly lower than that in the NIV group, with a risk difference of − 50.0% (95% CI, − 74.6 to − 12.9%, p = 0.015). One hour after extubation, the mean respiratory rates of both groups were faster than their baseline levels before extubation (p < 0.050). Twenty-four hours after extubation, the respiratory rate of the HFNC group had returned to baseline, but the NIV group was still higher than the baseline. Forty-eight hours after extubation, the respiratory rates of both groups were not significantly different from the baseline. The average number of daily airway care interventions in the NIV group was 7 (5–9.3), which was significantly higher than 6 (4–7) times in the HFNC group (p = 0.006). The comfort score and incidence of nasal and facial skin breakdown of the HFNC group was also significantly better than that of the NIV group [7 (6–8) vs 5 (4–7), P < 0.001] and [0 vs 9.6%, p = 0.027], respectively.

Conclusion

Among COPD patients with severe hypercapnic respiratory failure who received invasive ventilation, the use of HFNC after extubation did not result in increased rates of treatment failure compared with NIV. HFNC also had better tolerance and comfort than NIV.

Trial registration

chictr.org (ChiCTR1800018530). Registered on 22 September 2018, http://www.chictr.org.cn/usercenter.aspx

European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD

Background

While the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients.

Materials and methods

The European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients.

Results

The task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode.

Conclusions

Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.

Continuous remote monitoring of COPD patients-justification and explanation of the requirements and a survey of the available technologies

Remote patient monitoring should reduce mortality rates, improve care, and reduce costs. We present an overview of the available technologies for the remote monitoring of chronic obstructive pulmonary disease (COPD) patients, together with the most important medical information regarding COPD in a language that is adapted for engineers. Our aim is to bridge the gap between the technical and medical worlds and to facilitate and motivate future research in the field. We also present a justification, motivation, and explanation of how to monitor the most important parameters for COPD patients, together with pointers for the challenges that remain. Additionally, we propose and justify the importance of electrocardiograms (ECGs) and the arterial carbon dioxide partial pressure (PaCO2) as two crucial physiological parameters that have not been used so far to any great extent in the monitoring of COPD patients. We cover four possibilities for the remote monitoring of COPD patients: continuous monitoring during normal daily activities for the prediction and early detection of exacerbations and life-threatening events, monitoring during the home treatment of mild exacerbations, monitoring oxygen therapy applications, and monitoring exercise. We also present and discuss the current approaches to decision support at remote locations and list the normal and pathological values/ranges for all the relevant physiological parameters. The paper concludes with our insights into the future developments and remaining challenges for improvements to continuous remote monitoring systems. Graphical abstract ᅟ.