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Perry MA, Jones B, Devan H, Neill A, Piper A, Ingham T. Non-invasive ventilation for people with neuromuscular disorders in Australia and New Zealand: a qualitative study of clinician perspectives. Med J Aust 2023; 219:270-274. [PMID: 37449654 DOI: 10.5694/mja2.52036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES To explore the experiences of Australian and New Zealand clinicians with respect to care pathways, their awareness and use of non-invasive ventilation guidelines, and their perspectives on delivering quality non-invasive ventilation services to people with neuromuscular disorders. DESIGN, SETTING, PARTICIPANTS Qualitative study; semi-structured focus groups and individual interviews with Australian and New Zealand clinicians who provide non-invasive ventilation services to people with neuromuscular disorders, recruited from participants at a 2017 sleep medicine conference. Interviews were conducted during 1 October 2017 - 31 May 2018. MAIN OUTCOME MEASURES Major themes identified by an iterative, semantic, and inductive analysis. RESULTS A total of 28 participants attended the four focus group sessions and five individual interviews; fourteen each from New Zealand and Australia, seventeen women and eleven men, eighteen physicians and ten other clinicians. Two major themes were identified: decision making for current practice, and resource constraints. Participants noted variable use of clinical guidelines and limited training to meet the needs of people with neuromuscular disorders who require non-invasive ventilation. They described a lack of dedicated funding, unstructured care pathways, equipment supply levels that do not meet need, low staff-to-patient ratios and staff shortages, and the inability to deliver quality multidisciplinary care. The need for clinical guidelines and service specifications was highlighted as requisite for reducing variation in clinical care. CONCLUSIONS Systemic factors influence the needs-based provision of non-invasive ventilation for people with neuromuscular disorders. Development of clinical guidelines for Australia and New Zealand, dedicated funding for respiratory services for people with neuromuscular disorders, and specialist clinician training are important for equitable and high quality non-invasive ventilation care.
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Affiliation(s)
- Meredith A Perry
- Centre for Health, Activity and Rehabilitation Research (CHARR), University of Otago, Dunedin, New Zealand
| | | | - Hemakumar Devan
- Centre for Health, Activity and Rehabilitation Research (CHARR), University of Otago, Dunedin, New Zealand
| | - Alister Neill
- University of Otago, Wellington, New Zealand
- Capital and Coast District Health Board, Newtown, New Zealand
| | - Amanda Piper
- The University of Sydney Central Clinical School, Sydney, NSW
- Royal Prince Alfred Hospital, Sydney, NSW
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Neill A, Ingham TR, Perry M, Aldridge D, Miller J, Jones B. Noninvasive ventilation in New Zealand: a national prevalence survey. Intern Med J 2023; 53:1458-1468. [PMID: 36326217 DOI: 10.1111/imj.15960] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 10/09/2022] [Indexed: 08/22/2023]
Abstract
BACKGROUND Home-based noninvasive ventilation (NIV) is an effective treatment for a range of conditions that cause respiratory failure which reduces hospitalisation and mortality and improves quality of life. AIMS To collect NIV prevalence, disease burden and equity data needed for effective national NIV health service planning. METHODS The authors collected demographics and the primary diagnosis of patients receiving publicly funded NIV in New Zealand in 2018 by surveying all providers. National and regional prevalence rates were calculated using adult population data (aged ≥20 years) for each District Health Board region compared with a 2011 study. A subanalysis of individual-level data was used to calculate age-standardised rates by diagnostic category. RESULTS A total of 1197 adults were receiving NIV giving a national rate of 32.9 per 100 000; almost twice the 2011 rate (16.7 per 100 000). Significant regional variations in NIV provision (4.5-84.2 per 100 000) were observed. The most frequent indications were obesity hypoventilation syndrome (OHS) (562, 47%), obstructive pathologies (335, 28%) and neuromuscular disorders (175, 15%); all have significantly increased in prevalence since 2011. Māori and Pacific peoples were significantly overrepresented among NIV users (2.24 [95% confidence interval (CI), 1.72-2.93] and 7.03 [95% CI, 5.52-8.94], respectively). The prevalence of NIV-dependent use (>15 h/day) was 4%. CONCLUSIONS Home-based NIV provision has doubled since the previous survey, reflecting increased burden from OHS and obstructive pathologies and a disproportionate disease burden among Māori and Pacific populations. The large regional variations are concerning and highlight the urgent requirement for national service specifications, education and equipment provision. Further research is needed to address access equity.
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Affiliation(s)
- Alister Neill
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
- Department of Respiratory Medicine, Wellington Regional Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Tristram R Ingham
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
- Foundation for Equity and Research New Zealand, Wellington, New Zealand
| | - Meredith Perry
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Daniel Aldridge
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - James Miller
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Bernadette Jones
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
- Foundation for Equity and Research New Zealand, Wellington, New Zealand
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Perry MA, Jones B, Jenkins M, Devan H, Neill A, Ingham T. Health System Factors Affecting the Experience of Non-Invasive Ventilation Provision of People with Neuromuscular Disorders in New Zealand. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4758. [PMID: 36981666 PMCID: PMC10048586 DOI: 10.3390/ijerph20064758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
Non-invasive ventilation (NIV) is a critical therapy for many patients with neuromuscular disorders (NMD), supporting those with respiratory failure to achieve adequate respiration and improve their quality of life. The aim of this study was to explore the experiences of access to, consent, uptake, maintenance and safe use of non-invasive ventilation by people with NMD. Semi-structured individual interviews were conducted with 11 people with NMD, each using NIV for more than 12 months. A critical realism ontological paradigm with contextualism epistemology guided the Reflexive Thematic Analysis. An Equity of Health Care Framework underpinned the analysis. Three themes were interpreted: Uptake and informed consent for NIV therapy; Practicalities of NIV; and Patient-clinician relationships. We identified issues at the system, organization and health professional levels. Conclusions: We recommend the development of national service specifications with clear standards and dedicated funding for patients with NMD and call on the New Zealand Ministry of Health to proactively investigate and monitor the variations in service delivery identified. The specific areas of concern for patients with NMD suggest the need for NMD-related NIV research and service provision responsive to the distinct needs of this population.
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Affiliation(s)
- Meredith A. Perry
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, Dunedin 9016, New Zealand
| | - Bernadette Jones
- Department of Medicine, University of Otago—Wellington, Wellington 6242, New Zealand
- Foundation for Equity & Research New Zealand, Wellington 6147, New Zealand
| | - Matthew Jenkins
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, Dunedin 9016, New Zealand
| | - Hemakumar Devan
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, Dunedin 9016, New Zealand
| | - Alister Neill
- Department of Medicine, University of Otago—Wellington, Wellington 6242, New Zealand
- Department of Respiratory Medicine, Te Whatu Ora Capital, Coast and Hutt Valley, Wellington 6140, New Zealand
| | - Tristram Ingham
- Department of Medicine, University of Otago—Wellington, Wellington 6242, New Zealand
- Foundation for Equity & Research New Zealand, Wellington 6147, New Zealand
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Qu Y, Milross M, McGuiness O, Menadue C, Piper A. Survey of Home Cleaning Practices With Noninvasive Ventilation Equipment. Cardiopulm Phys Ther J 2022. [DOI: 10.1097/cpt.0000000000000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Perry MA, Jenkins M, Jones B, Bowick J, Shaw H, Robinson E, Rowan M, Spencer K, Neill A, Ingham T. "Me and ' that' machine": the lived experiences of people with neuromuscular disorders using non-invasive ventilation. Disabil Rehabil 2022; 45:1847-1856. [PMID: 35649702 DOI: 10.1080/09638288.2022.2076939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Neuromuscular disorders (NMD) encompasses a wide range of conditions, with respiratory weakness a common feature. Respiratory care can involve non-invasive ventilation (NIV) resulting in fewer hospital admissions, a lower mortality rate and improved quality of life. The aim of this study was to explore the 'lived experience' of NIV by people with NMD. METHODS Interpretive Phenomenological Analysis (IPA) with semi-structured, face to face interviews with 11 people with NMD, using bi-level positive airway pressure for NIV for more than 12 months. RESULTS Three themes were interpreted: (i) Alive, with a life; (ii) Me and 'that' machine; and (iii) Precariousness of this life. NIV enabled hope, independence and the opportunity to explore previously perceived unattainable life experiences. Yet, participants felt dependent on the machine. Furthermore, practical considerations and fear of NIV failure created a sense of precariousness to life and a reframing of personal identity. CONCLUSION The findings highlight the broad ranging positive and negative effects that may occur for people with NMD when using this important therapy. Ongoing non-judgemental support and empathy are required from health professionals as the use of NIV challenged concepts such as 'living life well' for people with NMD. IMPLICATIONS FOR REHABILITATIONNeuromuscular disorders may result in respiratory weakness requiring non-invasive ventilation (NIV).When prescribed early, NIV can results in fewer hospital admissions, a lower mortality rate and improved quality of life.The relationship of people with NMD with their NIV machine is complex and impacts on and requires adjustment to their identity.NIV users acknowledged that NIV provided hope but simultaneously recognised the precariousness of NIV on their life.In order to better support people with NMD healthcare professionals need to better understand how the physical, psychological and social implications of NIV affect an individual's life.
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Affiliation(s)
- Meredith A Perry
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Matthew Jenkins
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Bernadette Jones
- Department of Medicine, University of Otago, Wellington, New Zealand.,Foundation for Equity & Research New Zealand, Wellington, New Zealand
| | - Jarrod Bowick
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Hannah Shaw
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Emma Robinson
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Morgan Rowan
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Kate Spencer
- Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Alister Neill
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Tristram Ingham
- Department of Medicine, University of Otago, Wellington, New Zealand.,Foundation for Equity & Research New Zealand, Wellington, New Zealand
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Markussen H, Lehmann S, Nilsen RM, Natvig GK. Factors associated with change in health-related quality of life among individuals treated with long-term mechanical ventilation, a 6-year follow-up study. J Adv Nurs 2017; 74:651-665. [PMID: 28983937 DOI: 10.1111/jan.13472] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 11/29/2022]
Abstract
AIMS To examine changes and explanatory variables for changes in health-related quality of life in patients treated with long-term mechanical ventilation over a 6-year period. BACKGROUND Long-term mechanical ventilation is a treatment for individuals with chronic hypercapnic respiratory failure, primarily caused by neuromuscular diseases, obesity hypoventilation syndrome, chronic obstructive pulmonary and restrictive thoracic diseases. Studies on long-term outcome on health-related quality of life and factors influencing it are lacking. DESIGN Prospective cohort study. METHODS Data were collected from the Norwegian Long-Term-Mechanical-Ventilation Registry and from patient-reported questionnaire in 2008 and 2014. Health-related quality of life was measured by the Severe Respiratory Insufficiency questionnaire, containing 49 items and seven subdomains. Linear mixed effects models were used to measure changes and identify factors for changes. RESULTS After 6 years, 60 patients were still participating, out of 127 at baseline. Health-related quality of life improved significantly in the total score and in four subdomains of the questionnaire. Satisfaction with training in long-term mechanical ventilation was an explanatory variable for improved 'psychological well-being' and follow-up for improvement of 'anxiety'. Side effects of the treatment like facial soreness were associated with the total score. High age and high forced vital capacity were related to lower 'physical function' and improved 'social functioning', respectively. CONCLUSION Long-term mechanical ventilation over 6 years improved health-related quality of life in most patients. Patient training, follow-up and reduction of side effects, largely delivered by trained nurses, contribute to achieve the main goal of the treatment-improved health-related quality of life.
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Affiliation(s)
- Heidi Markussen
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sverre Lehmann
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Roy M Nilsen
- Department of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Gerd K Natvig
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Dretzke J, Blissett D, Dave C, Mukherjee R, Price M, Bayliss S, Wu X, Jordan R, Jowett S, Turner AM, Moore D. The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation. Health Technol Assess 2016; 19:1-246. [PMID: 26470875 DOI: 10.3310/hta19810] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic progressive lung disease characterised by non-reversible airflow obstruction. Exacerbations are a key cause of morbidity and mortality and place a considerable burden on health-care systems. While there is evidence that patients benefit from non-invasive ventilation (NIV) in hospital during an acute exacerbation, evidence supporting home use for more stable COPD patients is limited. In the U.K., domiciliary NIV is considered on health economic grounds in patients after three hospital admissions for acute hypercapnic respiratory failure. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of domiciliary NIV by systematic review and economic evaluation. DATA SOURCES Bibliographic databases, conference proceedings and ongoing trial registries up to September 2014. METHODS Standard systematic review methods were used for identifying relevant clinical effectiveness and cost-effectiveness studies assessing NIV compared with usual care or comparing different types of NIV. Risk of bias was assessed using Cochrane guidelines and relevant economic checklists. Results for primary effectiveness outcomes (mortality, hospitalisations, exacerbations and quality of life) were presented, where possible, in forest plots. A speculative Markov decision model was developed to compare the cost-effectiveness of domiciliary NIV with usual care from a UK perspective for post-hospital and more stable populations separately. RESULTS Thirty-one controlled effectiveness studies were identified, which report a variety of outcomes. For stable patients, a modest volume of evidence found no benefit from domiciliary NIV for survival and some non-significant beneficial trends for hospitalisations and quality of life. For post-hospital patients, no benefit from NIV could be shown in terms of survival (from randomised controlled trials) and findings for hospital admissions were inconsistent and based on limited evidence. No conclusions could be drawn regarding potential benefit from different types of NIV. No cost-effectiveness studies of domiciliary NIV were identified. Economic modelling suggested that NIV may be cost-effective in a stable population at a threshold of £30,000 per quality-adjusted life-year (QALY) gained (incremental cost-effectiveness ratio £28,162), but this is associated with uncertainty. In the case of the post-hospital population, results for three separate base cases ranged from usual care dominating to NIV being cost-effective, with an incremental cost-effectiveness ratio of less than £10,000 per QALY gained. All estimates were sensitive to effectiveness estimates, length of benefit from NIV (currently unknown) and some costs. Modelling suggested that reductions in the rate of hospital admissions per patient per year of 24% and 15% in the stable and post-hospital populations, respectively, are required for NIV to be cost-effective. LIMITATIONS Evidence on key clinical outcomes remains limited, particularly quality-of-life and long-term (> 2 years) effects. Economic modelling should be viewed as speculative because of uncertainty around effect estimates, baseline risks, length of benefit of NIV and limited quality-of-life/utility data. CONCLUSIONS The cost-effectiveness of domiciliary NIV remains uncertain and the findings in this report are sensitive to emergent data. Further evidence is required to identify patients most likely to benefit from domiciliary NIV and to establish optimum time points for starting NIV and equipment settings. FUTURE WORK RECOMMENDATIONS The results from this report will need to be re-examined in the light of any new trial results, particularly in terms of reducing the uncertainty in the economic model. Any new randomised controlled trials should consider including a sham non-invasive ventilation arm and/or a higher- and lower-pressure arm. Individual participant data analyses may help to determine whether or not there are any patient characteristics or equipment settings that are predictive of a benefit of NIV and to establish optimum time points for starting (and potentially discounting) NIV. STUDY REGISTRATION This study is registered as PROSPERO CRD42012003286. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Janine Dretzke
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Deirdre Blissett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Chirag Dave
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Rahul Mukherjee
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Malcolm Price
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sue Bayliss
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Xiaoying Wu
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Rachel Jordan
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Alice M Turner
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK.,Queen Elizabeth Hospital Research Laboratories, University of Birmingham, Birmingham, UK
| | - David Moore
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
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MacIntyre EJ, Asadi L, Mckim DA, Bagshaw SM. Clinical Outcomes Associated with Home Mechanical Ventilation: A Systematic Review. Can Respir J 2016; 2016:6547180. [PMID: 27445559 PMCID: PMC4904519 DOI: 10.1155/2016/6547180] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/23/2015] [Indexed: 11/18/2022] Open
Abstract
Background. The prevalence of patients supported with home mechanical ventilation (HMV) for chronic respiratory failure has increased. However, the clinical outcomes associated with HMV are largely unknown. Methods. We performed a systematic review of studies evaluating patients receiving HMV for indications other than obstructive lung disease, reporting at least one clinically relevant outcome including health-related quality of life (HRQL) measured by validated tools; hospitalization requirements; caregiver burden; and health service utilization. We searched MEDLINE, EMBASE, CINAHL, the Cochrane library, clinical trial registries, proceedings from selected scientific meetings, and bibliographies of retrieved citations. Results. We included 1 randomized control trial (RCT) and 25 observational studies of mixed methodological quality involving 4425 patients; neuromuscular disorders (NMD) (n = 1687); restrictive thoracic diseases (RTD) (n = 481); obesity hypoventilation syndrome (OHS) (n = 293); and others (n = 748). HRQL was generally described as good for HMV users. Mental rather than physical HRQL domains were rated higher, particularly where physical assessment was limited. Hospitalization rates and days in hospital appear to decrease with implementation of HMV. Caregiver burden associated with HMV was generally high; however, it is poorly described. Conclusion. HRQL and need for hospitalization may improve after establishment of HMV. These inferences are based on relatively few studies of marked heterogeneity and variable quality.
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Affiliation(s)
- Erika J. MacIntyre
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2B7
| | - Leyla Asadi
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2R3
| | - Doug A. Mckim
- Division of Respirology and Respiratory Rehabilitation Services, Faculty of Medicine and Dentistry, University of Ottawa, Ottawa, ON, Canada T6G 2R3
| | - Sean M. Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2B7
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2R3
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CHENG SUETLAI, CHAN VERONICAL, CHU CHUNGMING. Compliance with home non-invasive ventilation. Respirology 2012; 17:735-6. [DOI: 10.1111/j.1440-1843.2012.02169.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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