Clinical Outcomes Associated with Home Mechanical Ventilation: A Systematic Review

Rehabilitation in children with home invasive mechanical ventilation

Children with home invasive mechanical ventilation need special health care and rehabilitation services due to complications caused by both the pulmonary system and physical inactivity. Children who are dependent on invasive mechanical ventilators due to breathing difficulties and lung problems can benefit from rehabilitation programs. Rehabilitation requires a close relationship between the child, parents and/or caregivers, and healthcare professionals. The main goal of rehabilitation is to improve breathing, lung function and overall quality of life. In this review, although full standard approaches have not been determined yet, rehabilitation approaches for children dependent on home-type invasive mechanical ventilator will be discussed.

Non-invasive ventilation for people with neuromuscular disorders in Australia and New Zealand: a qualitative study of clinician perspectives

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.

Towards clinical application of implantable brain-computer interfaces for people with late-stage ALS: medical and ethical considerations

Individuals with amyotrophic lateral sclerosis (ALS) frequently develop speech and communication problems in the course of their disease. Currently available augmentative and alternative communication technologies do not present a solution for many people with advanced ALS, because these devices depend on residual and reliable motor activity. Brain-computer interfaces (BCIs) use neural signals for computer control and may allow people with late-stage ALS to communicate even when conventional technology falls short. Recent years have witnessed fast progression in the development and validation of implanted BCIs, which place neural signal recording electrodes in or on the cortex. Eventual widespread clinical application of implanted BCIs as an assistive communication technology for people with ALS will have significant consequences for their daily life, as well as for the clinical management of the disease, among others because of the potential interaction between the BCI and other procedures people with ALS undergo, such as tracheostomy. This article aims to facilitate responsible real-world implementation of implanted BCIs. We review the state of the art of research on implanted BCIs for communication, as well as the medical and ethical implications of the clinical application of this technology. We conclude that the contribution of all BCI stakeholders, including clinicians of the various ALS-related disciplines, will be needed to develop procedures for, and shape the process of, the responsible clinical application of implanted BCIs.

Effect of Respiratory Events on Health-Related Quality of Life in Patients Treated with Long-Term Noninvasive Ventilation

BACKGROUND

Long-term noninvasive ventilation (NIV) can increase or maintain health-related quality of life (HRQoL) for patients with chronic hypercapnic respiratory failure (CHRF). Evidence from studies systematically assessing how NIV-specific factors influence HRQoL is limited.

OBJECTIVES

The objective of this study was to describe HRQoL measured by the Severe Respiratory Insufficiency Questionnaire (SRI) in patients with CHRF treated with long-term NIV and to analyze the associations between HRQoL and hypoxemia, hypercapnia, and respiratory events such as apneas, hypopneas (AHI), and patient ventilator asynchrony (PVA) occurring during long-term NIV.

METHODS

We included sixty-seven stable patients with established long-term NIV due to neuromuscular disease or thoracic cage disorders in a prospective cross-sectional study at Oslo University Hospital. Patients answered the SRI and underwent daytime arterial blood gases, nocturnal pulse oximetry, sleep polygraphy, and nocturnal transcutaneous CO2.

RESULTS

The mean global SRI for 62 patients was 64.8 ± 14.5, with the highest score in SRI Social Relationships (79.5 ± 15.6). There were no differences in HRQoL between the different patient groups. Compliant patients had a significantly higher score in SRI Attendant and Sleep. Residual nocturnal hypoxemia affected both the subscale SRI "Respiratory Complaints" and SRI "Attendant Symptoms and Sleep." Persisting daytime hypercapnia, nocturnal hypoventilation, and high AHI affected the subscale SRI "Anxiety" negatively, while frequent PVA was associated with a lower score in SRI "Physical Function."

CONCLUSION

In a group of patients with long-term NIV, undesired respiratory events during NIV are associated with lower HRQoL in several of the SRI subscales. We suggest designing interventional studies to confirm the possible relationship between HRQoL and respiratory events during long-term NIV.

Mental health reported in adult invasive home mechanical ventilation through a tracheostomy: A scoping review

Background

Although people receiving invasive home mechanical ventilation through a tracheostomy are facing both physical and mental health challenges, healthcare services often focus mainly on physical symptoms. To ensure well-functioning treatment and care for people receiving tracheostomy ventilation in a home setting, their mental health needs to be promoted and seen as an integral part of their health in general.

Objective

This scoping review aimed to provide a summary of the current knowledge on the mental health of people receiving invasive home mechanical ventilation through a tracheostomy.

Design

A scoping review of published and gray literature based on the framework developed by Arksey and O'Malley and refined by the JBI was performed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist was used for reporting the findings.

Methods

A literature search was conducted by two researchers independently in the PubMed, CINAHL and PsycINFO databases. Additional searches for gray literature were conducted in Google, Google Scholar, websites of selected organisations, and the reference lists of included studies. The software system Covidence was used in the study selection process. For critical appraisal, the Mixed Methods Appraisal Tool was used.

Results

Thirteen studies were included in this review, of which six used qualitative, six quantitative, and one mixed methods. The majority of studies were authored in Europe (n = 10), followed by the Americas (n = 2) and the Western Pacific (n = 1). Mental health was investigated both directly and indirectly (61.5% vs. 38.5%). Categorizing the reported mental health outcomes, we found that emotional well-being was reported widely across the studies (n = 13), while psychological well-being (n = 5) and social well-being (n = 4) were less widely reported.

Conclusions

The mental health of people receiving home tracheostomy ventilation has received some scholarly attention. A heterogeneity of mental health outcomes was reported in the literature with emotional well-being being an important mental health area both in relation to the sub-components positive affect and quality of life appraisal. Mental health outcomes in relation to psychological well-being and social well-being were fragmented and only sparsely investigated.

Comparing the quality of care for long-term ventilated individuals at home versus in shared living communities: a convergent parallel mixed-methods study

BACKGROUND

People on home mechanical ventilation (HMV) belong to a heterogeneous population with complex care needs. In Germany, outpatient intensive care is provided in people's private home (PH) or in shared living communities (SLC). Increasing patient numbers have led to criticism of the quality of care in recent years. Since quality deficits from the perspective of those affected are largely unclear, the following research question emerged: How do interviews with ventilated individuals and family caregivers explain any differences or similarities in the quality of care between PH and SLC?

METHODS

This study used a mixed-methods convergent parallel design, where quantitative and qualitative components were separately collected and analysed. The quantitative component (structured interviews and online survey) included ventilation characteristics, health-related resource use, health-related quality of life (HRQL) measured with the Severe Respiratory Insufficiency Questionnaire (SRI; range 0-100; higher scores indicated higher HRQL) and the Burden Scale of the Family Caregivers short version (BSFC-s; range 0-30; higher scores indicated higher burden). The qualitative component (semi-structured interviews) focused on people's experience of person-centred care. Data were merged using a weaving method and the Picker framework of Person-Centred Care.

RESULTS

The quantitative component revealed that ventilated individuals living in PHs were on average 20 years younger than participants living in SLCs (n = 46; PH: 46.86 ±15.40 years vs. SLC: 65.07 ±11.78 years; p = .001). HRQL (n = 27; PH: 56.62 ±16.40 vs. SLC: 55.35 ±12.72; p > .999) and the burden of family caregivers (n = 16; PH: 13.20 ±10.18 vs. SLC: 12.64 ±8.55; p > .999) were not significantly different between living situation. The qualitative component revealed that person-centred care is possible in both care settings (ventilated individuals: n = 13; family caregivers: n = 18).

CONCLUSION

This study describes a care situation that is as heterogeneous as the population of people with HMV. HRQL and the burden of family caregivers are highly individual and, like person-centred care, independent of the living situation. Policy decisions that facilitate person-centred care need to recognise that quality of care is highly individual and starts with the free choice of the care setting.

Home-Based Adaptation to Night-Time Non-Invasive Ventilation in Patients with Amyotrophic Lateral Sclerosis: A Randomized Controlled Trial

Background: Initiation to Non-Invasive Ventilation (NIV) in amyotrophic lateral sclerosis (ALS) can be implemented in an inpatient or outpatient setting. Aims: We aimed to evaluate the efficacy of adaptation (the number of needed sessions) to home-based NIV compared to an outpatient one in ALS in terms of arterial carbon dioxide (PaCO2) improvement. NIV acceptance (mean use of ≥5 h NIV per night for three consecutive nights during the adaptation trial), adherence (night-time NIV usage for ≥150 h/month), quality of life (QoL), and caregiver burden were secondary outcomes. Methods: A total of 66 ALS patients with indications for NIV were involved in this randomized controlled trial (RCT): 34 underwent NIV initiation at home (home adaptation, HA) and 32 at multiple outpatient visits (outpatient adaptation, OA). Respiratory function tests were performed at baseline (the time of starting the NIV, T0) together with blood gas analysis, which was repeated at the end of adaptation (T1) and 2 (T2) and 6 (T3) months after T1. NIV adherence was measured at T2 and T3. Overnight cardiorespiratory polygraphy, Short Form Health Survey (SF-36), Caregiver Burden Inventory (CBI), Caregiver Burden Scale (CBS), and Zarit Burden Interview (ZBI) were performed at T0, T2, and T3. Results: Fifty-eight participants completed the study. No differences were found between groups in PaCO2 at T1 (p = 0.46), T2 (p = 0.50), and T3 (p = 0.34) in acceptance (p = 0.55) and adherence to NIV at T2 and T3 (p = 0.60 and p = 0.75, respectively). At T2, the patients’ QoL, assessed with SF-36, was significantly better in HA than in OA (p = 0.01), but this improvement was not maintained until T3 (p = 0.17). Conclusions: In ALS, adaptation to NIV in the patient’s home is as effective as that performed in an outpatient setting regarding PaCO2, acceptance, and adherence, which emphasizes the need for further studies to understand the role of the environment concerning NIV adherence.

"Me and 'that' machine": the lived experiences of people with neuromuscular disorders using non-invasive ventilation

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.

Effects of the Discharge Education Program on Family Caregivers Caring for Patients on Mechanical Home Ventilation in Korea: A Pilot Test

Patients on home ventilators rely on mechanical ventilation until their death; hence, family caregivers should perform additional caregiving, including tracheostomy, equipment management, and positive pressure ventilation by ambu-bag in emergencies. Therefore, a systematic discharge education program and evaluation of actual caregiver performance are necessary for safe home management. The program consists of suction and tracheostomy management, home ventilator management, emergency management, fundamental caregiving, and video material. To test clinical validity, family caregivers of patients about to be discharged to their homes from S hospital in Seoul, Korea, were selected by convenience sampling with a non-equivalent control group design. Of 18 participants, one refused, one died, and two became unstable after their agreement; therefore, 14 participants were finally included. To compare caregiving performance scores between the groups, we ran repeated measures ANOVA. Intergroup and period interaction of suction ( F = 6.08, p = .001) and tracheostomy management ( F = 3.00, p = .038) crucial for airway management, showed significant statistical differences. In short, the intervention group showed a faster increase in suction and tracheostomy management than the control group. Home ventilator management ( F = 22.53, p < .001), emergency management ( F = 12.01, p < .001), and fundamental caregiving ( F = 7.88, p < .001) showed significant differences within the group regarding the period. According to the results of the clinical validity test, the discharge education program increased the family caregiver’s suction and tracheostomy management performance scores. Further research is needed to demonstrate long-term effects of the program with a larger sample.

Exploring red cell distribution width as a biomarker for treatment efficacy in home mechanical ventilation

BACKGROUND

With the growing practice of home mechanical ventilation, there is a need to identify biological markers for adequate follow-up. Red cell distribution width (RDW) is a promising candidate because it is convenient, objective and may reflect treatment effect over a long period of time. The aim of this study was to explore the possible role of RDW as a marker for home mechanical ventilation in real-life, unselected chronic respiratory patient populations.

METHODS

First, we identified characteristic RDW values for mixed case, unselected chronic respiratory failure and home mechanical ventilated patients through retrospective review within our institutional database. Next, we conducted a prospective observational study to identify RDW changes during the first six months of optimized home mechanical ventilation treatment. Adult patients starting home mechanical ventilation were included. Factors affecting RDW change during the first 6 months of treatment were analysed.

RESULTS

RDW was elevated in both chronic respiratory failure and home mechanical ventilation patients compared to healthy individuals in the retrospective review. In the prospective study of 70 patients, we found that 55.4% of patients starting home mechanical ventilation have abnormal RDW values which are reduced from 14.7 (IQR = 13.2-16.2)% to 13.5 (IQR = 13.1-14.6)% during the first 6 months of HMV treatment (p < 0.001). RDW improvement correlates with improvement in self-reported health-related quality of life and sleepiness scale scores, as well as physical functional status during the same time frame. RDW proved to be a comparable marker to other parameters traditionally used to evaluate treatment efficacy.

CONCLUSIONS

RDW is elevated in chronic respiratory failure patients and is significantly reduced in the first six months of optimized home mechanical ventilation. Although further research is needed to verify if RDW change reflects outcome and how comorbidities influence RDW values, our results suggest that RDW is a promising marker of home mechanical ventilation efficacy. Trial registration This study was approved by and registered at the ethics committee of Semmelweis University (TUKEB 250/2017 and TUKEB 250-1/2017, 20th of December 2017 and 1st of October 2019).

How to improve the quality of care for people on home mechanical ventilation from the perspective of healthcare professionals: a qualitative study

BACKGROUND

The rapid increase in the use of home mechanical ventilation (HMV) for people with chronic respiratory failure poses extreme challenges for the healthcare system. People on HMV have complex care needs and require support from an interprofessional team. In Germany, HMV is criticised for inadequate quality standards, particularly in outpatient intensive care practice. The objective of this study was to describe the quality of care for people on outpatient HMV in Germany, Bavaria and provide recommendations for improvement from the perspective of healthcare professionals (HCPs).

METHODS

Semi-structured qualitative telephone interviews with HCPs (i.e., nurses, equipment providers, therapists, and physicians) were analysed using the framework method. The quality framework of Health Improvement Scotland (HIS), which aims to improve the quality of person-centred care, was used to build a deductive analysis matrix. The framework includes the three key areas: (1) Outcomes and impact, (2) Service delivery, and (3) Vision and leadership. The domains (meta-codes) and quality indicators (sub-codes) of the quality framework were used for deductive coding.

RESULTS

Overall, 87 HCPs (51 female, mean age of 44.3 years, mean professional experience in HMV of 9.4 years) were interviewed (mean duration of 31 min). There was a complex interaction between the existing health care system (Outcomes and impact, 955 meaning units), the delivery of outpatient intensive care (Service delivery, 939 meaning units), and improvement-focused leadership (Vision and leadership, 70 meaning units) that influenced the quality of care for people on HMV. The main barriers were an acceleration in transition management, a neglect of weaning potential, a shortage of qualified professionals and missing quality criteria. The central recommendations for promoting person-centred care were training and supervision of staff and an inspiring leadership. An integrated care structure supporting medical home visits and outpatient rehabilitation should be developed.

CONCLUSION

This study describes a heterogeneous and partly deficient care situation for people on HMV, but demonstrates that high quality care is possible if person-centred care is successfully implemented in all areas of service provision. The recommendations of this study could inform the development of a person-centred integrated care structure for people on HMV.

A qualitative study of patient and carer experiences with home respiratory therapies: Long-term oxygen therapy and home mechanical ventilation

Studies exploring the experience of patients receiving home respiratory therapies (HRT), such as long-term oxygen therapy (LTOT) and home mechanical ventilation (HMV), are still limited. This study focused on patients' and carers' experience with LTOT and HMV. An exploratory, cross-sectional qualitative study, using semi-structured focus groups, was carried out with 18 patients receiving HRT (median 71y, 78% male, 56% on both LTOT and HMV) and 6 carers (median age 67y, 67% female). Three focus groups were conducted in three regions of Portugal. Thematic analysis was performed by two independent researchers. Patients' and carers' experience was reflected in seven major topics, linked to specific time points and settings of the treatment: Initial symptoms/circumstances (n = 41), Prescription (n = 232), Implementation (n = 184), Carer involvement (n = 34), Quality of life impact (n = 301), Health care support/navigability (n = 173) and Suggestions (n = 14). Our findings demonstrate a general good perception of the HRT by patients and carers recognizing a significative quality of life impact improvement, while identifying specific points where improvements in healthcare are needed, particularly about navigability issues, articulation between the hospital, primary care and homecare teams, especially regardingprescriptionrenewal. This knowledge is crucial to promote a long-term HRT adherence and to optimize HRT delivery in line with patients' experience, needs, and values. Moreover, these key points can inform the development of a specific patient-reported experience measure (PREM) for patients on HRT, which is not currently available, and foster a more integrated respiratory care model.

Noninvasive Home Mechanical Ventilation in Adult Myotonic Dystrophy Type 1: A Systematic Review

INTRODUCTION

Chronic hypercapnic respiratory failure induces considerable morbidity and mortality in patients with myotonic dystrophy type 1 (DM1). This study systematically reviews the effects of noninvasive home mechanical ventilation (HMV) on gas exchange, quality of life, survival, and compliance in DM1 patients.

METHODS

A systematic Medline and Embase search was performed (January 1995 to January 2020). Records were screened for eligibility criteria, data were extracted from included studies, and risk of bias was assessed. We present findings mainly using a narrative synthesis.

RESULTS

Twenty-eight relevant full-text articles were screened for eligibility criteria. Nine studies were included. Randomized controlled trials were not found. Studies had either an observational (n = 8) or interventional (n = 1) design. In the pooled data analysis, HMV showed to improve mean oxygen saturation with 4.8% and decreased mean carbon dioxide values with 3 mm Hg. Compliance varied widely between studies, from no use to more than 12 h per day. Quality of life was not studied extensively, but some studies reported positive effects of HMV on symptoms of chronic respiratory failure. HMV may improve survival in DM1 patients with chronic hypercapnic respiratory failure.

CONCLUSION

This review shows that HMV can improve gas exchange and relieve symptoms with a possible survival benefit in DM1 patients with chronic hypercapnic respiratory failure. Future studies should focus on developing strategies to optimize the timing of HMV initiation and to promote compliance.

The treatment burden of long-term home noninvasive ventilation

The prevalence of long-term home noninvasive ventilation (NIV) has progressively increased over recent decades, supported by evidence of clinical effectiveness in a range of conditions leading to chronic respiratory failure [1, 2]. Simultaneous technological developments have improved the reliability, portability, and comfort of devices, making NIV increasingly accessible and acceptable as a treatment option [3]. Clinicians are usually fully cognisant of the clinical outcomes they anticipate when recommending or initiating long-term NIV, for example prolonging life, preventing complications or healthcare utilisation, and/or improving symptoms. The evidence on key clinical outcomes is variable between conditions but is comprehensively evaluated in relevant clinical guidelines; traditionally less emphasis is placed on the potential practical and psychosocial implications of domiciliary NIV. However, the preferences, values and resources of individuals can have a significant impact on NIV usage and therefore may affect potential clinical benefit. This editorial discusses the healthcare-associated workload, also known as the treatment burden, of domiciliary NIV that may be shouldered by patients, their families and caregivers, justifying why the cost/benefit ratio must be carefully considered on an individual basis.

Long-term home noninvasive ventilation has practical and psychosocial implications for individuals, families and caregivers. Exploring the impact of the workload of healthcare or “treatment burden” helps determine treatment feasibility and acceptability.https://bit.ly/39YUY2A

Mortality outcomes of patients on chronic mechanical ventilation in different care settings: A systematic review

Objectives

To determine the outcomes of chronically ventilated patients outside the setting of intensive care units.

Design

Systematic review.

Setting and participants

Studies evaluating patients on chronic invasive mechanical ventilation in different care settings.

Methods

A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion.

Results

Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death.

Conclusions and implications

Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources.

Cost-Utility Analysis of Home Mechanical Ventilation in Patients with Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis is a disease with rapid progression. The use of mechanical ventilation helps to manage symptoms and delays death. Use in a home environment could reduce costs and increase quality of life. The aim of this study is a cost–utility analysis of home mechanical ventilation in adult patients with amyotrophic lateral sclerosis from the perspective of healthcare payers in the Czech Republic. The study evaluates home mechanical ventilation (HMV) and mechanical ventilation (MV) in a healthcare facility. A Markov model was compiled for evaluation in a timeframe of 10 years. Model parameters were obtained from the literature and opinions of experts from companies dealing with home care and home mechanical ventilation. The cost–utility analysis was carried out at the end of the study and results are presented in incremental cost–utility ratio (ICUR) using quality-adjusted life-years. Uncertainty was assessed by one-way sensitivity analysis and scenario analysis. The cumulative costs of HMV are CZK 1,877,076 and the cumulative costs of the MV are CZK 7,386,629. The cumulative utilities of HMV are 12.57 quality-adjusted life year (QALY) and the cumulative utilities of MV are 11.32 QALY. The ICUR value is CZK-4,403,259. The results of this study suggest that HMV is cost effective.

Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology

Long-term mechanical ventilation is a well-established treatment for chronic hypercapnic respiratory failure (CHRF). It is aimed at improving CHRF-related symptoms, health-related quality of life, survival, and decreasing hospital admissions. In Switzerland, long-term mechanical ventilation has been increasingly used since the 1980s in hospital and home care settings. Over the years, its application has considerably expanded with accumulating evidence of beneficial effects in a broad range of conditions associated with CHRF. Most frequent indications for long-term mechanical ventilation are chronic obstructive pulmonary disease, obesity hypoventilation syndrome, neuromuscular and chest wall diseases. In the current consensus document, the Special Interest Group of the Swiss Society of Pulmonology reviews the most recent scientific literature on long-term mechanical ventilation and provides recommendations adapted to the particular setting of the Swiss healthcare system with a focus on the practice of non-invasive and invasive home ventilation in adults.

Noninvasive Ventilation Downloads and Monitoring

"Home noninvasive ventilation (NIV) is indicated for numerous conditions including neuromuscular disease, thoracic cage disorders, chronic obstructive pulmonary disease, and hypoventilation syndromes. Effective management of patients on home NIV requires clinicians to interpret data downloads from NIV devices. Clinicians must first look at adherence and factors that may impact this including mask comfort and fit. Next, leak assessment is undertaken. Once these are addressed, such information as apnea-hypopnea index, exhaled tidal volume, and percent triggered breaths help clinicians troubleshoot setting changes. Finally, overnight oximetry and transcutaneous CO2 monitoring are useful adjuncts to the data download to optimize NIV settings."

Telehealth: "virtual" lifeline for home-ventilated patients during the COVID-19 pandemic

The evolution of positive airway pressure (PAP) devices since their introduction by Colin Sullivan in 1980 has witnessed growing evidence supporting their use for medical conditions associated with chronic ventilatory failure. The emergence of PAP devices also resulted in a higher number of patients requiring long-term medical care and ventilation. The concept of “hospital at home” with home ventilation to ease the burden on overwhelmed hospitals was evident when the prevalence of home mechanical ventilation (HMV) users reported in 2016 was at 10.9 per 100 000 population [1].

Telehealth appears useful to fill in the void for home-ventilated patients to maintain the much-needed connectivity with their healthcare team during the #COVID19 pandemichttps://bit.ly/3ftvjxW

Home mechanical ventilation: back to basics

Over recent decades, the use of home mechanical ventilation (HMV) has steadily increased worldwide, with varying prevalence in different countries. The key indication for HMV is chronic respiratory failure with alveolar hypoventilation (e.g., neuromuscular and chest wall disease, obstructive airway diseases, and obesity-related respiratory failure). Most modern home ventilators are pressure-targeted and have sophisticated modes, alarms, and graphics, thereby facilitating optimization of the ventilator settings. However, different ventilators have different algorithms for tidal volume estimation and leak compensation, and there are also several different circuit configurations. Hence, a basic understanding of the fundamentals of HMV is of paramount importance to healthcare workers taking care of patients with HMV. When choosing a home ventilator, they should take into account many factors, including the current condition and prognosis of the primary disease, the patient’s daily performance status, time (hr/day) needed for ventilator support, family support, and financial costs. In this review, to help readers understand the basic concepts of HMV use, we describe the indications for HMV and the factors that influence successful delivery, including interface, circuits, ventilator accessories, and the ventilator itself.

Home mechanical ventilation: quality of life patterns after six months of treatment

Background

It has been shown that home mechanical ventilation improves quality of life, but it has not been widely studied which particular patient groups benefit the most from starting this type of therapy. The purpose of this prospective observational study was to evaluate quality of life change patterns 6 months after initiation of home mechanical ventilation in patients suffering from chronic respiratory failure using patient reported outcomes.

Methods

We enrolled 74 chronic respiratory failure patients starting invasive or noninvasive home mechanical ventilation through the Semmelweis University Home Mechanical Ventilation Program. Quality of life was evaluated at baseline and at 6 months after initiation of home mechanical ventilation using the Severe Respiratory Insufficiency Questionnaire.

Results

Overall quality of life showed 10.5% improvement 6 months after initiation of home mechanical ventilation (p < 0.001). The greatest improvement was observed in Respiratory complaint (20.4%, p = 0.015), Sleep and attendant symptoms (19.3%, p < 0.001), and Anxiety related subscales (14.4%, p < 0.001). Interface (invasive versus noninvasive ventilation) was not associated with improvement in quality of life (p = 0.660). Severely impaired patients showed the greatest improvement (CC = -0.328, p < 0.001). Initial diagnosis contributed to the observed change (p = 0.025), with chronic obstructive pulmonary disease and obesity hypoventilation syndrome patients showing the greatest improvement, while amyotrophic lateral sclerosis patients showed no improvement in quality of life. We found that patients who were started on long term ventilation in an acute setting, required oxygen supplementation and had low baseline quality of life, showed the most improvement during the six-month study period.

Conclusions

Our study highlights the profound effect of home mechanical ventilation on quality of life in chronic respiratory failure patients that is indifferent of ventilation interface but is dependent on initial diagnosis and some baseline characteristics, like acute initiation, oxygen supplementation need and baseline quality of life.

Trial registration

This study was approved by and registered at the ethics committee of Semmelweis University (SE TUKEB 251/2017; 20th of December, 2017).

Providing care to long-term mechanically ventilated patients in Germany – Current situation and needs for action from the perspective of health professionals / Die Versorgung langzeitbeatmeter Patienten in Deutschland – Aktuelle Situation und Handlungsbedarfe aus der Sicht von Gesundheitsberufsangehörigen

Background

The number of patients depending on long-term invasive mechanical ventilation (IMV) has been increasing for several years. Anecdotal reports indicate heterogeneous health structures, opaque patient pathways, nontransparent and sometimes questionable practices in individual areas of care, inadequate quality standards and control mechanisms in Germany. However, there is hardly any empirical data on this topic.

Aim

To report findings from a qualitative study conducted as part of a complex research project to assess the appropriateness of care provided to IMV patients in Germany.

Methods

Thirteen semi-structured expert interviews were conducted with 22 health professionals providing care for IMV patients. The data analysis was conducted with MAXQDA according to the framework by Meuser and Nagel.

Results

Interviewees emphasized similar healthcare deficits. They considered health providers to be nontransparent and influenced by secondary interests. Quality of care is reported to be jeopardized by shortage of trained staff. Warranty of self-determination and participatory decision-making is not a matter of fact. Clarifying issues of sustaining life, quality of life and shaping the end of life is often ignored. The professionals are familiar with the patient pathways, allocation processes and responsibilities described in existing guidelines, but criticize the fact that they are not sufficiently binding. Accordingly, patient pathways are frequently individual results of experience-based, informal networking, and often left to chance.

Conclusions

The results point to a considerable need for action to reach an appropriate, integrated, patient-centered level of care for long-term IMV patients and ensure its quality.

The effects of home noninvasive ventilation on the quality of life and physiological parameters of patients with chronic respiratory failure

INTRODUCTION

Home noninvasive mechanical ventilation (HNIV) in patients with chronic hypercapnic respiratory failure (CHRF) may improve the health-related quality of life (HRQoL) and reduce hospitalizations.

OBJECTIVE

To determine the effects of HNIV on HRQoL, sleep quality and hospitalization rates in restrictive thoracic diseases (RTD) and chronic obstructive pulmonary disease (COPD) patients with CHRF.

METHODS

In this prospective, single center study patients divided into two groups; the COPD and the RTD groups. HRQoL assessed by The Medical Outcome Study 36-Item Short-form Health Survey (SF-36) and Severe Respiratory Insufficiency (SRI); the sleep quality was assessed by Epworth and Pittsburgh Sleep Quality Index questionnaires. The patients were reevaluated first month, third months, sixth months and 1 year following HNIV establishment, during which time, hospitalization rates were recorded.

RESULTS

Ninety (COPD n = 50, RTD n = 40) out of 102 eligible patients completed the study. Significant improvements in blood gases and HRQoL were observed in the first month of HNIV establishment and remained stable. Mean ± SD SRI summary scale improved significantly from 30 ± 12 baseline to 65 ± 16 at 1 year in COPD group (P < 0.001) and from 39 ± 13 to 63 ± 18 in RTD group (P < 0.001). HNIV reduced hospitalization rates from a mean of 1.9 ± 1.1 to 0.5 ± 0.9 in COPD group (P < 0.001) and a mean of 1.9 ± 1 to 0.5 ± 0.7 in RTD group (P < 0.001).

CONCLUSION

HNIV improves HRQoL, sleep quality and gas exchange and reduces hospitalizations in patients with CHRF regardless of etiology.

Long-term outcome with focus on pulmonary hypertension in Obesity Hypoventilation Syndrome

INTRODUCTION

Pulmonary Hypertension (PH) is a frequent comorbidity in Obesity Hypoventilation Syndrome (OHS).

OBJECTIVE

We investigated long-term outcome of OHS with a particular emphasis on PH.

METHODS

In a prospective design, 64 patients with OHS and established noninvasive positive pressure ventilation (NPPV), were assessed by serum biomarkers, right heart catheterization, blood gases analysis, lung function, Epworth-Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), World Health Organization-functional class (WHO-FC) and health-related quality of life (HRQL) via the Severe Respiratory Insufficiency (SRI) questionnaire. After a planned follow-up of 5 years patients were reassessed regarding vital status, WHO-FC, ESS, SRI, PSQI, body mass index (BMI) and NPPV use. Prognostic markers were explored using univariate and multivariate Cox regression analyses.

RESULTS

At the 5-year follow-up, BMI tended to decrease (P = 0.05), while WHO-FC, ESS and PSQI remained unchanged. HRQL deteriorated in terms of SRI summary score and most subdomains (P < .05 each). NPPV adherence still was high (89%), while daily NPPV use increased from 6.7 (5.1; 8.0) h/d to 8.2 (7.4; 9.0) h/d (P < .05). After a 5-year follow-up, mortality was 25.8%. In univariate regression analyses only age > 69.5 years (HR = 4.145, 95%-CI = 1.180-14.565, P = 0.016), NT-proBNP > 1256 pg/mL (HR = 5.162, 95%-CI = 1.136-23.467, P = 0.018), diffusion capacity for carbon monoxide (DLCO, %pred) (HR = 0.341, 95%-CI = 0.114-1.019, P = 0.043) and higher oxygen use during daytime (HR = 5.236, 95%-CI = 1.489-18.406, P = 0.004) predicted mortality. No independent factor predicting mortality was detected in multivariate analysis.

CONCLUSION

Despite a high long-term NPPV use HRQL worsened. Age, oxygen use at baseline, DLCO (%pred) and NT-proBNP, as a surrogate parameter for PH, were related to long-term survival.

Validation of the Hungarian version of the SRI Questionnaire

BACKGROUND

Home mechanical ventilation is a reliable treatment for patients suffering from chronic respiratory failure, improving survival and quality of life. Prevalence has been increasing worldwide as a result of evolving technical possibilities, telemedicine and improving national guidelines. Projects to establish a national guideline and registry for patients treated with home mechanical ventilation are currently under way in Hungary and our aim was to validate a quality of life questionnaire suited for evaluation and follow up in this specific patient group. The Severe Respiratory Insufficiency Questionnaire (SRI) is a quality of life tool designed to evaluate patients receiving home mechanical ventilation and has been validated both in patient groups receiving invasive and noninvasive ventilation.

METHODS

The Hungarian version of the SRI was created using the translation-backtranslation method, which was then tested for validity, viability and reliability in a cohort involving patients from three centers, receiving long-term home mechanical ventilation for chronic respiratory failure through an invasive or noninvasive interface. Patient data was collected (demographic data, lung function test, arterial blood gas, ventilation settings) and quality of life was measured with the previously validated SF-36 and newly created Hungarian SRI Questionnaires at two time points.

RESULTS

One hundred four patients receiving home mechanical ventilation were enrolled. The time to complete the SRI Questionnaire was 8.6 (±3.1) minutes, 69.2% questionnaires were self-administered. Exploratory factor analysis explained 73.8% of the variance of the questionnaire, but resulted in 13 scales. We found correlations between the SRI subscale scores to corresponding scales of the previously validated general quality of life survey SF-36. The Cronbach alpha coefficient was 0.928 for the Summary Scale of the SRI Questionnaire, proving high internal consistency. Reproducibility was high for most scales, resulting in a high overall correlation for the summary score (0.877, p < 0.001).

CONCLUSIONS

The Hungarian version of the SRI Questionnaire is a viable, valid, reliable and reproduceable quality of life tool applicable for patients treated with home mechanical ventilation.

Long-Term Ventilation in Neuromuscular Patients: Review of Concerns, Beliefs, and Ethical Dilemmas

BACKGROUND

Noninvasive mechanical ventilation (NIV) is an effective treatment in patients with neuromuscular diseases (NMD) to improve symptoms, quality of life, and survival.

SUMMARY

NIV should be used early in the course of respiratory muscle involvement in NMD patients and its requirements may increase over time. Therefore, training on technical equipment at home and advice on problem solving are warranted. Remote monitoring of ventilator parameters using built-in ventilator software is recommended. Telemedicine may be helpful in reducing hospital admissions. Anticipatory planning and palliative care should be carried out to lessen the burden of care, to maintain or withdraw from NIV, and to guarantee the most respectful management in the last days of NMD patients' life. Key Message: Long-term NIV is effective but challenging in NMD patients. Efforts should be made by health care providers in arranging a planned transition to home and end-of-life discussions for ventilator-assisted individuals and their families.

National survey: current prevalence and characteristics of home mechanical ventilation in Hungary

BACKGROUND

Home mechanical ventilation is an established treatment for chronic respiratory failure resulting in improved survival and quality of life. Technological advancement, evolving health care reimbursement systems and newly implemented national guidelines result in increased utilization worldwide. Prevalence shows great geographical variations and data on East-Central European practice has been scarce to date. The aim of the current study was to evaluate prevalence and characteristics of home mechanical ventilation in Hungary.

METHODS

We conducted a nationwide study using an online survey focusing on patients receiving ventilatory support at home. The survey focused on characterization of the site (affiliation, type), experience with home mechanical ventilation, number of patients treated, indication for home mechanical ventilation (disease type), description of home mechanical ventilation (invasive/noninvasive, ventilation hours, duration of ventilation) and description of the care provided (type of follow up visits, hospitalization need, reimbursement).

RESULTS

Our survey uncovered a total of 384 patients amounting to a prevalence of 3.9/100,000 in Hungary. 10.4% of patients received invasive, while 89.6% received noninvasive ventilation. The most frequent diagnosis was central hypopnea syndromes (60%), while pulmonary (20%), neuromuscular (11%) and chest wall disorders (7%) were less frequent indications. Daily ventilation need was less than 8 h in 74.2%, between 8 and 16 h in 15.4% and more than 16 h in 10.4% of patients reported. When comparing sites with a limited (< 50 patients) versus substantial (> 50 patients) case number, we found the former had significantly higher ratio of neuromuscular conditions, were more likely to ventilate invasively, with more than 16 h/day ventilation need and were more likely to provide home visits and readmit patients (p < 0,001).

CONCLUSIONS

Our results show a reasonable current estimate and characterization of home mechanical ventilation practice in Hungary. Although a growing practice can be assumed, current prevalence is still markedly reduced compared to international data reported, the duality of current data hinting to a possible gap in diagnosis and care for more dependent patients. This points to the importance of establishing home mechanical ventilation centers, where increased experience will enable state of the art care to more dependent patients as well, increasing overall prevalence.

Non-Invasive Ventilation as an Adjunct to Exercise Training in Chronic Ventilatory Failure: A Narrative Review

BACKGROUND

Chronic ventilatory failure (CVF) may be associated with reduced exercise capacity. Long-term non-invasive ventilation (NIV) may reduce patients' symptoms, improve health-related quality of life and reduce mortality and hospitalisations. There is an increasing use of NIV during exercise training with the purpose to train patients at intensity levels higher than allowed by their pathophysiological conditions.

OBJECTIVE

This narrative review describes the possibility to train patients with CVF and NIV use as a tool to increase the benefits of exercise training.

METHODS

We searched papers published between 1985 and 2018 in (or with the summary in) English language in PubMed and Scopus databases using the keywords "chronic respiratory failure AND exercise," "non invasive ventilation AND exercise," "pulmonary rehabilitation" and "exercise training."

RESULTS

Exercise training is feasible and effective also in patients with CVF. Assisted ventilation can improve exercise tolerance in different clinical conditions. In patients under long-term home ventilatory support, NIV administered also during walking results in improved oxygenation, decreased dyspnoea and increased walking distance. Continuous positive airway pressure and different modalities of assisted ventilation have been delivered through different interfaces during exercise training programmes. Patients with CVF on long-term NIV may benefit from exercising with the same ventilators, interfaces and settings as used at home.

CONCLUSION

We need more randomised clinical trials to investigate the effects of NIV on exercise training in patients with CVF and define organisation and setting.

"I see myself as part of the team" - family caregivers' contribution to safety in advanced home care

BACKGROUND

The use of medical technology and the various contributing and interdepending human factors in home care have implications for patient safety. Although family caregivers are often involved in the provision of advanced home care, there is little research on their contribution to safety. The study aims to explore family caregivers in Home Mechanical Ventilation (HMV) safety experiences and how safety is perceived by them in this context. Furthermore, it seeks to understand how family caregivers contribute to the patients' and their own safety in HMV and what kind of support they expect from their health care team.

METHODS

An explorative, qualitative study was applied using elements from grounded theory methodology. Data were collected through individual interviews with 15 family caregivers to patients receiving HMV in two regions in Germany. The audiotaped interviews were then subject to thematic analysis.

RESULTS

The findings shows that family caregivers contribute to safety in HMV by trying to foster mutual information sharing about the patient and his/her situation, coordinating informally health care services and undertaking compensation of shortcomings in HMV.

CONCLUSION

Consequently, family caregivers take on considerable responsibility for patient safety in advanced home care by being actively and constantly committed to safety work.Nurses working in this setting should be clinically and technically skilled and focus on building partnership relations with family caregivers. This especially encompasses negotiation about their role in care and patient safety. Support and education should be offered if needed. Only skilled nurses, who can provide safe care and who can handle critical situations should be appointed to HMV. They should also serve as professional care coordinators and provide educational interventions to strengthen family caregivers' competence.

Health-related quality of life measurement in patients with chronic respiratory failure

The improvement of health-related quality of life (HRQL) is an important goal in managing patients with chronic respiratory failure (CRF) receiving long-term oxygen therapy (LTOT) and/or domiciliary noninvasive ventilation (NIV). Two condition-specific HRQL questionnaires have been developed to specifically assess these patients: the Maugeri Respiratory Failure Questionnaire (MRF) and the Severe Respiratory Insufficiency Questionnaire (SRI). The MRF is more advantageous in its ease of completion; conversely, the SRI measures diversified health impairments more multi-dimensionally and discriminatively with greater balance, especially in patients receiving NIV. The SRI is available in many different languages as a result of back-translation and validation processes, and is widely validated for various disorders such as chronic obstructive pulmonary disease, restrictive thoracic disorders, neuromuscular disorders, and obesity hypoventilation syndrome, among others. Dyspnea and psychological status were the main determinants for both questionnaires, while the MRF tended to place more emphasis on activity limitations than SRI. In comparison to existing generic questionnaires such as the Medical Outcomes Study 36-item short form (SF-36) and disease-specific questionnaires such as the St. George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Disease Questionnaire (CRQ), both the MRF and the SRI have been shown to be valid and reliable, and have better discriminatory, evaluative, and predictive features than other questionnaires. Thus, in assessing the HRQL of patients with CRF using LTOT and/or NIV, we might consider avoiding the use of the SF-36 or even the SGRQ or CRQ alone and consider using the CRF-specific SRI and MRF in addition to existing generic and/or disease-specific questionnaires.

Tracheotomy in the intensive care unit: Guidelines from a French expert panel: The French Intensive Care Society and the French Society of Anaesthesia and Intensive Care Medicine

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the grading of recommendations assessment, development and evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1±) and 6 a low level of proof (Grade 2±). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

Tracheotomy in the intensive care unit: guidelines from a French expert panel

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d'Anesthésie Réanimation) with the participation of the French Emergency Medicine Association (Société Française de Médecine d'Urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/-) and 6 a low level of proof (Grade 2+/-). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

Patterns of use, survival and prognostic factors in patients receiving home mechanical ventilation in Western Australia: A single centre historical cohort study

Home mechanical ventilation (HMV) is used in a wide range of disorders associated with chronic hypoventilation. We describe the patterns of use, survival and predictors of death in Western Australia. We identified 240 consecutive patients (60% male; mean age 58 years and body mass index 31 kg m^-2) referred for HMV between 2005 and 2010. The patients were grouped into four categories: motor neurone disorders (MND; 39%), pulmonary disease (PULM; 25%, mainly chronic obstructive pulmonary disease), non-MND neuromuscular and chest wall disorders (NMCW; 21%) and the obesity hypoventilation syndrome (OHS; 15%). On average, the patients had moderate ventilatory impairment (forced vital capacity: 51%predicted), sleep apnoea (apnoea-hypopnea index: 25 events h^-1), sleep-related hypoventilation (transcutaneous carbon dioxide rise of 20 mmHg) and daytime hypercarbia (PCO₂: 54 mmHg). Median durations of survival from HMV initiation were 1.0, 4.2, 9.9 and >11.5 years for MND, PULM, NMCW and OHS, respectively. Independent predictors of death varied between primary indications for HMV; the predictors included (a) age in all groups except for MND (hazard ratios (HRs) 1.03-1.10); (b) cardiovascular disease (HR: 2.35, 95% confidence interval (CI): 1.08-5.10) in MND; (c) obesity (HR: 0.28, 95% CI: 0.13-0.62) and oxygen therapy (HR: 0.33, 95% CI: 0.14-0.79) in PULM; and (d) forced expiratory volume in 1 s (%predicted; HR: 0.93, 95% CI: 0.88-1.00) in OHS.

Healthcare utilisation and costs of home mechanical ventilation

BACKGROUND

Individuals using home mechanical ventilation (HMV) frequently choose to live at home for quality of life, despite financial burden. Previous studies of healthcare utilisation and costs do not consider public and private expenditures, including caregiver time.

OBJECTIVES

To determine public and private healthcare utilisation and costs for HMV users living at home in two Canadian provinces, and examine factors associated with higher costs.

METHODS

Longitudinal, prospective observational cost analysis study (April 2012 to August 2015) collecting data on public and private (out-of-pocket, third-party insurance, caregiving) costs every 2 weeks for 6 months using the Ambulatory and Home Care Record. Functional Independence Measure (FIM) was used at baseline and study completion. Regression models examined variables associated with total monthly costs selected a priori using Andersen and Newman's framework for healthcare utilisation, relevant literature, and clinical expertise. Data are reported in 2015 Canadian dollars ($C1=US$0.78=₤0.51=€0.71).

RESULTS

We enrolled 134 HMV users; 95 with family caregivers. Overall median (IQR) monthly healthcare cost was $5275 ($2291-$10 181) with $2410 (58%) publicly funded; $1609 (39%) family caregiving; and $141 (3%) out-of-pocket (<1% third-party insurance). Median healthcare costs were $8733 ($5868-$15 274) for those invasively ventilated and $3925 ($1212-$7390) for non-invasive ventilation. Variables associated with highest monthly costs were amyotrophic lateral sclerosis (1.88, 95% CI 1.09 to 3.26, P<0.03) and lower FIM quintiles (higher dependency) (up to 6.98, 95% CI 3.88 to 12.55, P<0.0001) adjusting for age, sex, tracheostomy and ventilation duration.

CONCLUSIONS

For HMV users, most healthcare costs were publicly supported or associated with family caregiving. Highest costs were incurred by the most dependent users. Understanding healthcare costs for HMV users will inform policy decisions to optimise resource allocation, helping individuals live at home while minimising caregiver burden.

Transition from in-hospital ventilation to home ventilation: process description and quality indicators

The current demographic development of our society results in an increasing number of elderly patients with chronic diseases being treated in the intensive care unit. A possible long-term consequence of such a treatment is that patients remain dependent on certain invasive organ support systems, such as long-term ventilator dependency. The main goal of this project is to define the transition process between in-hospital and out of hospital (ambulatory) ventilator support. A further goal is to identify evidence-based quality indicators to help define and describe this process.

This project describes an ideal sequence of processes (process chain), based on the current evidence from the literature. Besides the process chain, key data and quality indicators were described in detail. Due to the limited project timeline, these indicators were not extensively tested in the clinical environment.

The results of this project may serve as a solid basis for proof of feasibility and proof of concept investigations, optimize the transition process of ventilator-dependent patients from a clinical to an ambulatory setting, as well as reduce the rate of emergency re-admissions.

Factors associated with change in health-related quality of life among individuals treated with long-term mechanical ventilation, a 6-year follow-up study

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.

Attitudes and preferences of home mechanical ventilation users from four European countries: an ERS/ELF survey

Home mechanical ventilation is increasingly used by people with chronic respiratory failure. However, there are few reports on attitudes towards treatment.

A web-based survey in eight languages was disseminated across 11 European countries to evaluate the perception of home mechanical ventilation provision in ventilator-assisted individuals and caregivers.

Out of 787 responders from 11 European countries, 687 were patients and 100 were caregivers. 95% of patients and 94% of caregivers were from only 4 countries (Germany, the Netherlands, Italy, Spain). The majority of respondents were male and aged 46–65 years. Obstructive lung diseases were proportionally more represented among respondent patients (46%), and neuromuscular diseases (65%) were more represented among patients of respondent caregivers. About 20% of respondent patients and caregivers were not sure of the modality of ventilation. Different interfaces were used, with a minority of respondents in all countries using invasive home mechanical ventilation by tracheostomy.

These results may be useful for healthcare providers and policy makers to improve the quality of patients' daily lives.

An @ERStalk/@EuropeanLung survey of European ventilator usershttp://ow.ly/u5e130csNFs

Long-term volume-targeted pressure-controlled ventilation: sense or nonsense?

The technology underlying the development of novel ventilatory modes for long-term noninvasive ventilation of patients with chronic hypercapnia is continuously evolving. Volume-targeted pressure-controlled ventilation is a hybrid ventilation mode designed to combine the advantages of conventional ventilation modes, while avoiding their drawbacks. However, manufacturers have created different names and have patented algorithms and set-up variables, which can result in confusion for physicians and respiratory therapists. In addition, clear evidence for the superiority of this novel mode has not yet been established. These factors have most likely hindered more widespread use of this mode in clinical practice. The current review presents the rationale, working principles, characteristics and set-up recommendations associated with volume-targeted modes. In addition, it summarises the clinical and laboratory studies that have challenged this mode.

'I need complete trust in nurses' - home mechanical ventilated patients' perceptions of safety

BACKGROUND

Although home care has advanced over the last few decades, little research on patient safety has been carried out in this setting. Furthermore, it is unclear how patients perceive their situation and safety. The insiders' views might be especially relevant for technology-dependent individuals, such as users of home mechanical ventilation (HMV).

AIM

The aim of this study was to examine how HMV patients perceive their situation and what makes them feel safe or unsafe.

DESIGN

Explorative qualitative study.

METHODS

Data were collected in two regions in Germany between April and December 2014 by means of semi-structured interviews with 21 HMV patients. Thematic analysis was used to analyse data.

FINDINGS

Three themes emerged: the meaning of an interpersonal relationship between the nurse and HMV patient is expressed in the theme Being familiar - Having trust. The importance of the attentiveness of nurses for the patients' feeling of safety is described in the theme Being able to communicate - Being noticed. The theme Experiencing continuity - Feeling presence points to the organisational dimension of HMV care provision.

CONCLUSIONS

The interpersonal nurse-patient relationship plays a key role in promoting HMV patients' feeling of safety. Thus, HMV patients have a relational approach to safety. In order to enhance the patients' feeling of safety, nurses should strive to develop a trusting relationship with patients and demonstrate their presence and attentiveness. Regarding the provision of care, competent and continuous care should be made a priority.