Impact of Ventilation Parameters and Duration of Ventilator Use on Non-Invasive Home Ventilation in Restrictive Thoracic Disorders

Update in Noninvasive Home Mechanical Ventilation: A Narrative Review of Indications, Outcomes, and Monitoring

Hypercapnic respiratory failure arises due to an imbalance in the load-capacity-drive relationship of the respiratory muscle pump, typically arising in patients with chronic obstructive pulmonary disease, obesity-related respiratory failure, and neuromuscular disease. Patients at risk of developing chronic respiratory failure and those with established disease should be referred to a specialist ventilation unit for evaluation and consideration of home noninvasive ventilation (NIV) initiation. Clinical trials demonstrate that, following careful patient selection, home NIV can improve a range of clinical, patient-reported, and physiological outcomes. This narrative review provides an overview of the pathophysiology of chronic respiratory failure, evidence-based applications of home NIV, and monitoring of patients established on home ventilation and describes technological advances in ventilation devices, interfaces, and monitoring to enhance comfort, promote long-term adherence, and optimise gas exchange.

A history of home mechanical ventilation: The past, present and future

This state-of-the-art review provides an overview of the history of home mechanical ventilation (HMV), including early descriptions of mechanical ventilation from ancient and Renaissance perspectives and the mass development of ventilators designed for long-term use during the poliomyelitis epidemic. Seminal data from key clinical trials supports the application of HMV in certain patients with chronic obstructive pulmonary disease, neuromuscular disease and obesity-related respiratory failure. Innovative engineering coupled with refined physiological understanding now permits widespread delivery of home mechanical ventilation to a global population, using portable devices with advanced ventilatory modes and telemonitoring capabilities. Exponential growth in digital technology continues, and ongoing research is needed to understand how to harness clinical and physiological data to benefit patients and healthcare services in a clinically- and cost-effective manner.

First Report of Spinal Anesthesia for Cesarean Delivery in a Parturient With Jeune Syndrome: A Case Report

Jeune syndrome, also known as asphyxiating thoracic dystrophy, is a rare form of autosomal recessive skeletal dysplasia. Respiratory distress due to thoracic and lung dysplasia is the primary complication associated with this disorder in neonates. Women with Jeune syndrome seldom conceive and give birth, as only a few survive until adulthood. Herein, we report the world's first case of a cesarean delivery under spinal anesthesia in a pregnant woman with Jeune syndrome with a history of chest wall reconstruction and spinal fusion surgeries.

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.

Integrated Care Intervention Supported by a Mobile Health Tool for Patients Using Noninvasive Ventilation at Home: Randomized Controlled Trial

BACKGROUND

Home-based noninvasive ventilation has proven cost-effective. But, adherence to therapy still constitutes a common clinical problem. We hypothesized that a behavioral intervention supported by a mobile health (mHealth) app could enhance patient self-efficacy. It is widely accepted that mHealth-supported services can enhance productive interactions among the stakeholders involved in home-based respiratory therapies.

OBJECTIVE

This study aimed to measure changes in self-efficacy in patients with chronic respiratory failure due to diverse etiologies during a 3-month follow-up period after the intervention. Ancillary objectives were assessment of usability and acceptability of the mobile app as well as its potential contribution to collaborative work among stakeholders.

METHODS

A single-blind, single-center, randomized controlled trial was conducted between February 2019 and June 2019 with 67 adult patients with chronic respiratory failure undergoing home-based noninvasive ventilation. In the intervention group, a psychologist delivered a face-to-face motivational intervention. Follow-up was supported by a mobile app that allowed patients to report the number of hours of daily noninvasive ventilation use and problems with the therapy. Advice was automatically delivered by the mobile app in case of a reported problem. The control group received usual care. The primary outcome was the change in the Self Efficacy in Sleep Apnea questionnaire score. Secondary outcomes included app usability, app acceptability, continuity of care, person-centered care, and ventilatory parameters.

RESULTS

Self-efficacy was not significantly different in the intervention group after the intervention (before: mean 3.4, SD 0.6; after: mean 3.4, SD 0.5, P=.51). No changes were observed in adherence to therapy nor quality of life. Overall, the mHealth tool had a good usability score (mean 78 points) and high acceptance rate (mean score of 7.5/10 on a Likert scale). It was considered user-friendly (mean score of 8.2/10 on a Likert scale) and easy to use without assistance (mean score of 8.5/10 on a Likert scale). Patients also scored the perception of continuity of care and person-centered care as high.

CONCLUSIONS

The integrated care intervention supported by the mobile app did not improve patient self-management. However, the high acceptance of the mobile app might indicate potential for enhanced communication among stakeholders. The study identified key elements required for mHealth tools to provide effective support to collaborative work and personalized care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03932175; https://clinicaltrials.gov/ct2/show/NCT03932175.

[Non-invasive and invasive out of hospital ventilation in chronic respiratory failure : Consensus report of the working group on ventilation and intensive care medicine of the Austrian Society of Pneumology]

The current consensus report was compiled under the patronage of the Austrian Society of Pneumology (Österreichischen Gesellschaft für Pneumologie, ÖGP) with the intention of providing practical guidelines for out-of-hospital ventilation that are in accordance with specific Austrian framework parameters and legal foundations. The guidelines are oriented toward a 2004 consensus ÖGP recommendation concerning the setup of long-term ventilated patients and the 2010 German Respiratory Society S2 guidelines on noninvasive and invasive ventilation of chronic respiratory insufficiency, adapted to national experiences and updated according to recent literature. In 11 chapters, the initiation, adjustment, and monitoring of out-of-hospital ventilation is described, as is the technical equipment and airway access. Additionally, the different indications-such as chronic obstructive pulmonary diseases, thoracic restrictive and neuromuscular diseases, obesity hypoventilation syndrome, and pediatric diseases-are discussed. Furthermore, the respiratory physiotherapy of adults and children on invasive and noninvasive long-term ventilation is addressed in detail.

Effectiveness and safety of mouthpiece ventilation and nocturnal non-invasive ventilation in patients with kyphoscoliosis: Short and long-term outcomes after an episode of acute respiratory failure

BACKGROUND

Kyphoscoliosis is a skeletal condition involving the hyperflexion of the thoracic spine. It is characterized by reduced chest wall compliance and impaired respiratory mechanisms leading to progressive hypo-ventilation. We evaluated the effectiveness and the safety of non-invasive ventilation (NIV) in patients after an episode of acute respiratory failure (ARF).

METHODS

Eighteen patients with severe kyphoscoliosis who had been hospitalized for an episode of ARF were followed for 4 years. NIV was applied via mouthpiece (MPV) during the daytime and via mask during the night. The primary outcomes were changes in physiological and functional parameters as well as quality of life. Secondary outcomes were considered re-hospitalization and mortality rate after discharge. A set of control subjects was used for comparison.

RESULTS

All patients showed a significant improvement in several clinical, physiological, functional and quality of life parameters. Four of them (22.2%) died during the four year follow-up period. In the uni-variate analysis patients who died had higher cardiac co-morbidity, lower MIP and SNIP, higher paCO2, and oxygen desaturation index at initial admission.

CONCLUSIONS

Diurnal MPV associated with nocturnal NIV had significantly improved lung function, clinical outcomes and quality of life. It should be considered as a safe alternative to traditional administering of NIV.

Intensive care and non-invasive mechanical ventilation in kyphoscoliosis: are new perspectives still needed?

Non-invasive ventilation (NIV) assists breathing and thus improves oxygenation in patients with Kyphoscoliosis. The benefits of short- and long-term intermittent nocturnal in such patients have been reported previously (improvement of vital capacity, total lung capacity, muscle strength, daytime oxygenation, exercise capacity, and pulmonary hypertension). We review this important study reporting patients with kyphoscoliosis and acute respiratory failure along with their long-term outcomes. We believe that this letter may provide important information regarding the prognosis and efficacy of NIV.

Management of kyphoscoliosis patients with respiratory failure in the intensive care unit and during long term follow up

BACKGROUND

We aimed to evaluate the ICU management and long-term outcomes of kyphoscoliosis patients with respiratory failure.

METHODS

A retrospective observational cohort study was performed in a respiratory ICU and outpatient clinic from 2002-2011. We enrolled all kyphoscoliosis patients admitted to the ICU and followed-up at regular intervals after discharge. Reasons for acute respiratory failure (ARF), ICU data, mortality, length of ICU stay and outpatient clinic data, non-invasive ventilation (NIV) device settings, and compliance were recorded. NIV failure in the ICU and the long term effect of NIV on pulmonary performance were analyzed.

RESULTS

Sixty-two consecutive ICU kyphoscoliosis patients with ARF were enrolled in the study. NIV was initially applied to 55 patients, 11 (20%) patients were intubated, and the majority had sepsis and septic shock (p < 0.001). Mortality in the ICU was 14.5% (n = 9), reduced pH, IMV, and sepsis/septic shock were significantly higher in the non-survivors (p values 0.02, 0.02, 0.028, 0.012 respectively). Among 46 patients attending the outpatient clinic, 17 were lost to follow up and six were died. The six minute walk distance was significantly increased in the final follow up (306 m versus 419 m, p < 0.001).

CONCLUSIONS

We strongly discourage the use of NIV in the case of septic shock in ICU kyphoscoliosis patients with ARF. Pulmonary performance improved with NIV during long term follow up.

Importance of the PaCO(2) from 3 to 6 months after initiation of long-term non-invasive ventilation

BACKGROUND

The level at which arterial carbon dioxide tension (PaCO(2)) a few months after introduction of long-term non-invasive positive pressure ventilation (NPPV) is associated with a favorable prognosis remains uncertain.

METHODS

Data on 184 post-tuberculosis patients with chronic restrictive ventilatory failure who were receiving long-term domiciliary NPPV were examined retrospectively. Average PaCO(2) 3-6 months after NPPV (3- to 6-mo PaCO(2)) and potential confounders were analyzed with discontinuation of long-term NPPV as the primary outcome. The effects of 3- to 6-mo PaCO(2) on annual hospitalization rates due to respiratory deterioration from 1 year before to 3 years after the initiation of NPPV were examined. The effect of the difference between the PaCO(2) value at the start of NPPV (0-mo PaCO(2)) and the PaCO(2) value 3- to 6-mo later (d-PaCO(2)) on continuation rates for NPPV was also assessed in patients who initiated NPPV while in a chronic state.

RESULTS

Patients with relatively low 3- to 6-mo PaCO(2) values maintained a relatively low PaCO(2) 6-36 months after NPPV (p < 0.0001) and had significantly better continuation rates (p < 0.03) and lower hospitalization rates from the 1st to 3rd year of NPPV (p = 0.008, 0.049, 0.009, respectively) than those with higher levels. The 0-mo PaCO(2) (p = 0.26) or d-PaCO(2) (p = 0.86) had no predictive value.

CONCLUSION

A relatively low 3- to 6-mo PaCO(2) value was predictive of long-term use of NPPV. The target values for 3- to 6-mo PaCO(2) may, therefore, be less than 60 mmHg in post-tuberculosis patients, although more studies are needed.

Clinical review: long-term noninvasive ventilation

Noninvasive positive ventilation has undergone a remarkable evolution over the past decades and is assuming an important role in the management of both acute and chronic respiratory failure. Long-term ventilatory support should be considered a standard of care to treat selected patients following an intensive care unit (ICU) stay. In this setting, appropriate use of noninvasive ventilation can be expected to improve patient outcomes, reduce ICU admission, enhance patient comfort, and increase the efficiency of health care resource utilization. Current literature indicates that noninvasive ventilation improves and stabilizes the clinical course of many patients with chronic ventilatory failure. Noninvasive ventilation also permits long-term mechanical ventilation to be an acceptable option for patients who otherwise would not have been treated if tracheostomy were the only alternative. Nevertheless, these results appear to be better in patients with neuromuscular/-parietal disorders than in chronic obstructive pulmonary disease. This clinical review will address the use of noninvasive ventilation (not including continuous positive airway pressure) mainly in diseases responsible for chronic hypoventilation (that is, restrictive disorders, including neuromuscular disease and lung disease) and incidentally in others such as obstructive sleep apnea or problems of central drive.

Predictors of long-term survival in patients with restrictive thoracic disorders and chronic respiratory failure undergoing non-invasive home ventilation

BACKGROUND AND OBJECTIVES

Non-invasive positive pressure ventilation (NPPV) is an established treatment in restrictive thoracic disorders (RTD) with chronic hypercapnic respiratory failure. The aim of this study was to identify predictors of long-term survival for patients on NPPV therapy.

METHODS

In a 10-year retrospective cohort of patients with RTD and chronic hypercapnic respiratory failure, survival and the predictive value of nocturnal and daytime blood gases, lung function and laboratory data measured before initiation of NPPV were assessed. The impact of ventilator settings and daily use of NPPV on survival were also evaluated. Patients were re-admitted every 6 months for follow-up assessment.

RESULTS

The study recruited 77 patients; 18 died during the study period and three ceased NPPV. Respiratory failure caused eight of the nine respiratory deaths (88.9%). One-, 2- and 5-year survival rates were 92.5%, 81.0% and 59.0%, respectively. In univariate analyses, higher night-time PaCO(2), base excess (night- and daytime) and lower Hb at baseline were associated with significantly worse survival (P < 0.05). Multivariate Cox regression analysis revealed night-time PaCO(2) as an independent predictor of survival (P = 0.042). The small differences in daily duration of use of NPPV and ventilator settings were not significantly related to survival. At follow up, significant improvements were observed for blood gases, lung and respiratory muscle function, as well as a decrease in Hb level (P < 0.01 each).

CONCLUSIONS

Base excess, Hb and particularly nocturnal PaCO(2) are relevant prognostic factors for survival in RTD and should be considered in assessing patients receiving NPPV.

Non-invasive positive ventilation in the treatment of sleep-related breathing disorders

This chapter addresses the use of long-term non-invasive positive pressure ventilation (NIPPV) (to the exclusion of continuous positive airway pressure) in the different clinical settings in which it is currently proposed: principally in diseases responsible for hypoventilation characterized by elevated PaCO(2). Nasal masks are predominantly used, followed by nasal pillow and facial masks. Mouthpieces are essentially indicated in case daytime ventilation is needed. Many clinicians currently prefer pressure-preset ventilator in assist mode as the first choice for the majority of the patients with the view of offering better synchronization. Nevertheless, assist-control mode with volume-preset ventilator is also efficient. The settings of the ventilator must insure adequate ventilation assessed by continuous nocturnal records of at least oxygen saturation of haemoglobin-measured by pulse oximetry. The main categories of relevant diseases include different types of neuromuscular disorders, chest-wall deformities and even lung diseases. Depending on the underlying diseases and on individual cases, two schematic situations may be individualized. Either intermittent positive pressure ventilation (IPPV) is continuously mandatory to avoid death in the case of complete or quasi-complete paralysis or is used every day for several hours, typically during sleep, producing enough improvement to allow free time during the daylight in spontaneous breathing while hypoventilation and related symptoms are improved. In case of complete or quasi-complete need of mechanical assistance, a tracheostomy may become an alternative to non-invasive access. In neuromuscular diseases, in kyphosis and in sequela of tuberculosis patients, NIPPV always significantly increases survival. Conversely, no data support a positive effect on survival in chronic obstructive pulmonary disease.

Nutritional depletion and its relationship to respiratory impairment in patients with chronic respiratory failure due to COPD or restrictive thoracic diseases

OBJECTIVE

While malnutrition, especially fat-free mass index (FFMI), is a predictor for mortality in chronic obstructive pulmonary disease (COPD), less information on prevalence and mechanisms is available in patients with chronic respiratory failure (CRF) due to restrictive thoracic diseases (RTD).

DESIGN AND SETTING

Cross-sectional study of patients consecutively admitted to an in-patient primary pulmonary centre.

SUBJECTS

One hundred and thirty-two patients (30% RTD; 70% COPD) with CRF and intermittent non-invasive positive pressure ventilation.

INTERVENTIONS

Malnutrition was quantified by bioelectrical impedance analysis or body mass index (BMI), and its relationship to laboratory, lung function, inspiratory muscle and blood gas parameters and 6-min walking distance (6-MWD) was assessed.

RESULTS

Malnutrition in terms of BMI<20 kg/m(2) occurred in 16.1% of patients with COPD but none of those with RTD. FFMI<17.4 (<15.0 in female patients) kg/m(2) was found in 35.4 and 30.7%, respectively. FFMI was correlated with airway obstruction (sR(aw), r = -0.50; FEV(1)/VC, r = -0.28; P< or = 0.01 each) and lung hyperinflation (intrathoracic gas volume, r = -0.41; total lung capacity (TLC), r = -0.50; P< or = 0.001 each) in COPD, and with lung restriction in RTD (TLC, r=0.40; P=0.011). Furthermore, malnourished patients showed a higher inspiratory load (P (0.1)) and reduced 6-MWD in both groups. In COPD, only hyperinflation and P (0.1) were independently related to FFMI.

CONCLUSIONS

Malnutrition as indicated by low FFMI was similarly prevalent in patients with CRF and COPD or RTD, but inadequately represented by BMI. The correlations between lung function impairments specific for the disease and FFMI emphasized the link between malnutrition and respiratory mechanical load irrespective of its aetiology.

Respiratory muscle training in restrictive thoracic disease: a randomized controlled trial

OBJECTIVE

To investigate the effects of respiratory muscle training (RMT) in patients with restrictive thoracic disorders and intermittent noninvasive positive-pressure ventilation (NPPV).

DESIGN

Prospective randomized controlled trial.

SETTING

Home-based RMT, with assessment in a primary care pulmonary center.

PARTICIPANTS

Thirty patients with restrictive thoracic disorders; 28 patients completed the trial.

INTERVENTION

Three months of RMT by isocapnic hyperpnea or sham training.

MAIN OUTCOME MEASURES

Respiratory muscle strength and endurance, lung function, exercise performance, and health-related quality of life (HRQOL).

RESULTS

After RMT, maximal inspiratory mouth pressure was increased (27.6%+/-36.5%, P=.013). In patients who could perform cycle ergometer testing (n=17), peak oxygen consumption (2.24+/-3.39mLxkg(-1).min(-1) vs -1.71+/-2.54mLxkg(-1).min(-1), P=.014) and maximal work rate (9.4+/-14.8W vs -5.1+/-10.8W, P=.043) increased relative to a control group. Similar differences occurred regarding changes of HRQOL (physical performance, 3.3+/-11.4 score vs -6.6+/-9.0 score; P=.012) and time of ventilator use (-0.6+/-1.2h/d vs 0.4+/-0.5h/d, P=.010). Lung volumes, 12-second maximum voluntary ventilation, 6-minute walking distance, and blood gases were unchanged.

CONCLUSIONS

In patients with restrictive thoracic disorders and NPPV, RMT improved inspiratory muscle strength. Exercise performance and HRQOL were improved when the 2 groups were compared. RMT was practicable and safe despite severe respiratory impairment. Further evaluation, including different training intensities and modalities, seems warranted.