Statement on Home Care for Patients with Respiratory Disorders

Codesign of remote data collection for chronic management of pediatric home mechanical ventilation

INTRODUCTION

Outpatient monitoring of children using invasive home mechanical ventilation (IHMV) is recommended, but access to care can be difficult. This study tested if remote (home-based) data collection was feasible and acceptable in chronic IHMV management.

METHODS

A codesign study was conducted with an IHMV program, home nurses, and English- and Spanish-speaking parent-guardians of children using IHMV (0-17 years; n = 19). After prototyping, parents used a remote patient monitoring (RPM) bundle to collect patient heart rate, respiratory rate (RR), oxygen saturation, end-tidal carbon dioxide (EtCO2 ), and ventilator pressure/volume over 8 weeks. User feedback was analyzed using qualitative methods and the System Usability Scale (SUS). Expected marginal mean differences within patient measures when awake, asleep, or after a break were calculated using mixed effects models.

RESULTS

Patients were a median 2.9 years old and 11 (58%) took breaks off the ventilator. RPM data were entered on a mean of 83.7% (SD ± 29.1%) weeks. SUS scores were 84.8 (SD ± 10.5) for nurses and 91.8 (SD ± 10.1) for parents. Over 90% of parents agreed/strongly agreed that RPM data collection was feasible and relevant to their child's care. Within-patient comparisons revealed that EtCO2 (break-vs-asleep 2.55 mmHg, d = 0.79 [0.42-1.15], p < .001; awake-vs-break 1.48, d = -0.49 [0.13-0.84], p = .02) and RR (break-vs-asleep 16.14, d = 2.12 [1.71-2.53], p < .001; awake-vs-break 3.44, d = 0.45 [0.10-0.04], p = .03) were significantly higher during ventilator breaks.

CONCLUSIONS

RPM data collection in children with IHMV was feasible, acceptable, and captured clinically meaningful vital sign changes during ventilator breaks, supporting the clinical utility of RPM in IHMV management.

PediHome: Development of a Family-Reported Measure of Pediatric Home Healthcare Quality

OBJECTIVE

No validated tools exist to measure pediatric home healthcare quality. The objective of this work was to develop a family-reported survey (PediHome) to measure the quality of home healthcare for children with medical complexity (CMC).

METHODS

A national multidisciplinary expert panel (N = 19) was convened to develop survey content domains. Panelist were joined by 3 additional experts to rank candidate survey items for importance and evaluate relevance and structure. Cognitive interviews were conducted with English-speaking (n = 12) and Spanish-speaking (n = 4) family caregivers of CMC to revise problematic items and clarify response options. A cross-sectional survey was then fielded (6/1/20-10/31/20) to parents whose children receive healthcare at 2 regional academic medical centers.

RESULTS

The final measure included N = 28 total items with 4 items quantifying access, 1 evaluating overall quality rating, and 21 items assessing provider tasks (11 home nursing only, 2 certified nursing assistant/home health aide only, and 1 dual). Out of 312 caregivers of CMC, 142 (46%) responded and one-half (n = 68, 48%) reported a child receiving home nursing. They received a weekly median of 58.4% (IQR ±31.2%) of approved nursing hours with 55% reporting a missed nursing shift within the last month. Median overall quality was 75-9 (0-10 scale) and median scores on specific quality items ranged from 31^-4 to 43^-4 (0-4 scale).

CONCLUSIONS

PediHome is a new content-valid family-reported measure of home healthcare quality for CMC that is useful for evaluating healthcare quality across several domains. Future work will involve assessing PediHome's construct and predictive validity.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

The Portuguese Model of Home Respiratory Care: Healthcare Professionals' Perspective

Patients' and carers' views regarding the Portuguese model of home respiratory care were recently described, yet the complementary perspective of healthcare professionals (HCPs) is still to be investigated. Thus, this study explored HCPs experience in the management of patients needing home respiratory therapies (HRT), and their perspective about the Portuguese model. A phenomenological descriptive study, using focus groups, was carried out with 28 HCPs (median 42 y, 68% female) with distinct backgrounds (57% pulmonologists, 29% clinical physiologists, 7% physiotherapists, 7% nurses). Three focus groups were conducted in three regions of Portugal. Thematic analysis was performed by two independent researchers. HCPs have in general a positive view about the organization of the Portuguese model of home respiratory care, which was revealed in four major topics: Prescription (number of references, n = 171), Implementation and maintenance (n = 162), Carer involvement (n = 65) and Quality of healthcare (n = 247). Improvements needed were related to patients' late referral, HRT prescription (usability of the medical electronic prescription system and renewals burden), patients' education, access to hospital care team, lack of multidisciplinary work and articulation between hospital, primary and home care teams. This study describes the perspective of HCPs about the Portuguese model of home respiratory care and identifies specific points where improvements and reflections are needed. This knowledge may be useful to decision makers improve the current healthcare model.

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.

[Oxygen Therapy in Lung Transplantation Candidates - A Single Center Retrospective Analysis of 807 Patients]

BACKGROUND

 Long-term oxygen treatment (LTOT) is frequently used in patients with advanced pulmonary diseases and respiratory failure. Oxygen treatment influences donor lung allocation for patients and is associated with increased mortality. This study investigates oxygen therapy in lung transplantation candidates.

METHODS

 A retrospective study at a large German transplantation centre between 09/2011 and 01/2019 was performed. Data regarding oxygen therapy was analyzed and LTOT-indication verified by titrated blood gas analysis. The study period splits into 2 periods before and after the introduction of oxygen titration (3rd quarter of 2015). Univariate and multivariate analysis for the endpoint "admission to waiting list" was performed.

RESULTS

 807 patients were included in the analysis, 396 in the first and 411 patients in the second period. Of those 293 patients (36.3 %) were transplanted. Six hundred thirty (78 %) patients stated using oxygen for more than 12 hours per day. After implementing oxygen titration in period 2, in 212 (57 %) of 372 patients LTOT indication could be confirmed. Titrated oxygen flow was lower in period 2 (0.5 l/min [IQR 0.0 - 2.0] versus 2 l/min [IQR 0.5 - 3.0]). In multivariate analysis oxygen flow was associated with admission to waiting list as an independent variable.

CONCLUSION

 Patients referred to lung transplantation use oxygen therapy in the vast majority. Indication for LTOT should be carefully reassessed in candidates. Confirmed LTOT-indication seems to be associated with the likelihood for admission to the waiting list for lung transplantation and could therefore be a selection criterium in the future.

Effectiveness of Home Visits in Adult Patients with Asthma: A Systematic Review of Randomized Controlled Trials

BACKGROUND

The effectiveness of home visits is well discussed for children with asthma, but limited in adults.

OBJECTIVE

The present systematic review aimed to investigate the potential role of home visits in improving outcomes among adult patients with asthma.

METHODS

The systematic review was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. An extensive literature search was conducted using databases such as PubMed, ProQuest, CINAHL, The Cochrane Library, PsycINFO, and Google Scholar from inception to June 2019. The studies included were randomized controlled trials, which reported asthma outcomes in adult patients.

RESULTS

The literature search yielded 8331 publications, of which 63 studies were selected for full-text review, and of these studies, 9 studies with a total of 2011 patients were included in the final analysis. The included randomized controlled trials reported quality of life, asthma symptoms, exacerbations, health care utilization, and pulmonary function. Improvements in asthma outcomes were observed predominantly in quality of life. The effects on asthma symptom control were inconsistent. The evidence on the impact of home visits in asthma exacerbations and health care utilization was rather limited. There were no significant differences observed between intervention versus control arms in terms of pulmonary function; however, 1 study reported significant improvements in peak expiratory flow rate.

CONCLUSIONS

Home visits may serve as an adjuvant activity that complements the existing health care system-based initiatives. It may be concluded that home visits have the potential to improve outcomes in adult patients with asthma; however, the randomized controlled trials reviewed in the present systematic review reported several limitations that warrant further investigation.

Pulmonary hypertension with a low cardiac index requires a higher PaO2 level to avoid tissue hypoxia

BACKGROUND AND OBJECTIVE

The optimal oxygen supplementation needed to avoid tissue hypoxia in patients with pulmonary hypertension (PH) remains unclear. This study aimed to identify the arterial oxygen tension (PaO₂ ) level needed to avoid tissue hypoxia which results in a poor prognosis in patients with PH.

METHODS

We retrospectively analysed the data for 1571 right heart catheterizations in patients suspected of having PH between 1983 and 2017 at our institution. Examinations were classified according to mean pulmonary arterial pressure (mPAP), cardiac index (CI) and the presence of lung disease, pulmonary arterial hypertension (PAH) or chronic thromboembolic PH (CTEPH). The PaO₂ levels needed to avoid tissue hypoxia were compared in each subgroup.

RESULTS

The estimated PaO₂ equivalent to a mixed venous oxygen tension (PvO₂ ) of 35 mm Hg (tissue hypoxia) was 63.2 mm Hg in all patients, 77.0 mm Hg in those with decreased CI (<2.5 L/min/m² ) and 57.0 mm Hg in those with preserved CI. Multivariate regression analysis identified mPAP, CI and PaO₂ to be independent predictors of extremely low PvO₂ . Similar results were observed regardless of the severity of PH or the presence of lung disease, PAH or CTEPH. The PaO₂ level needed to avoid tissue hypoxia was higher in patients with mild PH and decreased CI than in those with severe PH and preserved CI (70.2 vs 61.5 mm Hg).

CONCLUSION

These findings indicate that a decreased CI rather than increased mPAP induces tissue hypoxia in PH. Patients with PH and decreased CI may need adjustment of oxygen therapy at higher PaO₂ levels compared with patients with preserved CI.

Tele-monitoring in paediatric and young home-ventilated neuromuscular patients: A multicentre case-control trial

INTRODUCTION

Tele-monitoring (TM) has proved effective in the home management of adult ventilator-dependent neuromuscular disease (NMD) patients. We aimed to evaluate a 2-year longitudinal multicentre TM trial designed for young ventilated NMD patients in terms of feasibility, home management of exacerbations and caregivers' burden.

METHODS

The TM trial protocol included patients' weekly scheduled overnight home-recording of SpO₂, heart rate and ventilation and their transmission to each TM centre the following morning. Overnight data were reviewed by non-physicians and calls to families made to assess clinical condition. If clinical conditions (assessed by a scoring system) or overnight parameters worsened, either unscheduled transmissions or calls were activated and managed by non-physicians or medical team according to severity. Hospitalisations were compared with those of TM patients prior to TM start and with those of age-disease-severity-matched controls. Scores from the Caregiver Burden Inventory (CBI) questionnaire pre- and post-TM were compared.

RESULTS

Forty-eight patients were enrolled, 30 males, median age 16.4 years (interquartile range (IQR) 8.9-22.1), median ventilation/day 10.5 h (IQR 8-16). Exacerbations in TM patients did not differ (59 versus 53; p = 0.15) from controls. Hospitalisations were significantly reduced in TM patients when compared with those prior to TM (11 versus 24, p = 0.04) and to controls (11 versus 21, p = 0.03). Median hospitalisation length was significantly lower in TM patients than controls (6 versus 7 days, p = 0.03). Caregivers satisfaction was excellent whereas no significant changes in CBI were seen (32.5 versus 35.5, p = 0.06).

DISCUSSION

TM was effective in improving the home management of respiratory exacerbations in young ventilated NMD patients and overall well tolerated.

Characteristics of patients who progress from bridging to long-term oxygen therapy

BACKGROUND

Patients with persistent hypoxia following an acute hospital admission may be discharged with 'bridging' domiciliary oxygen as per criteria defined by the Thoracic Society of Australia and New Zealand. The need for continuous long-term oxygen therapy (LTOT) is then reassessed at a clinic review 1-2 months later.

AIM

To describe the characteristics of patients discharged from an acute hospital admission with continuous short-term oxygen therapy (STOT), and subsequently to investigate for differences between subjects who proceeded to qualify for continuous LTOT versus those who were able to cease STOT at review.

METHODS

This is a retrospective cohort study involving all subjects discharged from Alfred Health between 2011 and 2015 inclusive with bridging domiciliary oxygen. Multiple biochemical, physiological and demographic characteristics were collated and analysed.

RESULTS

Of all patients prescribed continuous STOT at time of discharge, 47.3% qualified for LTOT at outpatient review. This cohort had a significantly lower PaO₂ measurement at time of discharge, compared with those who no longer qualified.

CONCLUSION

PaO₂ at time of discharge provides a signal with the potential to identify who will require continuous LTOT following an acute hospital admission. Additionally, this study highlights the need to re-evaluate patients' oxygen requirements during a period of clinical stability.

The AIMAR recommendations for early diagnosis of chronic obstructive respiratory disease based on the WHO/GARD model*

Respiratory diseases in Italy already now represent an emergency (they are the 3(rd) ranking cause of death in the world, and the 2(nd) if Lung cancer is included). In countries similar to our own, they result as the principal cause for a visit to the general practitioner (GP) and the second main cause after injury for recourse to Emergency Care. Their frequency is probably higher than estimated (given that respiratory diseases are currently underdiagnosed). The trend is towards a further increase due to epidemiologic and demographic factors (foremost amongst which are the widespread diffusion of cigarette smoking, the increasing mean age of the general population, immigration, and pollution). Within the more general problem of chronic disease care, chronic respiratory diseases (CRDs) constitute one of the four national priorities in that they represent an important burden for society in terms of mortality, invalidity, and direct healthcare costs. The strategy suggested by the World Health Organization (WHO) is an integrated approach consisting of three goals: inform about health, reduce risk exposure, improve patient care. The three goals are translated into practice in the three areas of prevention (1-primary, 2-secondary, 3-tertiary) as: 1) actions of primary (universal) prevention targeted at the general population with the aim to control the causes of disease, and actions of Predictive Medicine - again addressing the general population but aimed at measuring the individual's risk for disease insurgence; 2) actions of early diagnosis targeted at groups or - more precisely - subgroups identified as at risk; 3) continuous improvement and integration of care and rehabilitation support - destined at the greatest possible number of patients, at all stages of disease severity. In Italy, COPD care is generally still inadequate. Existing guidelines, institutional and non-institutional, are inadequately implemented: the international guidelines are not always adaptable to the Italian context; the document of the Agency for Regional Healthcare Services (AGE.NA.S) is a more suited compendium for consultation, and the recent joint statement on integrated COPD management of the three major Italian scientific Associations in the respiratory area together with the contribution of a Society of General Medicine deals prevalently with some critical issues (appropriateness of diagnosis, pharmacological treatment, rehabilitation, continuing care); also the document "Care Continuity: Chronic Obstructive Pulmonary Disease (COPD)" of the Global Alliance against chronic Respiratory Diseases (GARD)-Italy does not treat in depth the issue of early diagnosis. The present document - produced by the AIMAR (Interdisciplinary Association for Research in Lung Disease) Task Force for early diagnosis of chronic respiratory disease based on the WHO/GARD model and on available evidence and expertise -after a general examination of the main epidemiologic aspects, proposes to integrate the above-mentioned existing documents. In particular: a) it formally indicates on the basis of the available evidence the modalities and the instruments necessary for carrying out secondary prevention at the primary care level (a pro-active,'case-finding'approach; assessment of the individual's level of risk of COPD; use of short questionnaires for an initial screening based on symptoms; use of simple spirometry for the second level of screening); b) it identifies possible ways of including these activities within primary care practice; c) it places early diagnosis within the "systemic", consequential management of chronic respiratory diseases, which will be briefly described with the aid of schemes taken from the Italian and international reference documents.

Best-practice care for people with advanced chronic obstructive pulmonary disease: the potential role of a chronic obstructive pulmonary disease care co-ordinator

OBJECTIVE

To explore service availability and accessibility for people with advanced chronic obstructive pulmonary disease (COPD) and their carers and strategies for improvement, including the potential role of a COPD care co-ordinator in ensuring best-practice care in the Australian context.

METHODS

This qualitative study used focus groups and interviews with health professionals, carers and consumers to explore gaps and restrictions in services, barriers to access and the functioning of services. Data were analysed deductively.

RESULTS

Key themes arising from the data included difficulties around access to care, lack of continuity of care, poor care co-ordination, the need for active disease management as well as supportive care, and poor communication. A COPD care co-ordinator was suggested as an effective strategy for ensuring best-practice care.

CONCLUSIONS

People with advanced COPD often have difficulty navigating the acute, primary and community care systems to deal with the multiple services that they may require. Lack of communication between health professionals and services is frequently a significant issue. A COPD care co-ordinator, encompassing advanced nursing skills, could ensure that care is centred on the needs of the person and their carer and that they receive continuing, appropriate and accessible care as they approach the end of their life.

Incidence and cost of pneumonia in older adults with COPD in the United States

Objectives

To estimate the incidence of pneumonia by COPD status and the excess cost of inpatient primary pneumonia in elders with COPD.

Study Design

A retrospective, longitudinal study using claims linked to eligibility/demographic data for a 5% sample of fee-for-service Medicare beneficiaries from 2005 through 2007.

Methods

Incidence rates of pneumonia were calculated for elders with and without COPD and for elders with COPD and coexistent congestive heart failure (CHF). Propensity-score matching with multivariate generalized linear regression was used to estimate the excess direct medical cost of inpatient primary pneumonia in elders with COPD as compared with elders with COPD but without a pneumonia hospitalization.

Results

Elders with COPD had nearly six-times the incidence of pneumonia compared with elders without COPD (167.6/1000 person-years versus 29.5/1000 person-years; RR=5.7, p <0 .01); RR increased to 8.1 for elders with COPD and CHF compared with elders without COPD. The incidence of inpatient primary pneumonia among elders with COPD was 54.2/1000 person-years compared with 7/1000 person-years for elders without COPD; RR=7.7, p<0.01); RR increased to 11.0 for elders with COPD and CHF compared with elders without COPD. The one-year excess direct medical cost of inpatient pneumonia in COPD patients was $ 22,697 ($45,456 in cases vs. $ 22,759 in controls (p <0.01)); 70.2% of this cost was accrued during the quarter of the index hospitalization. During months 13 through 24 following the index hospitalization, the excess direct medical cost was $ 5,941 ($23,215 in cases vs. $ 17,274 in controls, p<0.01).

Conclusions

Pneumonia occurs more frequently in elders with COPD than without COPD. The excess direct medical cost in elders with inpatient pneumonia extends up to 24 months following the index hospitalization and represents $28,638 in 2010 dollars.

Multiscale analysis of hypoxemia in methemoglobin anemia

Methemoglobinemia is a disease that results from abnormally high levels of methemoglobin (MetHb) in the red blood cell (RBC), which is caused by simultaneous uptake of oxygen (O(2)) and nitric oxide (NO) in the human lungs. MetHb is produced in the RBC by irreversible NO-induced oxidation of the oxygen carrying ferrous ion (Fe(2+)) present in the heme group of the hemoglobin (Hb) molecule to its non-oxygen binding ferric state (Fe(3+)). This paper studies the role of NO in the pathophysiology of methemoglobinemia and presents a multiscale quantitative analysis of the relation between the levels of NO inhaled by the patient and the hypoxemia resulting from the disease. Reactions of NO occurring in the RBC with both Hb and oxyhemoglobin are considered in conjunction with the usual reaction between oxygen and Hb to form oxyhemoglobin. Our dynamic simulations of NO and O(2) uptake in the RBC (micro scale), alveolar capillary (meso scale) and the entire lung (macro scale) under continuous, simultaneous exposure to both gases, reveal that NO uptake competes with the reactive uptake of O(2), thus suppressing the latter and causing hypoxemia. We also find that the mass transfer resistances increase from micro through meso to macro scales, thus decreasing O(2) saturation as one goes up the scales from the cellular to the organ (lung) level. We show that NO levels of 203 ppm or higher while breathing in room air may be considered to be fatal for methemoglobinemia patients since it causes severe hypoxemia by reducing the O(2) saturation below a critical value of 88%, at which Long Term Oxygen Therapy (LTOT) becomes necessary.

Supportive and palliative care of advanced nonmalignant lung disease

Supportive and palliative care is an interdisciplinary challenge with the aims of symptom relief and improvement of quality of life in end-stage patients. Main complaints of patients with advanced nonmalignant lung disease are depression and anxiety, dyspnea, pain, and coughing. The discomfort of many physicians, caregivers, and family members with discussions about end-of-life care is one obstacle for the timely initiation of palliative care and the uncertainty of the short-term prognosis in most advanced nonmalignant respiratory diseases. Early dialog about supportive care already at the onset of the patient's first symptoms and contemporaneous to life-prolonging therapy may overcome these barriers. Furthermore, continuing education for health professionals in palliative care ensures adequate palliative support. Here, we review insights into symptom control and palliative care in patients with advanced nonmalignant respiratory disease.

A pilot trial of telemedicine-assisted, integrated care for patients with advanced amyotrophic lateral sclerosis and their caregivers

Patients with amyotrophic lateral sclerosis (ALS) need a care programme as the disease progresses. We used telemedicine-assisted integrated care (TAIC) in 40 patients with ALS, for a mean duration of 8.6 months (range 1-12). A nurse-tutor played the key role, supported by respiratory physicians, neurologists and psychologists. Each patient used a portable pulse oximeter during the daily telephone contacts to assess clinical/oxygen variations. Patients also completed a satisfaction questionnaire. During the study period, each patient used TAIC at least five times per month. There were 1907 scheduled telephone calls (86% of the total) and 317 unscheduled calls. Of the unscheduled calls, 84% were managed by the nurse-tutor and only 16% of them required specialist intervention. The most common item was the ALS clinical interview (58%), followed by the description of acute symptoms, cough ability and oxygenation. TAIC staff recommended 4 out of 12 emergency hospital admissions (33%) and 77% of the other hospitalizations. Patients and caregivers were extremely satisfied (79%) with the nurse assistance provided and the patients' confidence in handling their disease improved in 71% of the cases. TAIC provides a nurse-centred, home-monitoring programme that can be a useful way of following up ALS patients.

[Hospital at home for acutely ill older]

The aging of population uses to evolve suffering from chronic diseases, many times in pluripathological shaped, which may engender frailty, disability and, as a last term, dependence. The aggravation of those and/or the appearance of others acute processes become the old people into a regular patient of our hospitals. The hospital at home (HaH) has showed that it may play an important role in the provision of range hospital cares to these patients, unimpaired of efficacy and security; but with indubitable benefits within the scope of their comfort (physical, psychical) and in the field of their functional condition. Available technical means at the present day and the staff's professionalism from these units make easier that any serious illness, medical or surgical, will be subsidiary in this type of attention sometime during their hospital care process. The HaH permits a more efficient rationalization of sanitary resources and should play an important role in the longed for interconnection between primary attention and specialized one.

Advanced lung disease: quality of life and role of palliative care

Advanced restrictive lung diseases remain a challenge for both the clinician and patient alike. Because there are few available treatment options that prolong survival for patients with diseases such as idiopathic pulmonary fibrosis, improvement in quality of life and palliation of significant symptoms become realistic treatment goals. Several validated instruments that assess quality of life and health-related quality of life have demonstrated the dramatic impact that lung disease has on patients. Quality-of-life assessments of patients with interstitial lung disease have commonly cited respiratory complaints as problematic, but other distressing symptoms often not addressed include fear, social isolation, anxiety, and depression. Not only do respiratory symptoms limit this patient population, but the awareness of decreased independence and ability for social participation also has an impact on the quality of life. Some patients describe a deepened spiritual well-being during their disease process; however, many patients' mental health suffers with experiences of fear, worry, anxiety, and panic. Many patients express desire for more attention to end-of-life issues from their physicians. Fears of worsening symptoms and suffocation exist with an expressed desire by most to die peacefully with symptom control. Interventions to improve quality of life are largely directed at symptom control. Pharmacologic and nonpharmacologic interventions have been helpful in relieving dyspnea. Studies have demonstrated that the use of supplemental oxygen in the face of advancing hypoxemia can have both positive and negative effects on quality of life. Patients using nasal prongs describe feelings of self-consciousness, embarrassment, and social withdrawal. Pulmonary rehabilitation is recommended, with some studies noting increased quality-of-life scores and decreased sensations of dyspnea. Sleep deprivation and poor sleep quality also have a negative impact on quality of life. Recognition and correction of nocturnal hypoxemia and other sleep disturbances should enhance quality of life in patients with restrictive lung disease; however, there is currently no evidence to support this claim. End-of-life care needs more attention by clinicians in the decision-making and preparatory phase. Physicians need to maintain their focus on quality-of-life issues as medical management shifts from curative therapies to comfort management therapies. Palliative care and hospice appear to be underused in patients with advanced diseases other than cancer. Because the only curative option for some end-stage restrictive lung diseases is lung transplantation, if transplantation is not an option, palliation of symptoms and hospice care may offer patients and families the opportunity to die with dignity and comfort.

A review of the information and support needs of family carers of patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

The objectives of this narrative review were to identify: (1) The information and support needs of carers of family members with chronic obstructive pulmonary disease; (2) appropriate interventions to support carers in their caregiving role; (3) information on carers' needs as reported in studies of patients living with COPD in the community.

BACKGROUND

Chronic obstructive pulmonary disease is a major health problem in the UK resulting in significant burden for patients, families and the health service. Current National Health Service policies emphasise, where medically appropriate, early discharge for acute exacerbations, hospital-at-home care and other models of community care to prevent or reduce re-hospitalisations of people with chronic conditions. Understanding carers' needs is important if health care professionals are to support carers in their caregiving role.

DESIGN

A narrative literature review.

METHODS

Thirty five papers were reviewed after searching electronic databases.

RESULTS

Few studies were identified which addressed, even peripherally, carers' needs for information and support, and no studies were found which described and evaluated interventions designed to enhance caregiving capacity. Several studies of hospital-at-home/early discharge, self care and home management programmes were identified which included some information on patients' living arrangements or marital status. However, there was little or no detail reported on the needs of, and in many cases, even the presence of a family carer.

CONCLUSIONS

This review highlights the dearth of information on the needs of carers of chronic obstructive pulmonary disease patients and the need for future research.

RELEVANCE TO CLINICAL PRACTICE

There is little research based knowledge of the needs of carers of chronic obstructive pulmonary disease patients and interventions to assist them in providing care. This knowledge is critical to ensure that carers receive the information they need to carry out this role while maintaining their own physical and emotional health.

End-of-life considerations in older patients who have lung disease

The goal of palliative care is to prevent suffering and manage symptoms, maintain quality of life, and provide physical, emotional, and spiritual support for patients and their loved ones. Research suggests that patients with chronic lung disease receive suboptimal palliative care largely because of inadequate communication with their physicians. When patients have made decisions about life-sustaining therapies, physicians often either do not know patients' wishes or misunderstand them. Clinicians should realize that most patients want more information about end-of-life care and that efforts to initiate and improve communication with their patients are important. This article reviews the potential for enhanced palliative care for older patients with chronic lung disease.

Patients with Complex Chronic Diseases: perspectives on supporting self-management

A Complex Chronic Disease (CCD) is a condition involving multiple morbidities that requires the attention of multiple health care providers or facilities and possibly community (home)-based care. A patient with CCD presents to the health care system with unique needs, disabilities, or functional limitations. The literature on how to best support self-management efforts in those with CCD is lacking. With this paper, the authors present the case of an individual with diabetes and end-stage renal disease who is having difficulty with self-management. The case is discussed in terms of intervention effectiveness in the areas of prevention, addiction, and self-management of single diseases. Implications for research are discussed.

Weaning from mechanical ventilation followed at home with the aid of a telemedicine program

We describe the use of telemedicine in support of weaning from invasive mechanical ventilation on a 63-year-old woman of at home by means of a telepneumology program (TPP). Under telephone assistance of a pulmonologist and a TPP nurse tutor, the pulsed arterial saturimetric (pSaT), heart rate (HR), breathing pattern tracing monitoring transmitted via a home telephone line and the aid of the caregiver, the patient was able to maintain diurnal spontaneous breathing after 24 spontaneous breathing trial (SBT) steps twice daily. The duration of each SBT period progressively increased starting from 30 minutes up to 8 hours. This case report shows that many patients at home on ventilators could possibly be weaned through the use of remote monitoring and call center response, with only family/caregivers on-site.

Assessment of the burden of caregiving for patients with chronic obstructive pulmonary disease

OBJECTIVE

To determine the effect of chronic obstructive pulmonary disease (COPD) on the quality of life of caregivers.

DESIGN AND METHODS

A cross-sectional study was carried out with forty-two COPD patients and their primary caregivers. Patients were assessed with the medical outcome survey short form (SF-36), the physical and mental component summary (PCS and MCS), Saint George's respiratory questionnaire (SGRQ), 6-min walking test, and spirometric and blood gas measurements. Caregivers were assessed using the medical outcome survey short form (SF-36), the physical and mental component summary (PCS and MCS), the 5-point Likert scale for measuring caregiver/patient relationships and the caregiver burden scale (CB scale).

RESULTS

The majority of caregivers were female (85.3%), married (59%) and had low levels of income and schooling. The mean age was 51.6+/-16 years. Mean caregiver PCS and MCS scores were 45.9+/-10 and 46+/-12, while the mean total burden score was 1.79+/-0.6. The regression analysis showed caregiver/patient relationship quality, caregiver MCS scores and patient PCS scores to be important predictors of burden and explained 63% of the variance.

CONCLUSIONS

COPD causes a significant impact on the quality of life of caregivers. The two most important predictors of COPD burden are the relationship between caregivers and patients and caregiver MCS scores.

Assessment of Hospice Nurses' Technique in the Use of Inhalers and Nebulizers

Dyspnea, a common distressing end-of-life symptom, is treated with oral (i.e., opioids and anxiolytics) and inhaled medications (anti-inflammatory and bronchodilator agents). Health care providers and patients have demonstrated an inability to use inhaler devices correctly, which can lead to suboptimal drug delivery and poor symptom relief. Hospice nurses are the primary health care providers educating patients, making it critical that they convey accurate device technique. This study assessed hospice nurses' ability to demonstrate proper inhaler device technique and their knowledge of agents used to treat dyspnea. Forty-seven nurses participated. Participants completed a written questionnaire, which gathered demographic data, as well as information regarding previous training with an inhaler device, administration, pharmacokinetics, mechanism of action, patient assessment, and nursing technique. Additionally, each nurse demonstrated the use of a metered dose inhaler, spacer, dry powder inhaler, and a nebulizer, while being observed by a pharmacist trained in the use of inhalers. A standardized evaluation form was used to ensure consistency between evaluators and subjects. Percentage of steps completed correctly by the study participants ranged from 34.9% with the dry powder inhaler to 67.6% with the metered dose inhaler. Years of experience, presence of hospice certification, personal use of inhaler, and nursing comfort level significantly impacted ability to use inhalation devices. This study demonstrated the existence of knowledge gaps regarding patient assessment, pharmacology and pharmacokinetics of inhaled medications, and inhalation device technique among hospice nurses. Formal education of hospice practitioners regarding inhaled medications and inhalation delivery devices is needed.

Hospital at home for chronic obstructive pulmonary disease: an integrated hospital and community based generic intermediate care service for prevention and early discharge

Recent randomized controlled studies have reported success for hospital at home for prevention and early discharge of chronic obstructive pulmonary disease (COPD) patients using hospital based respiratory nurse specialists. This observational study reports results using an integrated hospital and community based generic intermediate care service. The length of care, readmission within 60 days and death within 60 days in the early discharge (9.37 days, 21.1%, 7%) and the prevention of admission (five to six days, 34.1%, 3.8%) are similar to previous studies. We suggest that this generic community model of service may allow hospital at home services for COPD to be introduced in more areas.