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Sigle M, Berliner L, Richter E, van Iersel M, Gorgati E, Hubloue I, Bamberg M, Grasshoff C, Rosenberger P, Wunderlich R. Development of an Anticipatory Triage-Ranking Algorithm Using Dynamic Simulation of the Expected Time Course of Patients With Trauma: Modeling and Simulation Study. J Med Internet Res 2023; 25:e44042. [PMID: 37318826 PMCID: PMC10337428 DOI: 10.2196/44042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/14/2023] [Accepted: 05/03/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND In cases of terrorism, disasters, or mass casualty incidents, far-reaching life-and-death decisions about prioritizing patients are currently made using triage algorithms that focus solely on the patient's current health status rather than their prognosis, thus leaving a fatal gap of patients who are under- or overtriaged. OBJECTIVE The aim of this proof-of-concept study is to demonstrate a novel approach for triage that no longer classifies patients into triage categories but ranks their urgency according to the anticipated survival time without intervention. Using this approach, we aim to improve the prioritization of casualties by respecting individual injury patterns and vital signs, survival likelihoods, and the availability of rescue resources. METHODS We designed a mathematical model that allows dynamic simulation of the time course of a patient's vital parameters, depending on individual baseline vital signs and injury severity. The 2 variables were integrated using the well-established Revised Trauma Score (RTS) and the New Injury Severity Score (NISS). An artificial patient database of unique patients with trauma (N=82,277) was then generated and used for analysis of the time course modeling and triage classification. Comparative performance analysis of different triage algorithms was performed. In addition, we applied a sophisticated, state-of-the-art clustering method using the Gower distance to visualize patient cohorts at risk for mistriage. RESULTS The proposed triage algorithm realistically modeled the time course of a patient's life, depending on injury severity and current vital parameters. Different casualties were ranked by their anticipated time course, reflecting their priority for treatment. Regarding the identification of patients at risk for mistriage, the model outperformed the Simple Triage And Rapid Treatment's triage algorithm but also exclusive stratification by the RTS or the NISS. Multidimensional analysis separated patients with similar patterns of injuries and vital parameters into clusters with different triage classifications. In this large-scale analysis, our algorithm confirmed the previously mentioned conclusions during simulation and descriptive analysis and underlined the significance of this novel approach to triage. CONCLUSIONS The findings of this study suggest the feasibility and relevance of our model, which is unique in terms of its ranking system, prognosis outline, and time course anticipation. The proposed triage-ranking algorithm could offer an innovative triage method with a wide range of applications in prehospital, disaster, and emergency medicine, as well as simulation and research.
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Affiliation(s)
- Manuel Sigle
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
- University Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Leon Berliner
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Erich Richter
- University Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Mart van Iersel
- Interactive Simulation Emergency Exercise support limited company, Wemmel, Belgium
| | - Eleonora Gorgati
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Ives Hubloue
- Emergency Department, Universitair Ziekenhuis Brussel, Brussel, Belgium
- Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussel, Belgium
| | - Maximilian Bamberg
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Christian Grasshoff
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Peter Rosenberger
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Robert Wunderlich
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
- German Society for Disaster Medicine (Deutsche Gesellschaft für Katastrophenmedizin), Kirchseeon, Germany
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Helleman J, Bakers JNE, Pirard E, van den Berg LH, Visser-Meily JMA, Beelen A. Home-monitoring of vital capacity in people with a motor neuron disease. J Neurol 2022; 269:3713-3722. [PMID: 35129626 PMCID: PMC9217878 DOI: 10.1007/s00415-022-10996-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/22/2022] [Accepted: 01/23/2022] [Indexed: 12/12/2022]
Abstract
Background Home-monitoring of spirometry has the potential to improve care for patients with a motor neuron disease (MND) by enabling early detection of respiratory dysfunction and reducing travel burden. Our aim was to evaluate the validity and feasibility of home-monitoring vital capacity (VC) in patients with MND. Methods We included 33 patients with amyotrophic lateral sclerosis, progressive muscular atrophy or primary lateral sclerosis who completed a 12-week home-monitoring protocol, consisting of 4-weekly unsupervised home assessments of VC and a functional rating scale. At baseline, during a home visit, patients/caregivers were trained in performing a VC test, and the investigator performed a supervised VC test, which was repeated at final follow-up during a second home visit. Validity of the unsupervised VC tests was evaluated by the differences between supervised and unsupervised VC tests, and through Bland–Altman 95% limits-of-agreement. Feasibility was assessed by means of a survey of user-experiences. Results The 95% limits-of-agreement were [− 14.3; 11.7] %predicted VC, and 88% of unsupervised VC tests fell within 10%predicted of supervised VC. 88% of patients experienced VC testing as easy and not burdensome, however, 15% patients did not think their VC test was performed as well as in the clinic. 94% of patients would like home-monitoring of VC in MND care. Discussion Unsupervised VC testing at home, with prior face-to-face training, is a valid and time-efficient method for the remote monitoring of respiratory function, and well-accepted by patients with MND and their caregivers.
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Affiliation(s)
- Jochem Helleman
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Jaap N E Bakers
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Evelien Pirard
- Revant Center for Rehabilitation, Breda, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna M A Visser-Meily
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Anita Beelen
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.
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Sajjadi E, Seven YB, Ehrbar JG, Wymer JP, Mitchell GS, Smith BK. Acute intermittent hypoxia and respiratory muscle recruitment in people with amyotrophic lateral sclerosis: A preliminary study. Exp Neurol 2022; 347:113890. [PMID: 34624328 PMCID: PMC9488543 DOI: 10.1016/j.expneurol.2021.113890] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 01/03/2023]
Abstract
Respiratory failure is the main cause of death in amyotrophic lateral sclerosis (ALS). Since no effective treatments to preserve independent breathing are available, there is a critical need for new therapies to preserve or restore breathing ability. Since acute intermittent hypoxia (AIH) elicits spinal respiratory motor plasticity in rodent ALS models, and may restore breathing ability in people with ALS, we performed a proof-of-principle study to investigate this possibility in ALS patients. Quiet breathing, sniff nasal inspiratory pressure (SNIP) and maximal inspiratory pressure (MIP) were tested in 13 persons with ALS and 10 age-matched controls, before and 60 min post-AIH (15, 1 min episodes of 10% O2, 2 min normoxic intervals) or sham AIH (continuous normoxia). The root mean square (RMS) of the right and left diaphragm, 2nd parasternal, scalene and sternocleidomastoid muscles were monitored. A vector analysis was used to calculate summated vector magnitude (Mag) and similarity index (SI) of collective EMG activity during quiet breathing, SNIP and MIP maneuvers. AIH facilitated tidal volume and minute ventilation (treatment main effects: p < 0.05), and Mag (ie. collective respiratory muscle activity; p < 0.001) during quiet breathing in ALS and control subjects, but there was no effect on SI during quiet breathing. SNIP SI decreased in both groups post-AIH (p < 0.005), whereas Mag was unchanged (p = 0.09). No differences were observed in SNIP or MIP post AIH in either group. Discomfort was not reported during AIH by any subject, nor were adverse events observed. Thus, AIH may be a safe way to increase collective inspiratory muscle activity during quiet breathing in ALS patients, although a single AIH presentation was not sufficient to significantly increase peak inspiratory pressure generation. These preliminary results provide evidence that AIH may improve breathing function in people with ALS, and that future studies of prolonged, repetitive AIH protocols are warranted.
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Affiliation(s)
- Elaheh Sajjadi
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA, 32610,McKnight Brain Institute, University of Florida, Gainesville, FL, USA, 32610,Department of Physical Therapy, University of Florida, Gainesville, FL, USA, 32610
| | - Yasin B. Seven
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA, 32610,McKnight Brain Institute, University of Florida, Gainesville, FL, USA, 32610,Department of Physical Therapy, University of Florida, Gainesville, FL, USA, 32610
| | - Jessica G Ehrbar
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA, 32610
| | - James P. Wymer
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA, 32610,McKnight Brain Institute, University of Florida, Gainesville, FL, USA, 32610,Neurology, University of Florida, Gainesville, FL, USA, 32610
| | - Gordon S. Mitchell
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA, 32610,McKnight Brain Institute, University of Florida, Gainesville, FL, USA, 32610,Department of Physical Therapy, University of Florida, Gainesville, FL, USA, 32610
| | - Barbara K. Smith
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA, 32610,Department of Physical Therapy, University of Florida, Gainesville, FL, USA, 32610,Pediatrics, University of Florida, Gainesville, FL, USA, 32610
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Walsh LJ, Deasy KF, Gomez F, O'Sullivan E, Eustace J, Ryan AM, Murphy DM. Use of non-invasive ventilation in motor neuron disease - a retrospective cohort analysis. Chron Respir Dis 2021; 18:14799731211063886. [PMID: 34854787 PMCID: PMC8646818 DOI: 10.1177/14799731211063886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Motor neuron disease (MND) is a neurodegenerative disorder which leads to progressive muscle weakness including respiratory muscle decline. The introduction of non-invasive ventilation (NIV) has been shown to improve quality of life, survival and slow the rate of pulmonary function decline. A retrospective chart analysis of patients who attended the MND clinic from 2014 to 2019 at a tertiary-referral, academic, teaching hospital was carried out to evaluate if NIV and greater compliance with NIV was associated with improved survival. 111 patients were included. The mean age at diagnosis was 63.8 years and 61.3% were males. 66.7% of our cohort used NIV and of this 66.7%, 44.1% were compliant. There was a significantly longer survival in those who used NIV (p = 0.002) and in those who used NIV optimally (p = 0.02) when both groups were compared to those who did not use NIV. In the bulbar MND group those who were compliant with NIV survived longer than who those who did not use NIV (p = 0.001). We found a significantly longer survival with the use of NIV, the use of NIV optimally and with use of NIV in those with bulbar onset MND compared to those who did not use NIV.
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Affiliation(s)
- Laura J Walsh
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland
| | - Kevin F Deasy
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland
| | - Fernando Gomez
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland
| | | | - Joseph Eustace
- Health Research Board, Clinical Research Facility, 8795University College Cork, Cork, Ireland
| | - Aisling M Ryan
- Department of Neurology, 57983Cork University Hospital, Cork, Ireland
| | - Desmond M Murphy
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland.,Health Research Board, Clinical Research Facility, 8795University College Cork, Cork, Ireland
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Barry C, Larner E, Copsey H, Smith M, Peryer G. Non-invasive ventilation support for people with amyotrophic lateral sclerosis: multidisciplinary team management. Curr Opin Support Palliat Care 2021; 15:214-218. [PMID: 34561341 DOI: 10.1097/spc.0000000000000570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To summarise recent developments in the use of noninvasive ventilation (NIV) for people with amyotrophic lateral sclerosis (pwALS), with a specific focus on how multidisciplinary teams (MDT) can support best practice. RECENT FINDINGS We included 13 papers, 12 with observational designs and one qualitative interview design. The review is structured using four content domains: prognosis, the effectiveness of NIV, NIV tolerance, and MDT structure and delivery. Findings suggest a modest survival benefit of NIV for pwALS. Further evidence is needed to consider the appropriate time of initiation in the context of respiratory status and the influence of NIV on cognitive function over the course of the disease. A key emerging determinant of tolerability of NIV is secretion load. Palliative care professionals within the MDT can play a key role in supporting pwALS to consider the potential benefits of NIV in the context of their preferences, prognosis, symptom burden, and ALS variant. SUMMARY ALS MDTs allow timely information sharing about NIV between experts that is likely to improve outcomes. MDT practice must continually adapt to reflect pwALS's preferences for care and ensure those caring for them at home have access to support using digital innovations.
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Affiliation(s)
- Caroline Barry
- Norfolk and Norwich University Hospitals NHS Foundation Trust
| | - Emma Larner
- Norfolk and Norwich University Hospitals NHS Foundation Trust
| | - Helen Copsey
- Norfolk and Norwich University Hospitals NHS Foundation Trust
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Chao C, Berlowitz DJ, Howard ME, Rautela L, McDonald LA, Hannan LM. Measuring Adherence to Long-Term Noninvasive Ventilation. Respir Care 2021; 66:1469-1476. [PMID: 34257099 PMCID: PMC9993864 DOI: 10.4187/respcare.08745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obtaining benefits from long-term noninvasive ventilation (NIV) relies on achieving adequate adherence to treatment. Reported adherence to NIV is variable and could be influenced by high-volume users and attrition of nonusers and those who die. This observational study aimed to describe patterns of use and adherence rates in new unselected users of NIV. METHODS All adults (> 18 y old) commencing long-term NIV were consecutively enrolled and followed for 6 months. Ventilator data were manually downloaded from devices and usage (minutes per day) was collected. Subjects were categorized into adherent users (≥ 4 h/d) and nonadherent users (< 4 h/d). RESULTS Data were obtained from 86 subjects. Most (65%) had motor neuron disease, and most commenced NIV in an out-patient setting (72%). At one month after NIV implementation, overall average daily use was 302.1 min/d and categorical adherence was 57%. At 6 months or prior to death, overall average daily use increased (388.7 min/d), but categorical adherence was similar (62%). The majority of subjects (84%) remained in the same adherence category from their first month to their sixth month of use or death. Individuals with motor neuron disease demonstrated significantly lower rates of adherence compared to the rest of the cohort at 1 month (48% vs 73%, P = .03). In those who died within the study period (n = 19, all with motor neuron disease), this difference persisted to death (42% at death vs 73% at 6 months, P = .032). CONCLUSIONS Average daily usage may conceal true prevalence of adherence or nonadherence to NIV within a population. Reporting both average daily use data and categorical adherence rates (using a threshold of 4 h/d) may improve transparency of reported outcomes from clinical trials and identifies a therapeutic target for home mechanical ventilation services for quality improvement.
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Affiliation(s)
- Caroline Chao
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - David J Berlowitz
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Mark E Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Linda Rautela
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Luke A McDonald
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Liam M Hannan
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Northern Health, Epping, Victoria, Australia
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Walsh LJ, Murphy DM. The Benefit of Non-invasive Ventilation in Motor Neuron Disease. Open Respir Med J 2021; 14:53-61. [PMID: 33425067 PMCID: PMC7774097 DOI: 10.2174/1874306402014010053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 10/02/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Motor Neuron Disease (MND) is a progressive neurodegenerative disorder leading to respiratory muscle weakness with dyspnoea, morning headaches, orthopnoea, poor concentration, unrefreshing sleep, fatigue and daytime somnolence. Respiratory failure is the primary cause of death in those with MND. Methods: Although guidelines suggest the use of non-invasive ventilation (NIV) in MND, there lacks clear guidance as to when is the optimal time to initiate NIV and which markers of respiratory muscle decline are the best predictors of prognosis. There have been a number of studies that have found a significant survival advantage to the use of NIV in MND. Similarly, in quality-of-life questionnaires, those treated with NIV tend to perform better and maintain a better quality of life for longer. Furthermore, studies also suggest that improved compliance and greater tolerance of NIV confer a survival advantage. Results and Discussion: Forced Vital Capacity (FVC) has traditionally been the main pulmonary function test to determine the respiratory function in those with MND; however, FVC may not be entirely reflective of early respiratory muscle dysfunction. Evidence suggests that sniff nasal inspiratory pressure and maximum mouth inspiratory pressure may be better indicators of early respiratory muscle decline. These measures have been shown to be easier to perform later in the disease, in patients with bulbar onset disease, and may indeed be better prognostic indicators. Conclusion: Despite ongoing research, there remains a paucity of randomised controlled data in this area. This review aims to summarise the evidence to date on these topics.
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Affiliation(s)
- Laura J Walsh
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
| | - Desmond M Murphy
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The HRB- Clinical Research Facility, University College Cork, Cork, Ireland
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Kim J, Bireley JD, Hayat G, Kafaie J. Effects of noninvasive ventilation in amyotrophic lateral sclerosis: The complication of bulbar impairment. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2020. [DOI: 10.1177/2514183x20914183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis is a neurodegenerative illness that causes gradual loss of muscle function. Patients eventually develop bulbar impairment, requiring extensive respiratory support. Noninvasive ventilation (NIV) has gained attention as an easily accessible method with promising benefits. We conducted this systematic review to outline the therapeutic effects of NIV, add to previous publications discussing this topic by providing updates on newly completed and ongoing studies, and identify limitations that must be addressed in future trials. A search of PubMed and Cochran for relevant primary studies yielded 26 publications. Studies indicate NIV use is associated with improvements in quality of life, regardless of the severity of bulbar impairment. However, NIV’s benefits on survival were limited to patients with less bulbar impairment. In addition, our review found several limitations that undermine the efforts to establish a definitive treatment regimen. Future studies will need to address these problems in order to provide patients with better respiratory care.
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Affiliation(s)
- Junghyun Kim
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Ghazala Hayat
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
| | - Jafar Kafaie
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
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