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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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Khamankar N, Coan G, Weaver B, Mitchell CS. Associative Increases in Amyotrophic Lateral Sclerosis Survival Duration With Non-invasive Ventilation Initiation and Usage Protocols. Front Neurol 2018; 9:578. [PMID: 30050497 PMCID: PMC6052254 DOI: 10.3389/fneur.2018.00578] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/26/2018] [Indexed: 12/11/2022] Open
Abstract
Objective: It is hypothesized earlier non-invasive (NIV) ventilation benefits Amyotrophic Lateral Sclerosis (ALS) patients. NIV typically consists of the removable bi-level positive airway pressure (Bi-PAP) for adjunctive respiratory support and/or the cough assist intervention for secretion clearance. Historical international standards and current USA insurance standards often delay NIV until percent predicted forced vital capacity (FVC %predict) is <50. We identify the optimal point for Bi-PAP initiation and the synergistic benefit of daily Bi-PAP and cough assist on associative increases in survival duration. Methods: Study population consisted of a retrospective ALS cohort (Emory University, Atlanta, GA, USA). Primary analysis included 474 patients (403 Bi-PAP users, 71 non-users). Survival duration (time elapsed from baseline onset until death) is compared on the basis of Bi-PAP initiation threshold (FVC %predict); daily Bi-PAP usage protocol (hours/day); daily cough assist usage (users or non-users); ALS onset type; ALSFRS-R score; and time elapsed from baseline onset until Bi-PAP initiation, using Kruskal-Wallis one-way analysis of variance and Kaplan Meier. Results: Bi-PAP users' median survival (21.03 months, IQR = 23.97, N = 403) is significantly longer (p < 0.001) than non-users (13.84 months, IQR = 11.97, N = 71). Survival consistently increases (p < 0.01) with FVC %predict Bi-PAP initiation threshold: <50% (20.3 months); ≥50% (23.60 months); ≥80% (25.36 months). Bi-PAP usage >8 hours/day (23.20 months) or any daily Bi-PAP usage with cough assist (25.73 months) significantly (p < 0.001) extends survival compared to Bi-PAP alone (15.0 months). Cough assist without Bi-PAP has insignificant impact (14.17 months) over no intervention (13.68 months). Except for bulbar onset Bi-PAP users, higher ALSFRS-R total scores at Bi-PAP initiation significantly correlate with higher initiation FVC %predict and longer survival duration. Time elapsed since ALS onset is not a good predictor of when NIV should be initiated. Conclusions: The “optimized” NIV protocol (Bi-PAP initiation while FVC %predict ≥80, Bi-PAP usage >8 h/day, daily cough assist usage) has a 30. 8 month survival median, which is double that of a “standard” NIV protocol (initiation FVC %predict <50, usage >4 h/day, no cough assist). Earlier access to Bi-PAP and cough assist, prior to precipitous respiratory decline, is needed to maximize NIV synergy and associative survival benefit.
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Affiliation(s)
- Nishad Khamankar
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
| | - Grant Coan
- School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Barry Weaver
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
| | - Cassie S Mitchell
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
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Bourke SC, Steer J. Practical respiratory management in amyotrophic lateral sclerosis: evidence, controversies and recent advances. Neurodegener Dis Manag 2016; 6:147-60. [PMID: 27033240 DOI: 10.2217/nmt-2015-0010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
In amyotrophic lateral sclerosis, the onset of respiratory muscle weakness is silent, but survival following symptom recognition may only be a few weeks. Consequently, respiratory function and symptoms should be assessed every 2-3 months. Noninvasive ventilation improves symptoms, quality of life and survival, without increasing carer burden. Lung volume recruitment helps to reverse and prevent atelectasis, improving gas exchange, while techniques to enhance sputum clearance reduce the risk of mucus plugging and lower respiratory tract infections. When noninvasive support fails, often due to severe bulbar impairment, tracheostomy ventilation prolongs life. Most patients receiving tracheostomy ventilation at home report satisfactory quality of life, but at the expense of high carer burden. Diaphragmatic pacing is associated with an increased risk of death.
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Affiliation(s)
- Stephen C Bourke
- Department of Respiratory Medicine, North Tyneside General Hospital, North Shields, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - John Steer
- Department of Respiratory Medicine, North Tyneside General Hospital, North Shields, UK
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