"Tricks and tips for home mechanical ventilation" Home mechanical ventilation: set-up and monitoring protocols

Home mechanical ventilation: a narrative review and a proposal of practical approach

Growing evidence of the benefits of home ventilatory support in patients with chronic respiratory failure along with technological advances in ventilators have enabled their use in overly complex situations, shaping a new scenario for physicians. This has further given rise to new challenges related to their incorporation into current medical practice. However, this evolution needs to be coupled with knowledge and skills of physicians who are willing to prescribe Home Mechanical Ventilation (HMV), in order to prevent them from making inappropriate choices or adjustments that may ultimately have ethical and legal implications. This article aims to provide guidance and information to support the indication for HMV and the ventilation modalities to be implemented, review basic ventilation concepts, including the ventilator modes most commonly used in patients outside the hospital setting, list the brands and models available in the Brazilian market, provide the means for obtaining equipment for HMV, and finally, describe the requirements for selection of equipment, taking into account the individual characteristics of the patient to ensure safe perioperative care and earlier dehospitalization.

Interventions to improve adherence/compliance to home noninvasive positive pressure ventilation in stable hypercapnic chronic obstructive pulmonary disease patients: A systematic review protocol

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a prevalent condition often leading to chronic hypercapnic respiratory failure in its advanced stages. Home noninvasive positive pressure ventilation (Home-NIPPV) has emerged as a key therapeutic strategy for managing stable hypercapnic COPD patients, improving survival rates, and enhancing quality of life. Despite these benefits, patient adherence/compliance to Home-NIPPV remains a significant challenge, hindered by various barriers. The present paper is a protocol of a systematic review that aims to identify and evaluate interventions designed to improve adherence/compliance to Home-NIPPV in stable hypercapnic COPD patients.

METHODS

The protocol is developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines and was registered in PROSPERO (CRD42024581616). A comprehensive literature search across PubMed, Scopus and Cochrane Library will be conducted. Eligible studies will include randomized controlled trials that focus on interventions that aims to improve adherence/compliance to Home-NIPPV in stable hypercapnic COPD patients. Data extraction will be meticulously carried out by two independent reviewers. The Joanna Briggs Institute critical appraisal tool will be utilized to assess the quality and risk of bias of the included studies. The findings of this systematic review will be synthesized to provide a thorough understanding of effective strategies to enhance adherence/compliance to Home-NIPPV in stable hypercapnic COPD patients.

CONCLUSION

The results of this review could inform clinical practice and guide the development of targeted strategies to improve adherence/compliance to Home-NIPPV and consequently outcomes in stable hypercapnic COPD patients.

REGISTRATION

This protocol was registered in the International Prospective Register of Systematic Reviews under the reference code CRD42024581616.

Telemonitoring in Non-invasive Ventilation

Telemonitoring in non-invasive ventilation is constantly evolving to enable follow-up of adults and children. Depending on the device and manufacturer, different ventilator variables are displayed on web-based platforms. However, high-granularity measurement is not always available remotely, which precludes breath-by-breath waveforms and precise monitoring of nocturnal gas exchange. Therefore, telemonitoring is mainly useful for monitoring utilization of the device, leaks, and respiratory events. Coordinated relationships between patients, homecare providers, and hospital teams are necessary to transform available data into diagnosis and actions. Telemonitoring is time and cost-consuming. The balance between cost, workload, and clinical benefit should be further evaluated.

Impact of outpatient adaptation to home mechanical ventilation on health-related quality of life in patients with COPD: the OutVent study

Background

Home mechanical ventilation (HMV) is indicated in patients with severe hypercapnic COPD. Initiation of HMV commonly occurs during an inpatient period, but there has been increasing interest for outpatient adaptation. This study aimed to evaluate the outpatient initiation and adaptation of HMV and its impact on health-related quality of life (HRQoL) in patients with severe COPD.

Methods

A single-group pre-test-post-test study was conducted in an outpatient ventilation clinic of a tertiary hospital in Portugal. Patients with severe COPD and symptoms of chronic respiratory failure with daytime partial pressure of carbon dioxide (P CO2 ) ≥50 mmHg in a stable condition or with persistent hypercapnia ≥53 mmHg >14 days following an exacerbation with mechanical ventilation were included. After 3 months of HMV, patients completed the severe respiratory insufficiency (SRI), the S3-noninvasive ventilation (S3-NIV) and a patient experience questionnaire.

Results

53 patients (73.6% male, median 71 (p25-p75 61-77) years), with a median forced expiratory volume in 1 s of 35 (29-40)% and a median baseline P CO2 of 53.5 (51.9-56.5) mmHg completed the study. At 3 months patients had a median HMV usage of 6.5 h and decreased their P CO2 by 6.0 mmHg. After 3 months, there was a significant improvement in the SRI summary scale (+5.7), above the minimal clinically import difference of five. Patients who used HMV for more than 5 h had higher S3-NIV total score (6.8 versus 5.7, p=0.04) and S3-NIV sleep and NIV-related side effects subscore (7.1 versus 5.7, p=0.03).

Conclusion

Our findings might indicate that outpatient initiation and adaptation of HMV has a positive impact in short-term HRQoL in patients with COPD and that this approach is perceived as a positive experience by the patients.

Home NIV treatment quality in patients with chronic respiratory failure having participated to the French nationwide telemonitoring experimental program (The TELVENT study)

BACKGROUND

The ETAPES program is a national telemedicine experiment conducted in France between 2018 and 2023 to investigate whether home non-invasive ventilation (NIV) telemonitoring improves healthcare pathways in patients with chronic respiratory failure (CRF) and impacts healthcare organization. The program provides a combination of therapeutic education and NIV telemonitoring with data processed by an algorithm generating alerts. The TELVENT study objective was to analyze the evolution of ventilation quality in patients included in the ETAPES program.

METHODS

Multicentric cohort study on patients undergoing long-term NIV included in the ETAPES program between September 2018 and December 2020 and who did not refuse the use of their data for this research. Data were obtained from homecare provider databases. The primary endpoint was to attain successful NIV treatment, which was determined by a combination of daily NIV usage for > 4 h per day, low leaks, and a low apnea-hypopnea index (AHI) identified by the NIV device. Respiratory disability was assessed using the DIRECT questionnaire.

RESULTS

329 patients were included in the study of which 145 had COPD and 83 had started NIV and ETAPES within one-month delay. Approximately 25% of patients did not achieve the criteria for successful NIV at ETAPES entry. The proportion of patients with successful NIV treatment increased to 86.8% at six months (p = 0.003, Cochran-Armitage trend test) regardless of NIV history and continued to increase at 12 months in newly equipped NIV patients (93.8%, at month 12, p = 0.0026 for trend test). Over time, a significant increase in NIV use and compliance was observed, while AHI significantly decreased in the overall population. No significant decrease was observed for non-intentional leaks. Approximately 4.9 alerts were generated per patient per 6 months. Their number and type (low NIV use, high AHI or leaks) differed among patients based on their NIV history. Respiratory disability score decreased over time compared with baseline.

CONCLUSION

The TELVENT study highlights the importance of remote NIV monitoring to rapidly identify patients with unsuccessful ventilation. The combination of remote monitoring and therapeutic education may improve the quality of home NIV, especially in the first months of treatment.

Supplemental oxygen and noninvasive ventilation

The respiratory system attempts to maintain normal levels of oxygen and carbon dioxide. However, airflow limitation, parenchymal abnormalities and dysfunction of the respiratory pump may be compromised in individuals with advanced COPD, eventually leading to respiratory failure, with reduced arterial oxygen tension (hypoxaemia) and/or increased arterial carbon dioxide tension (P aCO2 ; hypercapnia). Hypoxaemia may persist in individuals with severe COPD despite smoking cessation and optimisation of pharmacotherapy. Long-term oxygen therapy (LTOT) can improve survival in those with severe daytime hypoxaemia, whereas those with less severe hypoxaemia may only have improved exercise capacity and dyspnoea. Changes in respiratory physiology that occur during sleep further predispose to hypoxaemia, particularly in individuals with COPD. However, the major cause of hypoxaemia is hypoventilation. Noninvasive ventilation (NIV) may reduce mortality and need for intubation in individuals with COPD and acute hypercapnic respiratory failure. However, NIV may also improve survival and quality of life in individuals with stable, chronic hypercapnia and is now suggested for those with prolonged hypercapnia (e.g. P aCO2 >55 mmHg 2-6 weeks after hospital discharge) when clinically stable and after optimisation of medical therapy including LTOT if indicated. Many questions remain about the optimal mode, settings and goal of NIV therapy.

Using Telemedicine to Monitor the Patient with Chronic Respiratory Failure

Background: Advances in management have improved mortality of individuals with chronic respiratory failure (CRF), leading to an increase in need for long-term oxygen therapy and/or ventilatory support. These individuals require frequent visits and monitoring of their physiological parameters as well as of the functioning of their devices, such as ventilators or oxygen concentrators. Telemedicine is a clinical application of Information Communication Technology connecting patients to specialised care consultants. This narrative review aims to explore the current available telemonitoring options for individuals with CRF and reported or potential results. Methods: The research focused on EMBASE, CINALH, PubMed, and Scopus databases. Papers published between 2003 and 2021 in English were considered. Results: Different sensors, transmission devices and systems, and interventions are used with promising but not conclusive clinical results. However, legal problems are still unsolved, and economic advantages for health care systems, although potentially high, are still under debate. Conclusions: Telemonitoring systems for individuals with CRF are increasingly used; with promising results still to be clarified, legal, economical and organisational issues must be defined.