Cost effectiveness of ward based non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease: economic analysis of randomised controlled trial

COPD: Providing the right treatment for the right patient at the right time

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Developing and Implementing Noninvasive Ventilator Training in Haiti during the COVID-19 Pandemic

Background

Noninvasive ventilation (NIV) is an important component of respiratory therapy for a range of cardiopulmonary conditions. The World Health Organization recommends NIV use to decrease the use of intensive care unit resources and improve outcomes among patients with respiratory failure during periods of high patient capacity from coronavirus disease (COVID-19). However, healthcare providers in many low- and middle-income countries, including Haiti, do not have experience with NIV. We conducted NIV training and evaluation in Port-au-Prince, Haiti.

Objectives

To design and implement a multimodal NIV training program in Haiti that would improve confidence and knowledge of NIV use for respiratory failure.

Methods

In January 2021, we conducted a 3-day multimodal NIV training consisting of didactic sessions, team-based learning, and multistation simulation for 36 Haitian healthcare workers. The course included 5 didactic session and 10 problem-based and simulation sessions. All course material was independently created by the study team on the basis of Accreditation Council for Continuing Medical Education-approved content and review of available evidence. All participants completed pre- and post-training knowledge-based examinations and confidence surveys, which used a 5-point Likert scale.

Results

A total of 36 participants were included in the training and analysis, mean age was 39.94 years (standard deviation [SD] = 9.45), and participants had an average of 14.32 years (SD = 1.21) of clinical experience. Most trainees (75%, n = 27) were physicians. Other specialties included nursing (19%, n = 7), nurse anesthesia (3%, n = 1), and respiratory therapy (3%, n = 1). Fifty percent (n = 18) of participants stated they had previous experience with NIV. The majority of trainees (77%) had an increase in confidence survey score; the mean confidence survey score increased significantly after training from 2.75 (SD = 0.77) to 3.70 (SD = 0.85) (P < 0.05). The mean knowledge examination score increased by 39.63% (SD = 15.99%) after training, which was also significant (P < 0.001).

Conclusion

This multimodal NIV training, which included didactic, simulation, and team-based learning, was feasible and resulted in significant increases in trainee confidence and knowledge with NIV. This curriculum has the potential to provide NIV training to numerous low- and middle-income countries as they manage the ongoing COVID-19 pandemic and rising burden of noncommunicable disease. Further research is necessary to ensure the sustainability of these improvements and adaptability to other low- and middle-income settings.

Dexmedetomidine in critically ill adults requiring noninvasive ventilation

Noninvasive ventilation (NIV) is an effective therapy for hypercapnic and hypoxemic respiratory failure and can reduce the need for intubation and mechanical ventilation.¹ It may also reduce intensive care unit (ICU) length of stay, pneumonia, and mortality.^2-6 However, NIV can be uncomfortable for patients due to the mask interface and respiratory pressures delivered, and over one-third of patients placed on NIV will experience agitation.^7,8 Intolerance to NIV typically requires intubation. A variety of interventions can be utilized to improve compliance with NIV, including medications such as dexmedetomidine, an α-2 agonist with sedative and analgesic effects.⁹ Current guidelines recommend the use of a non-benzodiazepine sedative such as propofol or dexmedetomidine in critically ill, mechanically ventilated adults, as these medications may improve delirium, ICU length of stay, and duration of mechanical ventilation.¹⁰.

Predictors of Successful Weaning from Noninvasive Ventilation in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Single-Center Retrospective Cohort Study

Purpose

Noninvasive ventilation (NIV) is often required for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and it can significantly reduce the need for endotracheal intubation. Currently, there is no standard method for predicting successful weaning from NIV. Therefore, we aimed to evaluate whether a weaning index can predict NIV outcomes of patients with AECOPD.

Methods

This study was conducted at a single academic public hospital in northern Taiwan from February 2019 to January 2021. Patients with AECOPD admitted to the hospital with respiratory failure who were treated with NIV were included in the study. Univariate and multivariate logistic regression analyses were used to identify independent predictors of successful weaning from NIV. Receiver operating characteristic curve methodology was used to assess the predictive capacity.

Results

A total of 85 patients were enrolled, 65.9% of whom were successfully weaned from NIV. The patients had a mean age of 75.8 years and were mostly men (89.4%). The rapid shallow breathing index (RSBI) (P < 0.001), maximum inspiratory pressure (P = 0.014), and maximum expiratory pressure (P = 0.004) of the successful group were significant while preparing to wean. The area under the receiver operating characteristic curve for the RSBI was 0.804, which was considered excellent discrimination.

Conclusion

The RSBI predicted successful weaning from NIV in patients with AECOPD with hypercapnic respiratory failure. This index may be useful for selecting patients with AECOPD that are suitable for NIV weaning.

Safety and Efficacy of Dexmedetomidine in Acutely Ill Adults Requiring Noninvasive Ventilation: A Systematic Review and Meta-analysis of Randomized Trials

BACKGROUND

Although clinical studies have evaluated dexmedetomidine as a strategy to improve noninvasive ventilation (NIV) comfort and tolerance in patients with acute respiratory failure (ARF), their results have not been summarized.

RESEARCH QUESTION

Does dexmedetomidine, when compared with another sedative or placebo, reduce the risk of delirium, mortality, need for intubation and mechanical ventilation, or ICU length of stay (LOS) in adults with ARF initiated on NIV in the ICU?

STUDY DESIGN AND METHODS

We electronically searched MEDLINE, EMBASE, and the Cochrane Library from inception through July 31, 2020, for randomized clinical trials (RCTs). We calculated pooled relative risks (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with the corresponding 95% CIs using a random-effect model.

RESULTS

Twelve RCTs were included in our final analysis (n = 738 patients). The use of dexmedetomidine, compared with other sedation strategies or placebo, reduced the risk of intubation (RR, 0.54; 95% CI, 0.41-0.71; moderate certainty), delirium (RR, 0.34; 95% CI, 0.22-0.54; moderate certainty), and ICU LOS (MD, -2.40 days; 95% CI, -3.51 to -1.29 days; low certainty). Use of dexmedetomidine was associated with an increased risk of bradycardia (RR, 2.80; 95% CI, 1.92-4.07; moderate certainty) and hypotension (RR, 1.98; 95% CI, 1.32-2.98; moderate certainty).

INTERPRETATION

Compared with any sedation strategy or placebo, dexmedetomidine reduced the risk of delirium and the need for mechanical ventilation while increasing the risk of bradycardia and hypotension. The results are limited by imprecision, and further large RCTs are needed.

TRIAL REGISTRY

PROSPERO; No.: 175086; URL: www.crd.york.ac.uk/prospero/.

Non-Invasive Ventilation in a Non-Standard Setting – Is it Safe to Ventilate Outside the ICU?

Non-invasive ventilation (NIV) is considered a fundamental method in treating patients with various disorders, requiring respiratory support. Often the lack of beds in the intensive care unit (ICU) and the concomitant medical conditions, which refer patients as unsuitable for aggressive treatment in the ICU, highlight the need of NIV application in general non-monitored wards and unusual settings – most commonly emergency departments, high-dependency units, pulmonary wards, and even ambulances. Recent studies suggest faster improvement of all physiological variables, reduced intubation rates, postoperative pulmonary complications and hospital mortality with better outcome and quality of life by early well-monitored ward-based NIV compared to standard medical therapy in patients with exacerbation of a chronic obstructive pulmonary disease, after a surgical procedure or acute hypoxemic respiratory failure in hematologic malignancies. NIV is a ceiling of treatment and a comfort measure in many patients with do-not-intubate orders due to terminal illnesses. NIV is beneficial only by proper administration with appropriate monitoring and screening for early NIV failure. Successful NIV application in a ward requires a well-equipped area and adequately trained multidisciplinary team. It could be initiated not only by attending physicians, respiratory technicians, and nurses but also by medical emergency teams. Ward-based NIV is supposed to be more cost-effective than NIV in the ICU, but further investigation is required to establish the safety and efficacy in hospital wards with a low nurse to patient ratio.

Impact of end-expiratory pressure fluctuation on tidal volume in the trilevel positive airway pressure mode

INTRODUCTION

In noninvasive positive-pressure ventilation (NPPV), the changes in the expiratory positive airway pressure (EPAP) directly affect the magnitude of the tidal volume.

OBJECTIVES

This experimental study aims to verify the precise effects of end-expiratory fluctuation on the body tidal volume to better assist NPPV in clinical practice.

METHODS

We selected the TestChest-simulated lung simulation of different populations, including healthy subjects (normal group), patients with chronic obstructive pulmonary disease (COPD) with emphysema as their primary phenotype (COPD1 group), and patients with COPD with bronchitis as their primary phenotype (COPD2 group).

RESULTS

Regarding the tidal volume curves of the three groups under various conditions, sixfold charts revealed that the tidal volume changed with the end-expiratory pressure fluctuations. In addition, regression coefficients for end-expiratory pressure fluctuations, (IPAP-EPAP) and (IPAP-EEPAP) exhibited a significant contribution to the tidal volume. The two coefficients in the normal, COPD1 and COPD2 groups were 52.294 and 10.414, 46.192 and -8.816, and 11.922 and 17.947, respectively. The circuit simulation results showed that the simulation curve fitted the experimental curve better by changing the coefficient of the descending edge of the expiratory phase.

CONCLUSIONS

The study results suggest that the end-expiratory pressure fluctuation affects the body tidal volume. Compared with the bilevel positive airway pressure (PAP), the trilevel PAP provides additional respiratory support to the body during a respiratory difference in initial respiration and descent.

Noninvasive Ventilation and High-Flow Nasal Therapy Administration in Chronic Obstructive Pulmonary Disease Exacerbations

Noninvasive ventilation (NIV) is considered to be the standard of care for the management of acute hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease exacerbation. It can be delivered safely in any dedicated setting, from emergency rooms to high dependency or intensive care units and wards. NIV helps improving dyspnea and gas exchange, reduces the need for endotracheal intubation, and morbidity and mortality rates. It is therefore recognized as the gold standard in this condition. High-flow nasal therapy helps improving ventilatory efficiency and reducing the work of breathing in patients with severe chronic obstructive pulmonary disease. Early studies indicate that some patients with acute hypercapnic respiratory failure can be managed with high-flow nasal therapy, but more information is needed before specific recommendations for this therapy can be made. Therefore, high-flow nasal therapy use should be individualized in each particular situation and institution, taking into account resources, and local and personal experience with all respiratory support therapies.

Challenges to and opportunities for the implementation of non-invasive positive pressure ventilation in the Asia-Pacific region

Non-invasive positive pressure ventilation (NPPV) is undoubtedly one of the most significant advancements in mechanical ventilation technology in the past 30 years. With accumulating evidence from clinical studies and support from clinical guidelines, NPPV is now widely used in hospitals and increasingly prescribed for home therapy in the Asia-Pacific region. However, in comparison with the developed Western countries, overall use of NPPV in the region is lagging behind. This study reviews this imbalance of NPPV use both in the acute and domiciliary settings in the Asia-Pacific region. Important issues related to NPPV use are also discussed along with speculation around potential strategies that could promote wider implementation of NPPV in the region. We hope this review will stimulate interest in the clinical application and potential research avenues for NPPV in the Asia-Pacific region, and promote education and staff training in the technique.

Cost-Minimization Analysis of Non-Invasive and Invasive Mechanical Ventilation for De Novo Acute Hypoxemic Respiratory Failure in an Eastern European Setting

Introduction: In the light of constant pressure for minimizing healthcare costs we made a cost-minimization analysis comparing invasive mechanical ventilation (IMV) and non-invasive ventilation (NIV) as treatment for hypoxemic acute respiratory failure (ARF).

Aim: The primary objective was to estimate the direct medical costs generated by a patient on IMV and NIV. A secondary objective was to identify which aspect of the treatment was most expensive.

Material and Methods: This is a single center retrospective study including 36 patients on mechanical ventilation due to hypoxemic ARF, separated in two groups – NIV (n = 18) and IMV (n = 18). We calculated all direct medical costs in Euro and compared them statistically.

Results: On admission the PaO2/FiO2 and SAPS II score were comparable in both groups. We observed a significant difference in the costs per patient for drug treatment (NIV: 616.07; IQR: 236.68, IMV:1456.18; IQR:1741.95, p = 0.005), consumables (NIV: 16.47; IQR: 21.44, IMV: 98.79; IQR: 81.52, p < 0.001) and diagnostic tests (NIV: 351; IQR: 183.88, IMV: 765.69; IQR: 851.43, p < 0.001). We also computed the costs per patient per day and there was a significant difference in the costs in all above listed categories. In both groups the highest costs were for drug treatment – around 61%.

Conclusions: In the setting of hypoxemic ARF NIV reduces significantly the direct medical costs of treatment in comparison to IMV. The decreased costs in NIV are not associated with severity of disease according to the respiratory quotient and SAPS II score.

Non-invAsive VentIlation for early General wArd respiraTory failurE (NAVIGATE): A multicenter randomized controlled study. Protocol and statistical analysis plan

OBJECTIVE

Few randomized trials have evaluated the use of non-invasive ventilation (NIV) for early acute respiratory failure (ARF) in non-intensive care unit (ICU) wards. The aim of this study is to test the hypothesis that early NIV for mild-moderate ARF in non-ICU wards can prevent development of severe ARF.

DESIGN

Pragmatic, parallel group, randomized, controlled, multicenter trial.

SETTING

Non-intensive care wards of tertiary centers.

PATIENTS

Non-ICU ward patients with mild to moderate ARF without an established indication for NIV.

INTERVENTIONS

Patients will be randomized to receive or not receive NIV in addition to best available care.

MEASUREMENTS AND MAIN RESULTS

We will enroll 520 patients, 260 in each group. The primary endpoint of the study will be the development of severe ARF. Secondary endpoints will be 28-day mortality, length of hospital stay, safety of NIV in non-ICU environments, and a composite endpoint of all in-hospital respiratory complications.

CONCLUSIONS

This trial will help determine whether the early use of NIV in non-ICU wards can prevent progression from mild-moderate ARF to severe ARF.

Ward-Based Non-Invasive Ventilation in Acute Exacerbations of COPD: A Narrative Review of Current Practice and Outcomes in the UK

Non-invasive ventilation (NIV) is frequently used as a treatment for acute hypercapnic respiratory failure (AHRF) in hospitalised patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In the UK, many patients with AHRF secondary to AECOPD are treated with ward-based NIV, rather than being treated in critical care. NIV has been increasingly used as an alternative to invasive ventilation and as a ceiling of treatment in patients with a ‘do not intubate’ order. This narrative review describes the evidence base for ward-based NIV in the context of AECOPD and summarises current practice and clinical outcomes in the UK.

Management of severe acute exacerbations of COPD: an updated narrative review

Background

Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital.

Main body

In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD.

Conclusion

Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.

COPD is independently associated with 6-month survival in patients who have life support withheld in intensive care

BACKGROUND

In-hospital outcomes following decisions of withholding or withdrawing in Intensive Care Unit (ICU) patients have been previously assessed, little is known about outcomes after ICU and hospital discharge. Our objective was to report the 6-month outcomes of discharged patients who had treatment limitations in a general ICU and to identify prognostic factors of survival.

METHODS

We retrospectively collected the data of patients discharged from the ICU for whom life support was withheld from 2009 to 2011. We assessed the survival status of all patients at 6 months post-discharge and their duration of survival. Survivors and non-survivors were compared using univariate and multivariate analyses by Cox's proportional hazard model.

RESULTS

One hundred fourteen patients were included. The survival rate at 6 months was 58.8%. Survival was associated with acute respiratory failure (48% vs 19%, P = .006), a history of COPD (40% vs 21%, P = .03) and a lower SAPS II score (44 vs 49, P = .006). We identified a history of COPD as a prognostic factor for survival in the multivariate analysis (HR = 2.1; IC 95% 1.02-4.36, P = .04).

CONCLUSION

A total of 58.8% of patients for whom life-sustaining therapies were withheld in the ICU survived for at least 6 months after discharge. Patients with COPD appeared to have a significantly higher survival rate. The decision to withhold life support in patients should not lead to a cessation of post-ICU care and to non-readmission of COPD patients.

Cost-utility of non-invasive mechanical ventilation: Analysis and implications in acute respiratory failure. A brief narrative review

The growing interest in the quality of patient care at the levels of the health care managers, insurance companies, and health professionals is evident. Further, the growing population requires good quality health services. In this review, we analyzed the cost-effectiveness of noninvasive ventilation (NIV) in an acute setting for the treatment of respiratory failure. The strength of this review is that it identified and summarized the most relevant studies regarding various aspects of the cost-utility of NIV in an acute setting. This is the first review that focuses on the importance of the skills and training of the team in the reduction of costs associated with NIV. However, the small number of studies, heterogeneity of quality, and different outcomes of the different studies are the greatest limitations of this review. In conclusion, although there is great variation in the data drawn from the literature, NIV seems to be a cost-effective tool, especially in specific patients (those with chronic obstructive pulmonary disease) for whom the addition of NIV improves outcomes and has a positive impact on this expenditure.

Non-invasive ventilation in children and adults in low- and low-middle income countries: A systematic review and meta-analysis

PURPOSE

We systematically reviewed the effects of NIV for acute respiratory failure (ARF) in low- and low-middle income countries.

MATERIALS AND METHODS

We searched MEDLINE, CENTRAL, and EMBASE (to January 2016) for observational studies and trials of NIV for ARF or in the peri-extubation period in adults and post-neonatal children. We abstracted outcomes data and assessed quality. Meta-analyses used random-effect models.

RESULTS

Fifty-four studies (ten pediatric/n=1099; 44 adult/n=2904), mostly South Asian, were included. Common diagnoses were pneumonia and chronic obstructive pulmonary disease (COPD). Considering observational studies and the NIV arm of trials, NIV was associated with moderate risks of mortality (pooled risk 9.5%, 95% confidence interval (CI) 4.6-14.5% in children; 16.2% [11.2-21.2%] in adults); NIV failure (10.5% [4.6-16.5%] in children; 28.5% [22.4-34.6%] in adults); and intubation (5.3% [0.8-9.7%] in children; 28.8% [21.9-35.8%] in adults). The risk of mortality was greater (p=0.035) in adults with hypoxemic (25.7% [15.2-36.1%]) vs. hypercapneic (12.8% [7.0-18.6%]) ARF. NIV reduced mortality in COPD (relative risk [RR] 0.47 [0.27-0.79]) and in patients weaning from ventilation (RR 0.48 [0.28-0.80]). The pooled pneumothorax risk was 2.4% (0.8-3.9%) in children and 5.2% (1.0-9.4%) in adults. Meta-analyses had high heterogeneity.

CONCLUSIONS

NIV for ARF in these settings appears to be effective.

Models of care for non-invasive ventilation in the Acute COPD Comparison of three Tertiary hospitals (ACT3) study

BACKGROUND AND OBJECTIVE

Non-invasive ventilation (NIV) improves clinical outcomes in hypercapnic acute exacerbations of COPD (AECOPD), but the optimal model of care remains unknown.

METHODS

We conducted a prospective observational non-inferiority study comparing three models of NIV care: general ward (Ward) (1:4 nurse to patient ratio, thrice weekly consultant ward round), a high dependency unit (HDU) (1:2 ratio, twice daily ward round) and an intensive care unit (ICU) (1:1 ratio, twice daily ward round) model in three similar teaching tertiary hospitals. Changes in arterial blood gases (ABG) and clinical outcomes were compared and corrected for differences in AECOPD severity (Blood urea > 9 mmol/L, Altered mental status (Glasgow coma scale (GCS) < 14), Pulse > 109 bpm, age > 65 (BAP-65)) and co-morbidities. An economic analysis was also undertaken.

RESULTS

There was no significant difference in age (70 ± 10 years), forced expiratory volume in 1 s (FEV₁ ) (0.84 ± 0.35 L), initial pH (7.29 ± 0.08), partial pressure of CO₂ in arterial blood (PaCO₂ ) (72 ± 22 mm Hg) or BAP-65 scores (2.9 ± 1.01) across the three models. The Ward achieved an increase in pH (0.12 ± 0.07) and a decrease in PaCO₂ (12 ± 18 mm Hg) that was equivalent to HDU and ICU. However, the Ward treated more patients (38 vs 28 vs 15, P < 0.001), for a longer duration in the first 24 h (12.3 ± 4.8 vs 7.9 ± 4.1 vs 8.4 ± 5.3 h, P < 0.05) and was more cost-effective per treatment day ($AUD 1231 ± 382 vs 1745 ± 2673 vs 2386 ± 1120, P < 0.05) than HDU and ICU. ICU had a longer hospital stay (9 ± 11 vs 7 ± 7 vs 13 ± 28 days, P < 0.002) compared with the Ward and HDU. There was no significant difference in intubation rate or survival.

CONCLUSION

In acute hypercapnic Chronic obstructive pulmonary disease (COPD) patients, the Ward model of NIV care achieved equivalent clinical outcomes, whilst being more cost-effective than HDU or ICU models.

NIV by an interdisciplinary respiratory care team in severe respiratory failure in the emergency department limited to day time hours

Non-invasive ventilatory support is frequently used in patients with severe respiratory failure (SRF), but is often limited to intensive care units (ICU). We hypothesized that an instantaneous short course of NIV (up to 2 h), limited to regular working hours as an additional therapy on the emergency department (ED) would be feasible and could improve patient´s dyspnoea measured by respiratory rate and Borg visual dyspnea scale. NIV was set up by an interdisciplinary respiratory care team. Outside these predefined hours NIV was performed in the ICU. This is an observational cohort study over 1 year in the ED in a non-university hospital. Fifty-one % of medical emergencies arrived during regular working hours (5475 of 10,718 patients). In total, 63 patients were treated with instantaneous NIV. Door to NIV in the ED was 56 (31-97) min, door to ICU outside regular working hours was 84 (57-166) min. Within 1 h of NIV, the respiratory rate decreased from 30/min (25-35) to 19/min (14-24, p < 0.001), the Borg dyspnoea scale improved from 7 (5-8) to 2 (0-3, p < 0.001). In hypercapnic patients, the blood-pH increased from 7.29 (7.24-7.33) to 7.35 (7.29-7.40) and the pCO₂ dropped from 8.82 (8.13-10.15) to 7.45 (6.60-8.75) kPa. In patients with SRF of varying origin, instantaneous NIV in the ED during regular working hours was feasible in a non-university hospital setting, and rapidly and significantly alleviated dyspnoea and reduced respiratory rate. This approach proved to be useful as a bridge to the ICU as well as an efficient palliative dyspnoea treatment.

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.

IL-8 predicts early mortality in patients with acute hypercapnic respiratory failure treated with noninvasive positive pressure ventilation

Background

Patients with Acute Hypercapnic Respiratory Failure (AHRF) who are unresponsive to appropriate medical treatment, are often treated with Noninvasive Positive Pressure Ventilation (NPPV). Clinical predictors of the outcome of this treatment are scarce. Therefore, we evaluated the role of the biomarkers IL-8 and GDF-15 in predicting 28-day mortality in patients with AHRF who receive treatment with NPPV.

Methods

The study population were 46 patients treated with NPPV for AHRF. Clinical and background data was registered and blood samples taken for analysis of inflammatory biomarkers. IL-8 and GDF-15 were selected for analysis, and related to risk of 28-day mortality (primary endpoint) using Cox proportional hazard models adjusted for gender, age and various clinical parameters.

Results

Of the 46 patients, there were 3 subgroup in regards to primary diagnosis: Acute Exacerbation of COPD (AECOPD, n = 34), Acute Heart Failure (AHF, n = 8) and Acute Exacerbation in Obesity Hypoventilation Syndrome (AEOHS, n = 4). There was significant difference in the basic characteristic of the subgroups, but not in the clinical parameters that were used in treatment decisions. 13 patients died within 28 days of admission (28%). The Hazard Ratio for 28-days mortality per 1-SD increment of IL-8 was 3.88 (95% CI 1.86–8.06, p < 0.001). When IL-8 values were divided into tertiles, the highest tertile had a significant association with 28 days mortality, HR 10.02 (95% CI 1.24–80.77, p for trend 0.03), compared with the lowest tertile. This correlation was maintained when the largest subgroup with AECOPD was analyzed. GDF-15 was correlated in the same way, but when put into the same model as IL-8, the significance disappeared.

Conclusion

IL-8 is a target to explore further as a predictor of 28 days mortality, in patients with AHRF treated with NPPV.

The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic progressive lung disease characterised by non-reversible airflow obstruction. Exacerbations are a key cause of morbidity and mortality and place a considerable burden on health-care systems. While there is evidence that patients benefit from non-invasive ventilation (NIV) in hospital during an acute exacerbation, evidence supporting home use for more stable COPD patients is limited. In the U.K., domiciliary NIV is considered on health economic grounds in patients after three hospital admissions for acute hypercapnic respiratory failure.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of domiciliary NIV by systematic review and economic evaluation.

DATA SOURCES

Bibliographic databases, conference proceedings and ongoing trial registries up to September 2014.

METHODS

Standard systematic review methods were used for identifying relevant clinical effectiveness and cost-effectiveness studies assessing NIV compared with usual care or comparing different types of NIV. Risk of bias was assessed using Cochrane guidelines and relevant economic checklists. Results for primary effectiveness outcomes (mortality, hospitalisations, exacerbations and quality of life) were presented, where possible, in forest plots. A speculative Markov decision model was developed to compare the cost-effectiveness of domiciliary NIV with usual care from a UK perspective for post-hospital and more stable populations separately.

RESULTS

Thirty-one controlled effectiveness studies were identified, which report a variety of outcomes. For stable patients, a modest volume of evidence found no benefit from domiciliary NIV for survival and some non-significant beneficial trends for hospitalisations and quality of life. For post-hospital patients, no benefit from NIV could be shown in terms of survival (from randomised controlled trials) and findings for hospital admissions were inconsistent and based on limited evidence. No conclusions could be drawn regarding potential benefit from different types of NIV. No cost-effectiveness studies of domiciliary NIV were identified. Economic modelling suggested that NIV may be cost-effective in a stable population at a threshold of £30,000 per quality-adjusted life-year (QALY) gained (incremental cost-effectiveness ratio £28,162), but this is associated with uncertainty. In the case of the post-hospital population, results for three separate base cases ranged from usual care dominating to NIV being cost-effective, with an incremental cost-effectiveness ratio of less than £10,000 per QALY gained. All estimates were sensitive to effectiveness estimates, length of benefit from NIV (currently unknown) and some costs. Modelling suggested that reductions in the rate of hospital admissions per patient per year of 24% and 15% in the stable and post-hospital populations, respectively, are required for NIV to be cost-effective.

LIMITATIONS

Evidence on key clinical outcomes remains limited, particularly quality-of-life and long-term (> 2 years) effects. Economic modelling should be viewed as speculative because of uncertainty around effect estimates, baseline risks, length of benefit of NIV and limited quality-of-life/utility data.

CONCLUSIONS

The cost-effectiveness of domiciliary NIV remains uncertain and the findings in this report are sensitive to emergent data. Further evidence is required to identify patients most likely to benefit from domiciliary NIV and to establish optimum time points for starting NIV and equipment settings.

FUTURE WORK RECOMMENDATIONS

The results from this report will need to be re-examined in the light of any new trial results, particularly in terms of reducing the uncertainty in the economic model. Any new randomised controlled trials should consider including a sham non-invasive ventilation arm and/or a higher- and lower-pressure arm. Individual participant data analyses may help to determine whether or not there are any patient characteristics or equipment settings that are predictive of a benefit of NIV and to establish optimum time points for starting (and potentially discounting) NIV.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003286.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Exacerbations of COPD

Exacerbations of chronic obstructive pulmonary disease (COPD) are defined as sustained worsening of a patient’s condition beyond normal day-to-day variations that is acute in onset, and that may also require a change in medication and/or hospitalization. Exacerbations have a significant and prolonged impact on health status and outcomes, and negative effects on pulmonary function. A significant proportion of exacerbations are unreported and therefore left untreated, leading to a poorer prognosis than those treated. COPD exacerbations are heterogeneous, and various phenotypes have been proposed which differ in biologic basis, prognosis, and response to therapy. Identification of biomarkers could enable phenotype-driven approaches for the management and prevention of exacerbations. For example, several biomarkers of inflammation can help to identify exacerbations most likely to respond to oral corticosteroids and antibiotics, and patients with a frequent exacerbator phenotype, for whom preventative treatment is appropriate. Reducing the frequency of exacerbations would have a beneficial impact on patient outcomes and prognosis. Preventative strategies include modification of risk factors, treatment of comorbid conditions, the use of bronchodilator therapy with long-acting β₂-agonists or long-acting muscarinic antagonists, and inhaled corticosteroids. A better understanding of the mechanisms underlying COPD exacerbations will help to optimize use of the currently available and new interventions for preventing and treating exacerbations.

Impact of a Dedicated Noninvasive Ventilation Team on Intubation and Mortality Rates in Severe COPD Exacerbations

BACKGROUND

Compared with usual care, noninvasive ventilation (NIV) lowers the risk of intubation and death for subjects with respiratory failure secondary to COPD exacerbations, but whether administration of NIV by a specialized, dedicated team improves its efficiency remains uncertain. Our aim was to test whether a dedicated team of respiratory therapists applying all acute NIV treatments would reduce the risk of intubation or death for subjects with COPD admitted for respiratory failure.

METHODS

We carried out a retrospective study comparing subjects with COPD admitted to the ICU before (2001-2003) and after (2010-2012) the creation of a dedicated NIV team in a regional acute care hospital. The primary outcome was the risk of intubation or death. The secondary outcomes were the individual components of the primary outcome and ICU/hospital stay.

RESULTS

A total of 126 subjects were included: 53 in the first cohort and 73 in the second. There was no significant difference in the demographic characteristics and severity of respiratory failure. Fifteen subjects (28.3%) died or had to undergo tracheal intubation in the first cohort, and only 10 subjects (13.7%) in the second cohort (odds ratio 0.40, 95% CI 0.16-0.99, P = .04). In-hospital mortality (15.1% vs 4.1%, P = .03) and median stay (ICU: 3.1 vs 1.9 d, P = .04; hospital: 11.5 vs 9.6 d, P = .04) were significantly lower in the second cohort, and a trend for a lower intubation risk was observed (20.8% vs 11% P = .13).

CONCLUSIONS

The delivery of NIV by a dedicated team was associated with a lower risk of death or intubation in subjects with respiratory failure secondary to COPD exacerbations. Therefore, the implementation of a team administering all NIV treatments on a 24-h basis should be considered in institutions admitting subjects with COPD exacerbations.

[Noninvasive ventilation for acute respiratory failure in a pulmonary department]

INTRODUCTION

Noninvasive ventilation (NIV) is considered as the first choice treatment for selected patients with acute respiratory failure (ARF), but many hospitals are forced to start NIV on medical wards.

METHODS

The aim of this retrospective study was to assess the outcomes of NIV initiated for ARF on a respiratory ward and to find the criteria predictive of failure. All patients were treated in a four-bed ward specifically dedicated to NIV. Failure of NIV was defined as the need for intubation and transfer to ICU, or death.

RESULTS

Among 105 admissions with ARF, 49 episodes needed NIV. These episodes were divided into 2 groups: PaCO2<45mmHg (10) and PaCO2>45mmHg (39). The overall failure rate of NIV and overall in-hospital mortality rate were 26.5% and 17% respectively. On multivariate analysis, SAPS II and respiratory acidosis with a pH less than 7.30 were significantly associated with failure of NIV.

CONCLUSIONS

NIV is practicable and is effective in the management of mild to moderate ARF on a respiratory ward. However, patients with respiratory acidosis and a pH less than 7.30 are at risk of NIV failure.

Lights and shadows of non-invasive mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations

Despite the overwhelming evidence justifying the use of non-invasive ventilation (NIV) for providing ventilatory support in chronic obstructive pulmonary disease (COPD) exacerbations, recent studies demonstrated that its application in real-life settings remains suboptimal. European clinical audits have shown that 1) NIV is not invariably available, 2) its availability depends on countries and hospital sizes, and 3) numerous centers declare their inability to provide NIV to all of the eligible patients presenting throughout the year. Even with an established indication, the use of NIV in acute respiratory failure due to COPD exacerbations faces important challenges. First, the location and personnel using NIV should be carefully selected. Second, the use of NIV is not straightforward despite the availability of technologically advanced ventilators. Third, NIV therapy of critically ill patients requires a thorough knowledge of both respiratory physiology and existing ventilatory devices. Accordingly, an optimal team-training experience, the careful selection of patients, and special attention to the selection of devices are critical for optimizing NIV outcomes. Additionally, when applied, NIV should be closely monitored, and endotracheal intubation should be promptly available in the case of failure. Another topic that merits careful consideration is the use of NIV in the elderly. This patient population is particularly fragile, with several physiological and social characteristics requiring specific attention in relation to NIV. Several other novel indications should also be critically examined, including the use of NIV during fiberoptic bronchoscopy or transesophageal echocardiography, as well as in interventional cardiology and pulmonology. The present narrative review aims to provide updated information on the use of NIV in acute settings to improve the clinical outcomes of patients hospitalized for COPD exacerbations.

Noninvasive positive pressure ventilation for acute respiratory failure following oesophagectomy: Is it safe? A systematic review of the literature

OBJECTIVE

To find, critically appraise and synthesise all published studies so as to determine the safety and spectrum of use of noninvasive positive pressure ventilation for acute respiratory failure following oesophagectomy.

DESIGN

Systematic review.

METHODS

The MEDLINE and EMBASE databases were searched and the quality of the studies and any bias or confounding were rated according to established protocols. Outcomes extracted included re-intubation, anastomotic leakage, length of intensive care unit stay and mortality. The data were analysed quantitatively and qualitatively. Pooling of outcomes was considered if appropriate.

RESULTS

The search identified four papers, demonstrating the understudying/underreporting of the topic. Three were case-series and one was a conference abstract. The overall methodological quality was low. Design-specific biases and confounding were high. Despite this, the included studies conclude that noninvasive positive pressure ventilation is safe and effective and that re-intubation rates, intensive care unit length of stay, mortality and anastomotic dehiscence is lower when it is used. Meta-analysis was deemed to be inappropriate.

CONCLUSIONS

Despite the conclusions and consensus of the included studies, there is no evidence to definitively conclude that noninvasive positive pressure ventilation is either safe or dangerous following oesophagectomy and the current literary evidence is inadequate. Current practice varies and is based on opinion and consensus. As such, randomised controlled studies are urgently required as current practice may cause undue harm to patients. The incidence of anastomotic leakage with noninvasive positive pressure ventilation use needs to be determined.

Evolution of the use of noninvasive mechanical ventilation in chronic obstructive pulmonary disease in a Spanish region, 1997-2010

INTRODUCTION

Noninvasive mechanical ventilation (NIV) appeared in the 1980s as an alternative to invasive mechanical ventilation (IMV) in patients with acute respiratory failure. We evaluated the introduction of NIV and the results in patients with acute exacerbation of chronic obstructive pulmonary disease in the Region of Murcia (Spain).

SUBJECTS AND METHODS

A retrospective observational study based on the minimum basic hospital discharge data of all patients hospitalised for this pathology in all public hospitals in the region between 1997 and 2010. We performed a time trend analysis on hospital attendance, the use of each ventilatory intervention and hospital mortality through joinpoint regression.

RESULTS

We identified 30.027 hospital discharges. Joinpoint analysis: downward trend in attendance (annual percentage change [APC]=-3.4, 95% CI: - 4.8; -2.0, P <.05) and in the group without ventilatory intervention (APC=-4.2%, -5.6; -2.8, P <.05); upward trend in the use of NIV (APC=16.4, 12.0; 20. 9, P <.05), and downward trend that was not statistically significant in IMV (APC=-4.5%, -10.3; 1.7). We observed an upward trend without statistical significance in overall mortality (APC=0.5, -1.3; 2.4) and in the group without intervention (APC=0.1, -1.6; 1.9); downward trend with statistical significance in the NIV group (APC=-7.1, -11.7; -2.2, P <.05) and not statistically significant in the IMV group (APC=-0,8, -6, 1; 4.8). The mean stay did not change substantially.

CONCLUSIONS

The introduction of NIV has reduced the group of patients not receiving assisted ventilation. No improvement in results was found in terms of mortality or length of stay.

Comparative effectiveness of noninvasive ventilation vs invasive mechanical ventilation in chronic obstructive pulmonary disease patients with acute respiratory failure

BACKGROUND

Limited evidence exists on the comparative effectiveness of noninvasive ventilation (NIV) vs invasive mechanical ventilation (IMV) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients with respiratory failure.

OBJECTIVES

To characterize the use of NIV and IMV, and to compare the effectiveness of NIV vs IMV in AECOPD.

DESIGN AND PATIENTS

Retrospective cohort study using data from the 2006-2008 Nationwide Emergency Department Sample. Emergency department visits for AECOPD with acute respiratory failure were identified with codes from the International Classification of Diseases, Ninth Revision, Clinical Modification.

MEASURES

The outcome measures were inpatient mortality, hospital length of stay, hospital charges, and complications.

RESULTS

There were an estimated 101,000 visits annually for AECOPD with acute respiratory failure; 96% were admitted to the hospital. Of these, NIV use increased from 14% in 2006 to 16% in 2008 (P=0.049). Use of NIV, however, varied widely between hospitals, ranging from 0% to 100% with a median of 11%. Noninvasive ventilation was more often used in higher-case volume, Northeastern hospitals. In a propensity score analysis, NIV use, compared with IMV, was associated with lower inpatient mortality (risk ratio: 0.54, 95% confidence interval [CI]: 0.50-0.59), shortened hospital length of stay (-3.2 days; 95% CI: -3.4 to -2.9 days), lower hospital charges (-$35,012; 95% CI: -$36,848 to -$33,176), and lower risk of iatrogenic pneumothorax (0.05% vs 0.5%, P<0.001).

CONCLUSIONS

Although NIV use is increasing in US hospitals, its adoption remains low and varies widely between hospitals. Our observational study suggests NIV appears to be more effective and safer than IMV for AECOPD in the real-world setting.

[Non-invasive mechanical ventilation in COPD]

Non-invasive mechanical ventilation is the preferred method for the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). Primary contraindications and stopping criteria must be regarded to avoid delaying endotracheal intubation. The primary interface is usually a nasal-oral mask. Cautious sedation can facilitate non-invasive ventilation in some patients. Under certain circumstances non-invasive ventilation may enable successful extubation in COPD patients with prolonged weaning. COPD patients can also benefit from preventive non-invasive ventilation in order to avoid re-intubation after a planned extubation. Domiciliary nocturnal non-invasive ventilation is an option for some patients with COPD in chronic hypercapnic respiratory failure. This treatment should be established in a specialised unit.

Economics of mechanical ventilation and respiratory failure

For patients with acute respiratory failure, mechanical ventilation provides the most definitive life-sustaining therapy. Because of the intense resources required to care for these patients, its use accounts for considerable costs. There is great societal need to ensure that use of mechanical ventilation maximizes societal benefits while minimizing costs, and that mechanical ventilation, and ventilator support in general, is delivered in the most efficient and cost-effective manner. This review summarizes the economic aspects of mechanical ventilation and summarizes the existing literature that examines its economic impact cost effectiveness.

Non-invasive ventilation in acute respiratory failure

Non-invasive mechanical ventilation has been increasingly used to avoid or serve as an alternative to intubation. Compared with medical therapy, and in some instances with invasive mechanical ventilation, it improves survival and reduces complications in selected patients with acute respiratory failure. The main indications are exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, pulmonary infiltrates in immunocompromised patients, and weaning of previously intubated stable patients with chronic obstructive pulmonary disease. Furthermore, this technique can be used in postoperative patients or those with neurological diseases, to palliate symptoms in terminally ill patients, or to help with bronchoscopy; however further studies are needed in these situations before it can be regarded as first-line treatment. Non-invasive ventilation implemented as an alternative to intubation should be provided in an intensive care or high-dependency unit. When used to prevent intubation in otherwise stable patients it can be safely administered in an adequately staffed and monitored ward.

Use of noninvasive positive-pressure ventilation in the emergency department

To optimize the successful use of noninvasive positive-pressure ventilation (NPPV) in the emergency department (ED), clinicians must acquire the necessary knowledge, experience, and skill in its proper application. The purpose of this article is to provide a concise but thorough review of the current state of knowledge relating to the proper application of NPPV pertaining to its use in the ED.

Predictors of successful noninvasive ventilation treatment for patients suffering acute respiratory failure

BACKGROUND

To identify predictors of successful noninvasive ventilation (NIV) treatment for patients with acute respiratory failure.

METHODS

This was a prospective intervention study of the intensive care unit of a teaching hospital in Chia-Yi, Taiwan. Patients were enrolled if they had acute respiratory failure and had been admitted to the intensive care unit of our hospital between October 1, 2004 and September 30, 2005 inclusively.

RESULTS

All 86 patients who satisfied the study's inclusion criteria agreed to participate in the study, and each patient was followed-up until the discontinuation of NIV treatment or their death. We measured the Acute Physiology and Chronic Health Evaluation (APACHE) II score prior to their treatment and also conducted serial measurements of respiratory rate (RR), tidal volume, rapid shallow breathing index, maximal inspiratory pressure (PImax), and maximal expiratory pressure (PEmax) prior to, and 30 minutes and 60 minutes subsequent to NIV treatment (denoted by, respectively, the subscripted numbers 0, 30 and 60). NIV treatment was determined as being successful for 55 patients (the success group, for which individuals endotracheal intubation was avoided) and as being a failure for 31 patients (the failure group). APACHE II scores prior to treatment, PImax30 (PImax 30 minutes subsequent to NIV), RR30 (RR 30 minutes subsequent to NIV), and RR60 (RR 60 minutes subsequent to NIV) were all significantly lower for the success group than for the failure group. The success group also had significantly better values for RR during the first 30 minutes of NIV treatment and for PEmax during the first 60 minutes of NIV treatment compared to individuals from the failure group.

CONCLUSION

APACHE II scores recorded prior to NIV treatment, PImax30, RR30, RR60, as well as improvements to RR during the first 30 minutes of NIV treatment and to PEmax during the first 60 minutes of NIV treatment were predictors of successful NIV treatment for patients suffering from acute respiratory failure. Such parameters may be helpful in selecting patients to receive NIV treatment and also for deciding when early termination of the treatment is appropriate.

Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients

The Task Force reviewed and discussed the available literature on the effectiveness of physiotherapy for acute and chronic critically ill adult patients. Evidence from randomized controlled trials or meta-analyses was limited and most of the recommendations were level C (evidence from uncontrolled or nonrandomized trials, or from observational studies) and D (expert opinion). However, the following evidence-based targets for physiotherapy were identified: deconditioning, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. Discrepancies and lack of data on the efficacy of physiotherapy in clinical trials support the need to identify guidelines for physiotherapy assessments, in particular to identify patient characteristics that enable treatments to be prescribed and modified on an individual basis. There is a need to standardize pathways for clinical decision-making and education, to define the professional profile of physiotherapists, and increase the awareness of the benefits of prevention and treatment of immobility and deconditioning for critically ill adult patients.

Non-invasive ventilation in exacerbations of COPD

Randomized controlled trials have confirmed the evidence and helped to define when and where non invasive mechanical ventilation (NIV) should be the first line treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Noninvasive ventilation has its best indication in moderate-to-severe respiratory acidosis in patients with AECOPD. For this indication, studies conducted in ICU, in wards and in accident and emergency departments confirmed its effectiveness in preventing endotracheal intubation and reducing mortality. The skill of the health care team promotes proper NIV utilization and improves the patient outcome. Patients with severe acidosis or with altered levels of consciousness due to hypercapnic acute respiratory failure are exposed to high risk of NIV failure. In these patients a NIV trial may be attempted in closely monitored clinical settings where prompt endotracheal intubation may be assured.

Non-invasive ventilation in chronic hypercapnic COPD patients with exacerbation and a pH of 7.35 or higher

BACKGROUND

Current guidelines suggest the use of non-invasive ventilation (NIV) in hypercapnic chronic obstructive pulmonary disease (COPD) exacerbations in patients presenting with a pH of 7.25-7.35. The aim of this study was to investigate the role of NIV in COPD patients with chronic hypercapnic respiratory failure admitted to the hospital with acute exacerbations and an arterial pH of 7.35 or higher.

METHODS

Forty-seven COPD patients with chronic hypercapnic respiratory failure admitted for exacerbations and with a pH of 7.35 or higher were randomized to receive standard medical therapy (control group) or medical therapy plus NIV (NIV group). Arterial blood gases were measured at baseline, after 1 h, 6 h, 12 h, 24 h, 48 h, and at discharge. Need for admission to intensive care unit (ICU), death, and duration of hospitalization were recorded. The final analysis included 42 patients (21 controls and 21 NIV patients).

RESULTS

NIV resulted in a shorter hospital stay (5.5+/-2.6 vs 10.1+/-4.4 days for controls, p=0.0004). Two patients from the control group were admitted to the ICU and one eventually died, whereas all NIV patients were successfully discharged. The NIV group showed a faster improvement in PaCO(2) and pH. At discharge, the NIV group had a lower PaCO(2) (6.5+/-0.6 kPa vs 7.5+/-1.1 kPa, p=0.01) but a comparable pH (7.43+/-0.03 vs 7.43+/-0.04, p=0.93). PaO(2) and PaO(2)/FiO(2) levels showed similar improvement in both groups at discharge.

CONCLUSION

Early administration of NIV in COPD patients with chronic hypercapnic respiratory failure admitted for acute exacerbations with a pH of 7.35 or higher results in a reduced hospital stay and faster improvement of arterial blood gases.

Limitations of acceptability curves for presenting uncertainty in cost-effectiveness analysis

Clinical journals increasingly illustrate uncertainty about the cost and effect of health care interventions using cost-effectiveness acceptability curves (CEACs). CEACs present the probability that each competing alternative is optimal for a range of values of the cost-effectiveness threshold. The objective of this article is to demonstrate the limitations of CEACs for presenting uncertainty in cost-effectiveness analyses. These limitations arise because the CEAC is unable to distinguish dramatically different joint distributions of incremental cost and effect. A CEAC is not sensitive to any change of the incremental joint distribution in the upper left and lower right quadrants of the cost-effectiveness plane; neither is it sensitive to radial shift of the incremental joint distribution in the upper right and lower left quadrants. As a result, CEACs are ambiguous to risk-averse policy makers, inhibit integration with risk attitude, hamper synthesis with other evidence or opinions, and are unhelpful to assess the need for more research. Moreover, CEACs may mislead policy makers and can incorrectly suggest medical importance. Both for guiding immediate decisions and for prioritizing future research, these considerable drawbacks of CEACs should make us rethink their use in communicating uncertainty. As opposed to CEACs, confidence and credible intervals do not conflate magnitude and precision of the net benefit of health care interventions. Therefore, they allow (in)formal synthesis of study results with risk attitude and other evidence or opinions. Presenting the value of information in addition to these intervals allows policy makers to evaluate the need for more empirical research.