1
|
Murphy PB, Brueggenjuergen B, Reinhold T, Gu Q, Fusfeld L, Criner G, Goss TF, Hart N. Cost-effectiveness of home non-invasive ventilation in patients with persistent hypercapnia after an acute exacerbation of COPD in the UK. Thorax 2023; 78:523-525. [PMID: 36823164 PMCID: PMC10176417 DOI: 10.1136/thorax-2022-219653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/23/2022] [Indexed: 02/25/2023]
Abstract
Home non-invasive mechanical ventilation (HMV) with home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of chronic obstructive pulmonary disease delays hospital readmission. The economic impact of this treatment is unknown. We evaluated the cost-effectiveness of HMV in the UK healthcare system using data from a previously published efficacy trial. Quality-adjusted life-years (QALYs) were computed from EQ-5D-5L. Accounting for all direct patient costs HOT-HMV was £512 (95%CI £36 to £990) more expensive per patient per year than HOT-alone. This small increase in cost was accompanied by increased quality of life leading to an incremental cost-effectiveness ratio of £10 259 per QALY. HOT-HMV was cost-effective in this clinical population. Trial registration number: NCT00990132.
Collapse
Affiliation(s)
- Patrick Brian Murphy
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Bernd Brueggenjuergen
- Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH) im DIAKOVERE Annastift, Hannover Medical School Affilliated Hospital, Hannover, Germany
| | - Thomas Reinhold
- Institute of Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and HumboldtUniversität zu Berlin, Berlin, Germany
| | - Qing Gu
- Health Economics and Outcomes Research, Boston Healthcare Associates Inc, Boston, Massachusetts, USA
| | - Laura Fusfeld
- Health Economics and Outcomes Research, Boston Healthcare Associates Inc, Boston, Massachusetts, USA
| | - Gerard Criner
- Respiratory Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Thomas F Goss
- Health Economics and Outcomes Research, Boston Healthcare Associates Inc, Boston, Massachusetts, USA
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| |
Collapse
|
2
|
Murphy PB, Patout M, Arbane G, Mandal S, Kaltsakas G, Polkey MI, Elliott M, Muir JF, Douiri A, Parkin D, Janssens JP, Pépin JL, Cuvelier A, Flach C, Hart N. Cost-effectiveness of outpatient versus inpatient non-invasive ventilation setup in obesity hypoventilation syndrome: the OPIP trial. Thorax 2023; 78:24-31. [PMID: 36342884 DOI: 10.1136/thorax-2021-218497] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current guidelines recommend that patients with obesity hypoventilation syndrome (OHS) are electively admitted for inpatient initiation of home non-invasive ventilation (NIV). We hypothesised that outpatient NIV setup would be more cost-effective. METHODS Patients with stable OHS referred to six participating European centres for home NIV setup were recruited to an open-labelled clinical trial. Patients were randomised via web-based system using stratification to inpatient setup, with standard fixed level NIV and titrated during an attended overnight respiratory study or outpatient setup using an autotitrating NIV device and a set protocol, including home oximetry. The primary outcome was cost-effectiveness at 3 months with daytime carbon dioxide (PaCO2) as a non-inferiority safety outcome; non-inferiority margin 0.5 kPa. Data were analysed on an intention-to-treat basis. Health-related quality of life (HRQL) was measured using EQ-5D-5L (5 level EQ-5D tool) and costs were converted using purchasing power parities to £(GBP). RESULTS Between May 2015 and March 2018, 82 patients were randomised. Age 59±14 years, body mass index 47±10 kg/m2 and PaCO2 6.8±0.6 kPa. Safety analysis demonstrated no difference in ∆PaCO2 (difference -0.27 kPa, 95% CI -0.70 to 0.17 kPa). Efficacy analysis showed similar total per-patient costs (inpatient £2962±£580, outpatient £3169±£525; difference £188.20, 95% CI -£61.61 to £438.01) and similar improvement in HRQL (EQ-5D-5L difference -0.006, 95% CI -0.05 to 0.04). There were no differences in secondary outcomes. DISCUSSION There was no difference in medium-term cost-effectiveness, with similar clinical effectiveness, between outpatient and inpatient NIV setup. The home NIV setup strategy can be led by local resource demand and patient and clinician preference. TRIAL REGISTRATION NUMBERS NCT02342899 and ISRCTN51420481.
Collapse
Affiliation(s)
- Patrick Brian Murphy
- Lane Fox Respiratory Service, Guy's and St Thomas' Hospitals NHS Trust, London, UK .,Centre for Human & Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Maxime Patout
- Service des Pathologies du Sommeil (Département R3S), Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France.,UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France
| | - Gill Arbane
- Lane Fox Respiratory Service, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Swapna Mandal
- Thoracic Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - Georgios Kaltsakas
- Lane Fox Respiratory Service, Guy's and St Thomas' Hospitals NHS Trust, London, UK.,Centre for Human & Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Michael I Polkey
- NIHR Respiratory BRU, Royal Brompton Hospital and National Heart and Lung Institute, London, UK
| | - Mark Elliott
- Respiratory Medicine, St James' University Hospital, Leeds, UK
| | - Jean-François Muir
- Institute for Research and Innovation in Biomedicine (IRIB), Normandie Univ, UNIRouen, Rouen, France.,ADIR Assistance, Fédération ANTADIR, Paris, France
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, UK
| | | | - Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospital, Geneva, Switzerland
| | - Jean Louis Pépin
- HP2 laboratory, INSERM U1042, Universite Grenoble Alpes, Saint-Martin-d'Heres, France.,Pôle Locomoteur, Rééducation et Physiologie, CHU de Grenoble, Grenoble, France
| | | | - Clare Flach
- School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's and St Thomas' Hospitals NHS Trust, London, UK.,Centre for Human & Applied Physiological Sciences (CHAPS), King's College London, London, UK
| |
Collapse
|
3
|
Shah NM, D'Cruz RF, Murphy PB. Novel modes of non-invasive ventilation in chronic respiratory failure: a narrative review. J Thorac Dis 2020; 12:S217-S224. [PMID: 33214925 PMCID: PMC7642641 DOI: 10.21037/jtd-cus-2020-013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Home non-invasive ventilation (NIV) is central in the management of chronic hypercapnic respiratory failure and is associated with improvements in clinically relevant outcomes. Home NIV typically involves delivery of fixed positive inspiratory and expiratory airway pressures. These pressures do not reflect physiological changes to respiratory mechanics and airway calibre during sleep, which may impact on physiological efficacy, subsequent clinical outcomes, and therapy adherence. Novel ventilator modes have been designed in an attempt to address these issues. Volume-assured pressure support modes aim to automatically adjust inspiratory pressure to achieve a pre-set target tidal volume. The addition of auto-titrating expiratory pressure to maintain upper airway calibre is designed for patients at risk of upper airway collapse, such as obese patients and those with obstructive sleep apnoea complicating their hypercapnic failure. Heterogeneity in setup protocols, patient selection and trial design limit firm conclusions to be drawn on the clinical efficacy of these modes. However, there are data to suggest that compared to fixed-pressure NIV, volume-assured modes may improve nocturnal carbon dioxide, sleep quality and ventilator adherence in select patients. The use of the forced oscillation technique to identify expiratory flow limitation and adjust expiratory pressure to eliminate it is the most recent addition to these advanced modes and is yet to be assessed in formal clinical trials.
Collapse
Affiliation(s)
- Neeraj Mukesh Shah
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Rebecca F D'Cruz
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Patrick B Murphy
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| |
Collapse
|
4
|
Mandal S, Ramsay M, Suh ES, Harding R, Thompson A, Douiri A, Moxham J, Murphy PB, Hart N. External heated humidification during non-invasive ventilation set up: results from a pilot cross-over clinical trial. Eur Respir J 2020; 55:13993003.01126-2019. [PMID: 32366486 DOI: 10.1183/13993003.01126-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 01/25/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Swapna Mandal
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, King's Health Partners, London, UK.,King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michelle Ramsay
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, King's Health Partners, London, UK.,King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Eui-Sik Suh
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, King's Health Partners, London, UK.,King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rachel Harding
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, King's Health Partners, London, UK.,King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - April Thompson
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, King's Health Partners, London, UK.,King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Abdel Douiri
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - John Moxham
- King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK
| | - Patrick Brian Murphy
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, King's Health Partners, London, UK.,King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, King's Health Partners, London, UK .,King's College London, School of Life Sciences, Centre for Human and Applied Physiological, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
5
|
Dolidon S, Dupuis J, Molano Valencia LC, Salaün M, Thiberville L, Muir JF, Cuvelier A, Patout M. Characteristics and outcome of patients set up on high-flow oxygen therapy at home. Ther Adv Respir Dis 2020; 13:1753466619879794. [PMID: 31610722 PMCID: PMC6794649 DOI: 10.1177/1753466619879794] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: High-flow oxygen therapy (HFOT) is increasingly used for acute respiratory
failure. Few data support its use at home for the treatment of chronic
respiratory failure. Our aim was to report the pattern of the use of
long-term HFOT in our center and the outcome of patients setup on long-term
HFOT. Methods: A retrospective monocentric study including all patients setup on long-term
HFOT between January 2011 and April 2018 in Rouen University Hospital was
carried out. Patients were divided into two groups, patients with hypoxemic
respiratory failure treated with nasal HFOT (nHFOT) and tracheotomized
patients treated with tracheal HFOT (tHFOT). Results: A total of 71 patients were established on long-term HFOT. Out of these 43
(61%) were included in the nHFOT group and 28 (39%) were included in the
tHFOT group. In the nHFOT group, underlying respiratory diseases were
interstitial lung disease (n = 15, 35%), pulmonary
hypertension (n = 12, 28%), lung cancer
(n = 9, 21%), and chronic airway disease
(n = 7, 16%). In the tHFOT group, the number of
admissions for exacerbation decreased by −0.78 per year (–2 to 0)
(p = 0.045). In total, 51 (72%) patients were
discharged to their homes and 20 (28%) went to a post-acute re-enablement
facility. Median survival following HFOT was 7.5 months. Survival was
significantly lower in the nHFOT group with a median survival of 3.6 months
whereas median survival was not reached in the tHFOT group
(p < 0.001). Monthly costs associated with home
delivery of HFOT were €476 (296–533) with significant differences in costs
between the nHFOT group of €520 (408–628) and costs in the tHFOT group of
€296 (261–475) (p < 0.001). Conclusions: The use of long-term HFOT allows very severe patients to be discharged at a
reasonable cost from acute care facilities. The reviews of this paper are available via the supplementary
material section.
Collapse
Affiliation(s)
- Samuel Dolidon
- Rouen University Hospital, Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen, France
| | | | - Luis-Carlos Molano Valencia
- Rouen University Hospital, Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen, France
| | - Mathieu Salaün
- Rouen University Hospital, Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen, France
| | - Luc Thiberville
- Rouen University Hospital, Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen, France
| | - Jean-François Muir
- Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB) and Rouen University Hospital, Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen, France
| | - Antoine Cuvelier
- Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB) and Rouen University Hospital, Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen, France
| | - Maxime Patout
- Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB) and Rouen University Hospital, Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen 76000, France
| |
Collapse
|
6
|
Patout M, Gagnadoux F, Rabec C, Trzepizur W, Georges M, Perrin C, Tamisier R, Pépin JL, Llontop C, Attali V, Goutorbe F, Pontier-Marchandise S, Cervantes P, Bironneau V, Portmann A, Delrieu J, Cuvelier A, Muir JF. AVAPS-AE versus ST mode: A randomized controlled trial in patients with obesity hypoventilation syndrome. Respirology 2020; 25:1073-1081. [PMID: 32052923 DOI: 10.1111/resp.13784] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/21/2020] [Accepted: 01/28/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Average volume-assured pressure support-automated expiratory positive airway pressure (AVAPS-AE) combines an automated positive expiratory pressure to maintain upper airway patency to an automated pressure support with a targeted tidal volume. The aim of this study was to compare the effects of 2-month AVAPS-AE ventilation versus pressure support (ST) ventilation on objective sleep quality in stable patients with OHS. Secondary outcomes included arterial blood gases, health-related quality of life, daytime sleepiness, subjective sleep quality and compliance to NIV. METHODS This is a prospective multicentric randomized controlled trial. Consecutive OHS patients included had daytime Pa CO2 > 6 kPa, BMI ≥ 30 kg/m2 , clinical stability for more than 2 weeks and were naive from home NIV. PSG were analysed centrally by two independent experts. Primary endpoint was sleep quality improvement at 2 months. RESULTS Among 69 trial patients, 60 patients had successful NIV setup. Baseline and follow-up PSG were available for 26 patients randomized in the ST group and 30 in the AVAPS-AE group. At baseline, Pa CO2 was 6.94 ± 0.71 kPa in the ST group and 6.61 ± 0.71 in the AVAPS-AE group (P = 0.032). No significant between-group difference was observed for objective sleep quality indices. Improvement in Pa CO2 was similar between groups with a mean reduction of -0.87 kPa (95% CI: -1.12 to -0.46) in the ST group versus -0.87 kPa (95% CI: -1.14 to -0.50) in the AVAPS-AE group (P = 0.984). Mean NIV use was 6.2 h per night in both groups (P = 0.93). NIV setup duration was shorter in the AVAPS-AE group (P = 0.012). CONCLUSION AVAPS-AE and ST ventilation for 2 months had similar impact on sleep quality and gas exchange.
Collapse
Affiliation(s)
- Maxime Patout
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | - Frédéric Gagnadoux
- Département de Pneumologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Claudio Rabec
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France
| | - Wojciech Trzepizur
- Département de Pneumologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Marjolaine Georges
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France
| | | | - Renaud Tamisier
- Pôle Thorax and Vaisseaux, Grenoble Alps University Hospital, Grenoble, France
| | | | - Claudia Llontop
- Service d'Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Valerie Attali
- UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France.,Service des Pathologies du Sommeil (Département 'R3S'), Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | | | | | - Pierre Cervantes
- Service de Pneumologie Hôpitaux Privés de Metz, Hôpital Robert Schuman, Metz, France
| | - Vanessa Bironneau
- Pneumologie, Centre Hospitalier Universitaire de Poitiers, Poitiers, France.,ANTADIR, Paris, France
| | - Adriana Portmann
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | | | - Antoine Cuvelier
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | - Jean-François Muir
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,ANTADIR, Paris, France
| |
Collapse
|
7
|
Duiverman ML, Vonk JM, Bladder G, van Melle JP, Nieuwenhuis J, Hazenberg A, Kerstjens HAM, van Boven JFM, Wijkstra PJ. Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial. Thorax 2019; 75:244-252. [PMID: 31484786 PMCID: PMC7063397 DOI: 10.1136/thoraxjnl-2019-213303] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/01/2019] [Accepted: 07/11/2019] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic COPD patients. While the number of patients increases, home initiation of NIV would greatly alleviate the healthcare burden. We hypothesise that home initiation of NIV with the use of telemedicine in stable hypercapnic COPD is non-inferior to in-hospital NIV initiation. METHODS Sixty-seven stable hypercapnic COPD patients were randomised to initiation of NIV in the hospital or at home using telemedicine. Primary outcome was daytime arterial carbon dioxide pressure (PaCO2) reduction after 6 months NIV, with a non-inferiority margin of 0.4 kPa. Secondary outcomes were health-related quality of life (HRQoL) and costs. RESULTS Home NIV initiation was non-inferior to in-hospital initiation (adjusted mean difference in PaCO2 change home vs in-hospital: 0.04 kPa (95% CI -0.31 to 0.38 kPa), with both groups showing a PaCO2 reduction at 6 months compared with baseline (home: from 7.3±0.9 to 6.4±0.8 kPa (p<0.001) and in-hospital: from 7.4±1.0 to 6.4±0.6 kPa (p<0.001)). In both groups, HRQoL improved without a difference in change between groups (Clinical COPD Questionnaire total score-adjusted mean difference 0.0 (95% CI -0.4 to 0.5)). Furthermore, home NIV initiation was significantly cheaper (home: median €3768 (IQR €3546-€4163) vs in-hospital: median €8537 (IQR €7540-€9175); p<0.001). DISCUSSION This is the first study showing that home initiation of chronic NIV in stable hypercapnic COPD patients, with the use of telemedicine, is non-inferior to in-hospital initiation, safe and reduces costs by over 50%. TRIAL REGISTRATION NUMBER NCT02652559.
Collapse
Affiliation(s)
- Marieke L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands .,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith M Vonk
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerrie Bladder
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joost P van Melle
- Thoraxcenter, Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jellie Nieuwenhuis
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anda Hazenberg
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Job F M van Boven
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of General Practice & Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
8
|
Piper AJ. Advances in non‐invasive positive airway pressure technology. Respirology 2019; 25:372-382. [DOI: 10.1111/resp.13631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 04/28/2019] [Accepted: 06/10/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Amanda J. Piper
- Department of Respiratory and Sleep MedicineRoyal Prince Alfred Hospital Sydney NSW Australia
- Faculty of Medicine and HealthUniversity of Sydney Sydney New South Wales Australia
| |
Collapse
|
9
|
Masa JF, Pépin JL, Borel JC, Mokhlesi B, Murphy PB, Sánchez-Quiroga MÁ. Obesity hypoventilation syndrome. Eur Respir Rev 2019; 28:180097. [PMID: 30872398 PMCID: PMC9491327 DOI: 10.1183/16000617.0097-2018] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/23/2019] [Indexed: 12/18/2022] Open
Abstract
Obesity hypoventilation syndrome (OHS) is defined as a combination of obesity (body mass index ≥30 kg·m-2), daytime hypercapnia (arterial carbon dioxide tension ≥45 mmHg) and sleep disordered breathing, after ruling out other disorders that may cause alveolar hypoventilation. OHS prevalence has been estimated to be ∼0.4% of the adult population. OHS is typically diagnosed during an episode of acute-on-chronic hypercapnic respiratory failure or when symptoms lead to pulmonary or sleep consultation in stable conditions. The diagnosis is firmly established after arterial blood gases and a sleep study. The presence of daytime hypercapnia is explained by several co-existing mechanisms such as obesity-related changes in the respiratory system, alterations in respiratory drive and breathing abnormalities during sleep. The most frequent comorbidities are metabolic and cardiovascular, mainly heart failure, coronary disease and pulmonary hypertension. Both continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) improve clinical symptoms, quality of life, gas exchange, and sleep disordered breathing. CPAP is considered the first-line treatment modality for OHS phenotype with concomitant severe obstructive sleep apnoea, whereas NIV is preferred in the minority of OHS patients with hypoventilation during sleep with no or milder forms of obstructive sleep apnoea (approximately <30% of OHS patients). Acute-on-chronic hypercapnic respiratory failure is habitually treated with NIV. Appropriate management of comorbidities including medications and rehabilitation programmes are key issues for improving prognosis.
Collapse
Affiliation(s)
- Juan F Masa
- San Pedro de Alcántara Hospital, Cáceres, Spain
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
- Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE) , Cáceres, Spain
| | - Jean-Louis Pépin
- Université Grenoble Alpes, HP2, Inserm U1042, Grenoble, France
- CHU de Grenoble, Laboratoire EFCR, Pôle Thorax et Vaisseaux, Grenoble, France
| | - Jean-Christian Borel
- Université Grenoble Alpes, HP2, Inserm U1042, Grenoble, France
- AGIR à dom. Association, Meylan, France
| | | | - Patrick B Murphy
- Guy's & St Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences King's College London, London, UK
| | - Maria Ángeles Sánchez-Quiroga
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
- Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE) , Cáceres, Spain
- Virgen del Puerto Hospital, Cáceres, Spain
| |
Collapse
|
10
|
Suh ES, Murphy PB, Hart N. Home mechanical ventilation for chronic obstructive pulmonary disease: What next after the HOT-HMV trial? Respirology 2019; 24:732-739. [PMID: 30729638 DOI: 10.1111/resp.13484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/02/2019] [Indexed: 12/26/2022]
Abstract
The benefits of acute non-invasive ventilation to treat acidotic exacerbations of chronic obstructive pulmonary disease (COPD) are well-established. Until recently, the evidence for home mechanical ventilation (HMV) to treat patients with stable COPD had been lacking. This has subsequently been addressed by the application of higher levels of pressure support combined with targeted management of chronic respiratory failure, which demonstrated a reduction in all-cause mortality. Similarly, the previous trial of home oxygen therapy (HOT) and HMV delivered following an acute exacerbation failed to demonstrate an improvement in outcome. With the focus on patients with persistent hypercapnic respiratory failure in the recovery phase following a life-threatening exacerbation combined with targeted reduction in carbon dioxide, HOT and HMV (HOT-HMV) was shown to be clinically effective in reducing the time to readmission or death and cost effective in both the United Kingdom and United States healthcare systems. Future work will need to focus on promoting adherence to home ventilation and novel auto-titrating ventilator modes to facilitate and optimize the set-up of overnight ventilatory support in different target population such as COPD patients with obstructive sleep apnoea and COPD patients with episodic nocturnal hypoventilation.
Collapse
Affiliation(s)
- Eui-Sik Suh
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Patrick B Murphy
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| |
Collapse
|
11
|
Patout M, Arbane G, Cuvelier A, Muir JF, Hart N, Murphy PB. Polysomnography versus limited respiratory monitoring and nurse-led titration to optimise non-invasive ventilation set-up: a pilot randomised clinical trial. Thorax 2018; 74:83-86. [DOI: 10.1136/thoraxjnl-2017-211067] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 03/13/2018] [Accepted: 03/19/2018] [Indexed: 11/04/2022]
Abstract
Polysomnography (PSG) is recommended for non-invasive ventilation (NIV) set-up in patients with chronic respiratory failure. In this pilot randomised clinical trial, we compared the physiological effectiveness of NIV set-up guided by PSG to limited respiratory monitoring (LRM) and nurse-led titration in patients with COPD–obstructive sleep apnoea (OSA) overlap. The principal outcome of interest was change in daytime arterial partial pressure of carbon dioxide (PaCO2) at 3 months. Fourteen patients with daytime PaCO2 >6 kPa and body mass index >30 kg/m2 were recruited. At 3 months, PaCO2 was reduced by −0.88 kPa (95% CI −1.52 to −0.24 kPa) in the LRM group and by −0.36 kPa (95% CI −0.96 to 0.24 kPa) in the PSG group. These pilot data provide support to undertake a clinical trial investigating the clinical effectiveness of attended limited respiratory monitoring and PSG to establish NIV in patients with COPD–OSA overlap.Trial numberResults, NCT02444806.
Collapse
|
12
|
Mansell SK, Cutts S, Hackney I, Wood MJ, Hawksworth K, Creer DD, Kilbride C, Mandal S. Using domiciliary non-invasive ventilator data downloads to inform clinical decision-making to optimise ventilation delivery and patient compliance. BMJ Open Respir Res 2018. [PMID: 29531743 PMCID: PMC5844385 DOI: 10.1136/bmjresp-2017-000238] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction Ventilation parameter data from patients receiving home mechanical ventilation can be collected via secure data cards and modem technology. This can then be reviewed by clinicians and ventilator prescriptions adjusted. Typically available measures include tidal volume (VT), leak, respiratory rate, minute ventilation, patient triggered breaths, achieved pressures and patient compliance. This study aimed to assess the potential impact of ventilator data downloads on management of patients requiring home non-invasive ventilation (NIV). Methods A longitudinal within-group design with repeated measurements was used. Baseline ventilator data were downloaded, reviewed and adjustments made to optimise ventilation. Leak, VT and compliance data were collected for comparison at the first review and 3-7 weeks later. Ventilator data were monitored and amended remotely via a modem by a consultant physiotherapist between the first review and second appointment. Results Analysis of data from 52 patients showed increased patient compliance (% days used >4 hours) from 90% to 96% (p=0.007), increased usage from 6.53 to 6.94 hours (p=0.211) and a change in VT(9.4 vs 8.7 mL/kg/ideal body weight, p=0.022). There was no change in leak following review of NIV prescriptions (mean (SD): 43 (23.4) L/min vs 45 (19.9)L/min, p=0.272). Conclusion Ventilator data downloads, via early remote assessment, can help optimise patient ventilation through identification of modifiable factors, in particular interface leak and ventilator prescriptions. However, a prospective study is required to assess whether using ventilator data downloads provides value in terms of patient outcomes and cost-effectiveness. The presented data will help to inform the design of such a study.
Collapse
Affiliation(s)
- Stephanie K Mansell
- Therapies Department, Royal Free London NHS Foundation Trust, London, UK
- Department of Thoracic Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - Steven Cutts
- Therapies Department, Royal Free London NHS Foundation Trust, London, UK
| | - Isobel Hackney
- Therapies Department, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Dean D Creer
- Department of Thoracic Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - Cherry Kilbride
- Therapies Department, Royal Free London NHS Foundation Trust, London, UK
- Department of Clinical Sciences, Brunel University London, London, UK
| | - Swapna Mandal
- Department of Thoracic Medicine, Royal Free London NHS Foundation Trust, London, UK
| |
Collapse
|
13
|
Pépin JL, Timsit JF, Tamisier R, Borel JC, Lévy P, Jaber S. Prevention and care of respiratory failure in obese patients. THE LANCET RESPIRATORY MEDICINE 2017; 4:407-18. [PMID: 27304558 DOI: 10.1016/s2213-2600(16)00054-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/25/2016] [Accepted: 01/28/2016] [Indexed: 12/14/2022]
Abstract
With the increase in the global prevalence of obesity, there is a parallel rise in the proportion of obese patients admitted to intensive care units, referred for major surgery or requiring long-term non-invasive ventilation (NIV) at home for chronic respiratory failure. We describe the physiological effect of obesity on the respiratory system mainly in terms of respiratory mechanics, respiratory drive, and patency of the upper airways. Particular attention is given to the prevention and the clinical management of respiratory failure in obese patients with a main focus on invasive and NIV in intensive care during the perioperative period and long-term use of NIV on return home. We also address other aspects of care of obese patients, including antibiotic dosing and catheter-related infections.
Collapse
Affiliation(s)
- Jean Louis Pépin
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France.
| | - Jean François Timsit
- IAME, INSERM UMR 1137, Paris Diderot University, Paris, France; Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University and Bichat Hospital, Paris, France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean Christian Borel
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Patrick Lévy
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, University of Montpellier, Saint Eloi Teaching Hospital, Montpellier, France; Centre National de la Recherche Scientifique (CNRS 9214), Institut National de la Santé et de la Recherche Medicale (INSERM U-1046), Montpellier University, Montpellier, France
| |
Collapse
|
14
|
Hodgson LE, Murphy PB. Update on clinical trials in home mechanical ventilation. J Thorac Dis 2016; 8:255-67. [PMID: 26904266 PMCID: PMC4739968 DOI: 10.3978/j.issn.2072-1439.2016.01.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/30/2015] [Indexed: 12/14/2022]
Abstract
Home mechanical ventilation (HMV) is an increasingly common intervention and is initiated for a range of pathological processes, including neuromuscular disease (NMD), chronic obstructive pulmonary disease (COPD) and obesity related respiratory failure. There have been important recent data published in this area, which helps to guide practice by indicating which populations may benefit from this intervention and the optimum method of setting up and controlling sleep disordered breathing. Recent superficially conflicting data has been published regarding HMV in COPD, with a trial in post-exacerbation patients suggesting no benefit, but in stable chronic hypercapnic patients suggesting a clear and sustained mortality benefit. The two studies are critiqued and the potential reasons for the differing results are discussed. Early and small trial data is frequently contradicted with larger randomised controlled trials and this has been the case with diaphragm pacing being shown to be potentially harmful in the latest data, confirming the importance of non-invasive ventilation (NIV) in NMD such as motor neurone disease. Advances in ventilator technology have so far appeared quicker than the clinical data to support their use; although small and often unblinded, the current data suggests equivalence to standard modes of NIV, but with potential comfort benefits that may enhance adherence. The indications for NIV have expanded since its inception, with an effort to treat sleep disordered breathing as a result of chronic heart failure (HF). The SERVE-HF trial has recently demonstrated no clear advantage to this technology and furthermore detected a potentially deleterious effect, with a worsening of all cause and cardiovascular mortality in the treated group compared to controls. The review serves to provide the reader with a critical review of recent advances in the field of sleep disordered breathing and HMV.
Collapse
|