Home mechanical ventilation: back to basics

Experimental validation of a novel portable device integrating an oxygen concentrator and a ventilation module for patients with ALI/ARDS in low resource countries: a cross-over non-inferiority trial

BACKGROUND

This non-inferiority, cross-over study aims to evaluate a novel proof-of-concept portable respiratory support device specifically designed for low-resource settings. The device integrates a ventilation module and an oxygen concentrator.

METHODS

We studied twelve 4-week-old piglets with a mean weight of 8.4 kg before and after oleic acid-induced acute respiratory distress syndrome (ARDS). In each condition, animals received 1-h pressure control ventilation using a conventional ventilator (Servo-i, Getinge, SE) and the experimental ventilator in random sequence. Arterial blood gas analysis was performed every half-hour to adjust the ventilator settings. The primary outcome was partial pressure of oxygen to FiO2 ratio (P/F) with a non-inferiority margin of 50 mmHg.

RESULTS

P/F did not differ significantly between the experimental and the control ventilation at baseline (459.6(30.9) vs 454.4(28.6) mmHg) and during ARDS condition (165.1(36.9) vs 182.5(48.4) mmHg). The upper 95% CI of the difference between P/F after ventilation using the control and the experimental ventilator was 37.3 and 44.1 mmHg during baseline and ARDS, respectively.

CONCLUSIONS

The experimental device was not inferior to a conventional ventilator during both baseline and ARDS conditions, suggesting that it can provide adequate treatment to infants with mild to moderate hypoxemic lung disease in resource-limited care settings.

IMPACT STATEMENT

This manuscript provides the results of a non-inferiority study that compared a novel proof-of-concept respiratory support device, integrating a ventilation module and an oxygen concentrator, specifically designed for respiratory support in low-resource settings, with a conventional pediatric intensive care ventilator in an oleic-acid model of acute lung injury. Our results showed that the experimental device was non-inferior to a conventional ventilator, suggesting that it can provide adequate treatment to infants with mild to moderate hypoxemic lung disease in resource-limited care settings. The developed solution can also be relevant for other applications, including home mechanical ventilation.

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

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

An investigation of the effect of the universal model of family-centered care on patient and family outcomes in patients under home invasive mechanical ventilation

BACKGROUND

The number of patients under home mechanical ventilation is increasing worldwide. The unique nature of these patients and their complex health needs exposes home caregivers to various needs and challenges regarding different dimensions of care.

OBJECTIVE

The present study was conducted to investigate the effect of the universal model of family-centered care on the clinical outcomes of the patient and the family.

METHODS

This clinical trial was conducted between 2020 and 2021. A total of 60 patients under invasive mechanical ventilation was selected and divided into control (routine training that is usually given by hospital staff to families to care for patients) and intervention (comprehensive pre-discharge training program to post-discharge follow-up using the universal model of family-centered care) groups using random block design and universal model of family-centered care. Home caregivers' functional skills and burden, as well as patients' readmission and mortality rates, were compared in the two groups.

RESULTS

Implementing the intervention 1 and 3 months later effectively increased home caregivers' functional skills. Moreover, a statistically significant difference was observed between the two groups in terms of the psychological burden of caregiving (P < .001); the implementation of the intervention could highly reduce the psychological burden of caregiving in the intervention group (EF = 0.94). The hospital readmission and mortality rate in the intervention group was significantly lower than in the control group (P = .02 and P = .03, respectively).

CONCLUSIONS

Given the significant impact of the universal model of family-centered care on the clinical outcomes of the patient and the family, pre-discharge training and its post-discharge follow-up and continuity of education with an active presence of nurses, as one of the main pillars of the treatment, seems essential.

Trisomy 13, home health-care and multidisciplinary approach: Case report

OBJECTIVE

To recognize and address Patau's syndrome, despite its rarity and associated low life expectancy, through the presentation of a case study of a 2-year-old patient receiving Home Care services.

CASE DESCRIPTION

We present a female patient who defied the odds with a prolonged survival, possible due to Home Care. She was delivered via cesarean section at 31 weeks + 4 days due to restricted uterine growth. The mother, aged 36, had received proper prenatal care and was in good health. The diagnosis of Patau's syndrome was confirmed through karyotyping after birth. Despite the severe clinical nature of the case, the patient, now with two years old, receives specialized home-based care, supported by a tracheostomy and gastrostomy. A dedicated 24-hour nursing technician ensures continuous monitoring, and the patient benefits from regular medical check-ups, physiotherapy five times a week, weekly speech therapy sessions, monthly consultations with a nutritionist, and ongoing psychological support for her family members.

COMMENTS

This multidisciplinary approach has resulted in a slight motor response, highlighting the positive impact of comprehensive care on her overall well-being. The existence of a robust support network for families facing similar challenges is crucial, and a multidisciplinary care can effectively prevent complications associated with this impactful syndrome.

Clinical evidence and technical aspects of innovative technology and monitoring of chronic NIV in COPD: a narrative review

INTRODUCTION

Chronic nocturnal noninvasive ventilation (NIV) improves outcomes in COPD patients with chronic hypercapnic respiratory failure. The aim of chronic NIV in COPD is to control chronic hypercapnic respiratory insufficiency and reduce symptoms of nocturnal hypoventilation, thereby improving quality of life. Chronic NIV care is more and more offered exclusively at home, enabling promising outcomes in terms of patient and caregiver satisfaction, hospital care consumption and cost reduction. Yet, to achieve and maintain optimal ventilation, during adaptation and follow-up, effective feasible (home) monitoring poses a significant challenge.

AREAS COVERED

Comprehensive monitoring of COPD patients receiving chronic NIV requires integrating data from ventilators and assessment of the patient's status including gas exchange, sleep quality, and patient-reported outcomes. The present article describes the physiological background of monitoring during NIV and aims to provide an overview of existing methods for monitoring, assessing their reliability and clinical relevance.

EXPERT OPINION

Patients on chronic NIV are 'ideal' candidates for home monitoring; the advantages of transforming hospital to home care are huge for patients and caregivers and for healthcare systems facing increasing patient numbers. Despite the multitude of available monitoring methods, identifying and characterizing the most relevant parameters associated with optimal patient well-being remains unclear.

Burden, social support, and coping strategies in family caregivers of individuals receiving home mechanical ventilation: a cross-sectional study

BACKGROUND

Home mechanical ventilation (HMV) is a treatment method for patients with chronic respiratory failure. HMV is a challenge for both patients and their caregivers. Some studies have shown a higher risk of depression, job loss, or lifestyle disturbance in family members caring for HMV patients. The purpose of the study was to measure caregiver burden, perceived social support, and coping strategies.

METHODS

In the cross-sectional study, 58 caregivers (65.52% female) of HMV patients treated at five healthcare institutions were surveyed. The questionnaires including patient/caregiver demographic data, the type and duration of MV, the Caregiver Burden Scale (CBS), the Social Support Scale (SSS), and the Brief-COPE questionnaire were applied. For statistical analysis, the Mann‒Whitney U test, the Kruskal‒Wallis H test, Dunn's test, and Spearman correlations were used.

RESULTS

In the CBS, a high level of burden was observed mainly in the isolation and disappointment subscales. The female caregivers achieved a higher score for general strain than did the male caregivers (p = 0.023). Differences in the distribution of the isolation (p = 0.028) and disappointment (p = 0.03) variables between the financial situation groups were observed. The older the patient, the lower the burden in the domains of isolation (p = 0.015) and disappointment (p = 0.005) was elicited. Invasive MV was associated with greater burdens of general strain (p = 0.005), isolation (p = 0.001), and disappointment (p = 0.001). A medium total SSS score was shown (74.5 ± 7.56). Caregivers used various coping strategies. The most common were planning, acceptance, and active coping. Self-blame and denial were positively related to several CBS subscales, whereas acceptance of difficult situations and positive reframing were related to lower scores.

CONCLUSIONS

Caregivers most frequently experienced a medium level of burden. Female caregivers were characterized by higher level of burden. Invasive ventilation increased the burden. Respondents who assessed their financial situations as good, had lower burden in the selected subscales. Using some positive coping strategies may reduce the level of burden. Interventions to ensure that caregivers overcome these burdens should be undertaken.

Adaptation of Caregivers of Individuals on Mechanical Ventilation to Caregiving Role

Aim

The aim of this study is to investigate the adaptation of caregivers of individuals on mechanical ventilation (MV) at home to their caregiver role.

Study design

The phenomenological research method, one of the qualitative research methods, was employed in the study.

Materials and methods

The sample consisted of 21 individuals who agreed to participate in the research. Necessary legal permissions were obtained to conduct the study.

Results

The data were analyzed according to the Roy adaptation model (RAM). Accordingly, the domains of the RAM were expressed with the following themes: Physiologic domain: The effects of care on the caregiver (reluctance toward self-care, psychological fatigue, insomnia, and limitation of social life); Self-concept domain: Supportive situations (trust in God and spiritual practices) and non-supportive situations (fear of losing and self-blame); Role-function domain: Adaptation of the caregiver role (thinking no one else can give similar care) and maladaptation of the caregiver role (fear of failing to cope with suddenly emerging situations, failing to fulfill roles and responsibilities, and economic inadequacy); Interdependence domain: Receiving support (support of healthcare professionals and support of family members) and lack of support (inadequacy of health services and loneliness).

Conclusion

It was concluded that individuals who provided care for patients on MV experienced many difficulties and that these difficulties increased their care burden and made it difficult to adapt to their caregiving roles.

How to cite this article

Aydin M, Bulut TY, Avcİ İA. Adaptation of Caregivers of Individuals on Mechanical Ventilation to Caregiving Role. Indian J Crit Care Med 2024;28(1):41-47.

Indications and evidence for domiciliary noninvasive ventilation

INTRODUCTION

Home noninvasive ventilation (HNIV) has expanded globally, with a greater evidence base for its use. HNIV improves multiple patient related outcomes in patients with chronic hypercapnic respiratory failure. Obesity hypoventilation syndrome (OHS) is rapidly taking over as the primary indication for HNIV and COPD patients who overlap with obstructive sleep apnea hypoventilation syndromes (OSAHS) and are increasingly recognized but add to the complexity of HNIV prescribing. Optimal settings vary for differing diseases, with higher inspiratory pressures often required in those with OHS and COPD, yet which settings translate into greatest patient benefit remains unknown.

AREAS COVERED

We cover the evidence base underpinning the common indications for HNIV in COPD, OHS, neuromuscular disease (NMD), and chest wall disease (CWD) and highlight common HNIV modes used.

EXPERT OPINION

Active screening for nocturnal hypoventilation in OHS and COPD may be important to guide earlier ventilation. Further research on which HNIV modalities best improve patient related outcomes and the right time for initiation in different patient phenotypes is rapidly needed. Worldwide, clinical research trials should aim to bridge the gap by reporting on patient-related outcomes and cost effectiveness in real-world populations to best understand the true benefit of HNIV amongst heterogenous patient populations.

Nusinersen for Spinal Muscular Atrophy Type I with Chronic Respiratory Failure: A Retrospective Study in South Korea

PURPOSE

To analyze the efficacy and safety of nusinersen in patients with spinal muscular atrophy (SMA) type I with chronic respiratory failure.

MATERIALS AND METHODS

We retrospectively reviewed seven patients diagnosed with SMA type I and chronic respiratory failure who were on permanent ventilation and treated with nusinersen at Gangnam Severance Hospital between January 2018 and July 2023. Patient demographics and clinical characteristics were recorded, and treatment progress was evaluated according to Hammersmith Infant Neurological Examination (HINE-2) and Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) scores.

RESULTS

Patients initially developed hypotonia at a mean age of 3.7 months. Mean age at start of nusinersen was 7.3 years; the mean duration of follow-up after starting nusinersen was 46.2 months. At 6-, 18-, 38-, 58-, and 74-month follow-up, the mean changes in CHOP-INTEND scores were 1.0, 2.9, 1.8, 1.5, and 1.5, respectively, and the proportions of patients who showed disease amelioration were 28.6%, 71.4%, 75.0%, 100%, and 100%, respectively.

CONCLUSION

Nusinersen is safe and effective in patients with SMA type I, even those with chronic respiratory failure and those on permanent ventilation. No significant adverse effects of nusinersen were observed.

Mental health reported in adult invasive home mechanical ventilation through a tracheostomy: A scoping review

Background

Although people receiving invasive home mechanical ventilation through a tracheostomy are facing both physical and mental health challenges, healthcare services often focus mainly on physical symptoms. To ensure well-functioning treatment and care for people receiving tracheostomy ventilation in a home setting, their mental health needs to be promoted and seen as an integral part of their health in general.

Objective

This scoping review aimed to provide a summary of the current knowledge on the mental health of people receiving invasive home mechanical ventilation through a tracheostomy.

Design

A scoping review of published and gray literature based on the framework developed by Arksey and O'Malley and refined by the JBI was performed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist was used for reporting the findings.

Methods

A literature search was conducted by two researchers independently in the PubMed, CINAHL and PsycINFO databases. Additional searches for gray literature were conducted in Google, Google Scholar, websites of selected organisations, and the reference lists of included studies. The software system Covidence was used in the study selection process. For critical appraisal, the Mixed Methods Appraisal Tool was used.

Results

Thirteen studies were included in this review, of which six used qualitative, six quantitative, and one mixed methods. The majority of studies were authored in Europe (n = 10), followed by the Americas (n = 2) and the Western Pacific (n = 1). Mental health was investigated both directly and indirectly (61.5% vs. 38.5%). Categorizing the reported mental health outcomes, we found that emotional well-being was reported widely across the studies (n = 13), while psychological well-being (n = 5) and social well-being (n = 4) were less widely reported.

Conclusions

The mental health of people receiving home tracheostomy ventilation has received some scholarly attention. A heterogeneity of mental health outcomes was reported in the literature with emotional well-being being an important mental health area both in relation to the sub-components positive affect and quality of life appraisal. Mental health outcomes in relation to psychological well-being and social well-being were fragmented and only sparsely investigated.

Treatment of acute respiratory failure: noninvasive mechanical ventilation

Background: Noninvasive ventilation (NIV) has been an important strategy to support patients with respiratory failure, while preventing complications assorted with invasive mechanical ventilation. Physicians need to be aware of the various roles of NIV and the challenges encountered in clinical practice.Current Concepts: Traditionally, the application of NIV has been well-known to be associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD) or acute pulmonary edema and those suffering from acute respiratory failure. However, despite some positive results of NIV treatment in patients with de novo hypoxemic respiratory failure such as acute pneumonia or acute respiratory distress syndrome, NIV failure (or delayed intubation) can have deleterious effects on patients outcomes. Besides, the aggravation of lung injury should also be taken into consideration when applied to patients exhibiting high respiratory drive. Nonetheless, NIV has potential for wide applications in various clinical situations such as facilitation of ventilator weaning, post-operative respiratory failure, or palliative treatment.Discussion and Conclusion: In addition to the strong evidence in patients with acute respiratory failure due to COPD or acute pulmonary edema, the NIV treatment can be potentially used for various clinical conditions. However, compared to European countries, the prevalence of NIV use continues to remain lower in South Korea. Nevertheless, when applied in appropriately selected patients in a timely manner, NIV treatment can be associated with improved patient outcomes.

APAP, BPAP, CPAP, and New Modes of Positive Airway Pressure Therapy

Positive airway pressure (PAP) is the primary treatment of sleep-disordered breathing including obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation. Just as clinicians use pharmacological mechanism of action and pharmacokinetic data to optimize medication therapy for an individual, understanding how PAP works and choosing the right mode and device are critical to optimizing therapy in an individual patient. The first section of this chapter will describe the technology inside PAP devices that is essential for understanding the algorithms used to control the airflow and pressure. The second section will review how different comfort settings including ramp and expiratory pressure relief and modes of PAP therapy including continuous positive airway pressure (CPAP), autotitrating CPAP, bilevel positive airway pressure, adaptive servoventilation, and volume-assured pressure support control the airflow and pressure. Proprietary algorithms from several different manufacturers are described. This chapter derives its descriptions of algorithms from multiple sources including literature review, manufacture publications and websites, patents, and peer-reviewed device comparisons and from personal communication with manufacturer representatives. Clinical considerations related to the technological aspects of the different algorithms and features will be reviewed.

Cross-sectional survey on home mechanical ventilator use: major deficiencies in a home care system in South Korea

Background

Despite the increased use of home mechanical ventilation (HMV), data on home care services for HMV users in Asian countries are scarce. This study investigated the current status of HMV use in the Seoul metropolitan area.

Methods

This cross-sectional study involved three university-affiliated hospitals. Subjects who were receiving HMV at home for >3 months were included, and door-to-door visits were done to collect data (e.g., on devices, caregivers, and healthcare service use) from the subjects or their families.

Results

Among the 140 individuals who were initially screened, 38 adults and 26 children were finally enrolled; the duration of HMV use was 14.5 (8.8–37.5) months and 20.5 (7.0–28.0) months, respectively. Tracheostomy ventilation was performed in 36.8% of the adults and 61.5% of the children, and life-support ventilator in 55.3% and 96.2%, respectively. Regarding ancillary devices, 42.1% of the adults and 80.8% of the children had an oxygen monitoring device, while only one member of each group had a cough assist device. Among those with a tracheostomy, 64.3% of adults and 81.3% of children had an AMBU-bag. Reliance on a family member for care was determined in 65.8% of adults and 88.5% of children, but a home visit by a hospital nurse during the previous year occurred in only 26.3% of the adults and 3.8% of the children. Emergency incidents at home occurred in 39.5% of the adults and 50.0% of the children, with dyspnea being the most common cause. Out-of-pocket expenses tended to be higher in the tracheostomy (vs. non-tracheostomy) group and in children (vs. adults).

Conclusions

Our study highlights the challenges faced by adults and children dependent on HMV, and their families. There is an urgent need for nationwide standardization of care for patients receiving HMV at home.