Home Care NetWork
Home Care Literature Review: January– June 2006
Home Mechanical Ventilation:
Laub M, Midgren B. The effects of nocturnal home mechanical ventilation on daytime blood gas disturbances. Clin Physiol Funct Imaging 2006; 26:79-82
This Swedish large database analysis of a national multicenter registry of 288 patients with multiple diagnoses and chronic alveolar hypoventilation on nocturnal home mechanical ventilation found statistically significant improvements in daytime Po2 and Pco2 (approximately 1 kPa in both) and in base excess but no changes in vital capacity or calculated alveolo-arterial gradient. All changes were independent of the observation period and only weakly diagnose-related after a 6 to 24 month follow-up. This study confirms previous findings that nocturnal home mechanical ventilation can result in lasting improvement in gas exchange even though the underlying lung disease appears to be unchanged.
Budweiser S, Heinemann F, Fischer W, et al. Long-term reduction of hyperinflation in stable COPD by non-invasive nocturnal home ventilation. Respir Med 2005; 99:976-984. Epub 2005 Apr 26
This German retrospective case series of 46 patients with stable COPD who were receiving noninvasive positive pressure ventilation (NPPD) found a 1-year survival of 89.1%, a significant reduction in nocturnal and daytime PaCO2, significant decrease in the ratio of residual volume to total lung capacity (RV/TLC, average of 5.2+/-9.8% - 15.2+/-29.7% pred; p<0.01) at 6 months and 3.9+/-9.0% (or 12.9+/-18.6% pred; p<0.001) at 12 months. This was associated with significant improvement in inspiratory capacity, vital capacity, and FEV1. Patients with the most severe hyperinflation (RV/TLC >75%), demonstrated a significant positive correlation between inspiratory positive airway pressure and reductions in PaCO2 (r=0.56; p<0.05) and RV/TLC (r=0.50; p<0.05). This case series is not definitive but does give hope that long-term nocturnal noninvasive positive pressure ventilation may be able to induce sustained improvement in lung function.
Home Care Literature Reviews 2005
Home Mechanical Ventilation:
Farrero E, Prats E, Povedano M, Martinez-Matos JA, Manresa F, Escarrabill J. Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement. Chest. 2005; 127:2132-8.
This Spanish case series utilized a retrospective database analysis from a tertiary referral center to analyze the effectiveness of a noninvasive home mechanical ventilation (HMV) protocol in 64 patients with amyotrophic lateral sclerosis (ALS). Compared to the 15 patients started on HMV prior to the initiation of the protocol, those 49 patients treated per the protocol were more likely to have HMV initiated during acute respiratory failure otherwise there were no differences in outcomes between the groups. A multivariate analysis, however, showed greater survival in the protocol group when patients had bulbar involvement. Noninvasive home mechanical ventilation was effective in this uncontrolled study of patients with ALS and appeared to be especially useful in patients with bulbar involvement. A definitive randomized clinical trial would be with very welcome addition to our understanding the management of this difficult problem.
Lloyd-Owen SJ, Donaldson GC, Ambrosino N, Escarabill J, Farre R, Fauroux B, Robert D, Schoenhofer B, Simonds AK, Wedzicha JA. Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey. Eur Respir J. 2005;25:1025-31.
This survey the patterns of home mechanical ventilation use in patients with chronic respiratory failure in the European Community found a prevalence of home mechanical ventilation of 6.6 per 100,000 people per year. There were marked national differences in rates and indications. It’s clear that the science of the use of home mechanical ventilation is lagging behind the technology when it comes to appropriate patient selection. This is an area that requires a great deal of further work.
Battisti A, Tassaux D, Janssens JP, Michotte JB, Jaber S, Jolliet P. Performance characteristics of 10 home mechanical ventilators in pressure-support mode: a comparative bench study. Chest. 2005;127:1784-92.
This Swiss bench analysis utilized a mechanical lung model to describe the pressure response characteristics of several home mechanical ventilators. The pressurization capacity varied widely as did the reliability of synchronization with inspiratory times. It’s not clear that any of these differences would lead to significant differences in clinical outcomes, however, this study does underline the importance of understanding the characteristics of particular ventilators used in the home (or for that matter anywhere).
Duiverman ML, Bladder G, Meinesz AF, Wijkstra PJ. Home mechanical ventilatory support in patients with restrictive ventilatory disorders: A 48-year experience. Respir Med. 2005 Jun 3; [Epub ahead of print]
This Dutch retrospective case series analyzed the effects of negative pressure ventilation, tracheal intermittent positive pressure ventilation, and nasal intermittent positive pressure ventilation (volume or pressure-controlled ventilatory mode), in 114 patients with restrictive ventilatory disorders instituted in a single hospital from 1956 until 2005. Patients were grouped as idiopathic kyphoscoliosis (N=64), post poliomyelitis syndrome (N=30), or miscellaneous (N=20). Patients with post polio syndromes had the highest survival while the miscellaneous group had the lowest. The type of ventilation did not seem to be important. This case series documents acceptable survival rates in the hands of a skilled group. The quality of life was not studied.
Cuvelier A, Grigoriu B, Molano LC, Muir JF. Limitations of transcutaneous carbon dioxide measurements for assessing long-term mechanical ventilation. Chest. 2005;127:1744-8.
This French bench study compared transcutaneous measurements of PaO2 and PaCO2 with arterial blood measurements in adult patients with COPD or restrictive lung disease on chronicle mechanical ventilation. Transcutaneous measurements correlated well with direct arterial measurements over most clinically important range, however, at extreme measures (i.e., PaCO2 values of > 56 mm Hg and PaO2 values of > 115 mm Hg.) the relationship broke down. Transcutaneous measurement works well when the values approached normal. Extreme values should be interpreted carefully.
Home Care Literature Reviews 2003
Home Mechanical Ventilation:
Massie CA, McArdle N, Hart RW, Schmidt-Nowara WW, Lankford A, Hudgel DW, Gordon N, Douglas NJ. Comparison between automatic and fixed positive airway pressure therapy in the home. Am J Respir Crit Care Med 2003;167:20-3
This multicenter, randomized, single-blind, cross-over, clinical trial studied 44 patients (mean age, 49 +/- 10 years) randomized to 6 weeks of continuous positive airway pressure (CPAP) at laboratory-determined fixed pressure and 6 weeks on autotitrating CPAP and found that the average nightly use was greater in automatic mode (306 v 271 minutes, p = 0.005); median and 95th percentile pressures in automatic mode were lower (p<0.002). Automatic CPAP resulted in better SF-36 Vitality scores (65 +/- 20 versus 58 +/- 23, p<0.05) and mental health scores (80 +/- 14 versus 75 +/- 18, p<0.05), but no significant difference in Epworth score (p=0.065). During automatic therapy, patients reported more restful sleep, better quality sleep, less discomfort from pressure, and less trouble getting to sleep for both the first week of therapy and for the averaged scores for Weeks 2-6 (all p values < 0.006). Patients who require higher fixed CPAP use autotitrating CPAP more and report greater benefit from this therapy. This study provides strong support for autotitration.
Douglas SL, Daly BJ. Caregivers of long-term ventilator patients: physical and psychological outcomes. Chest 2003;123:1073-81.
This case series described the post hospital outcomes of 135 patients receiving long-term mechanical ventilation (LTV) and their caregivers. Caregivers interviewed at hospital discharge and 6 months later reported a drop in physical health scores over that time (p = 0.0001). Caregivers of patients residing in an institution reported higher depression (p = 0.039) and overload scores (p = 0.002) than did caregivers of patients residing at home 6 months after discharge; 51.2% of caregivers at discharge and 36.4% at 6 months after discharge reported symptoms consistent with some degree of depression. In addition, 12.2% of caregivers at hospital discharge and 15.6% at 6 months after discharge were classified as having symptoms consistent with severe depression. Caregiver physical health (p = 0.025) and overload (p = 0.006) made statistically significant contributions to explaining caregiver depression. Home mechanical ventilation is an intense caregiving task and clearly takes a toll. Caregiver emotional support, as well as technical training and support, is important to maintaining patients at home with LTV
Sritippayawan S, Kun SS, Keens TG, Davidson Ward SL. Initiation of home mechanical ventilation in children with neuromuscular diseases. J Pediatr 2003;142:481-5.
This case series of 73 children (age, 2 months to 24 years) with neuromuscular disease requiring home mechanical ventilation (HMV) found that HMV was initiated electively in 21% of patients with neuromuscular disease and 69% of the nonelective HMV group had HMV initiated after respiratory failure caused by pneumonia. In the nonelective group, opportunities for discussion of therapeutic options with the patients and families could have occurred before respiratory failure during 111 hospitalizations for pneumonia, 13 preoperative evaluations, 43 abnormal PFTs, and 24 abnormal PSGs. This article points out the need for prior discussions of treatment options in children with neuromuscular disease who are at risk for respiratory insufficiency.
Gilgoff RL, Gilgoff IS. Long-term follow-up of home mechanical ventilation in young children with spinal cord injury and neuromuscular conditions. J Pediatr 2003;142:476-80.
This case series used data from chart review and interviews on 39 children who had become ventilator-dependent before their 6th birthday (23 had neuromuscular diseases and 16 had spinal cord injuries) and found that patients required an average of 0.7 rehospitalizations per year. Survival rates were 97% at 1 year, 97% at 3 years, 84% at 5 years, and 71% at 10 years. Thirty children attended school, 13 were in regular school (1 at university level), 5 were home-schooled, 5 were in special education schools, and 5 were in regular school with some special education classes. One graduated high school, and another graduated university and received a graduate degree. Three children had progressive weakness. Two gained significant muscle strength. There were eight deaths in the group and the quality of life was not explicitly measures.
Windisch W, Freidel K, Schucher B, Baumann H, Wiebel M, Matthys H, Petermann F. The Severe Respiratory Insufficiency (SRI) Questionnaire: a specific measure of health-related quality of life in patients receiving home mechanical ventilation. J Clin Epidemiol. 2003;56:752-9.
This German case series of 226 patients (mean age 57.3+/-14.0 years) receiving home mechanical ventilation (HMV) evaluated a new instrument, the Severe Respiratory Insufficiency (SRI) Questionnaire, for measuring health-related quality of life in patients receiving home HMV and found high internal consistency reliability, good construct validity, good concurrent validity (compared to subscales of the SF-36) and a high item discriminant validity. Different diagnostic groups (i.e., kyphoscoliosis, miscellaneous disorders, neuromuscular diseases, post-tuberculosis, and chronic obstructive pulmonary disease) could be discriminated by the SRI. Those interested in HMV will want to review this article.
Tuggey JM, Plant PK, Elliott MW. Domiciliary non-invasive ventilation for recurrent acidotic exacerbations of COPD: an economic analysis. Thorax. 2003;58:867-71.
This British case series evaluated the economic consequences of non-invasive ventilation (NIV) in patients with chronic stable COPD who suffer recurrent acidotic exacerbations. Thirteen patients who tolerated and responded well to NIV were identified. Home NIV resulted in a mean (95% CI) saving of £8254 (£4013, £12,495) per patient/year, hospital days fell from a 78 ± 51 (mean ± SD) to 25 ± 25 (p=0.004), number of admissions from 5 ± 3 to 2 ± 2 (p=0.007), and ICU days fell from a total of 25 to 4 (p=0.24). This is a small number of highly selected patients, none the less; the findings are interesting and may have implications for the use of home NIV in this country.
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