Health plans for COPD patients undergoing home non-invasive mechanical ventilation (HNIMV): from hospital to home. S. Aiolfi, V. Patruno, G. Beghi, L.

Health plans for COPD patients Health plans for COPD patients undergoing home non-invasive undergoing home non-invasive

mechanical ventilation (HNIMV): mechanical ventilation (HNIMV): from hospital to home.from hospital to home.

S. Aiolfi, V. Patruno, G. Beghi, L. Chiesa, U. Zorza, M. Rota Pulmonary Rehabilitation Unit

A.O. “Ospedale Maggiore” - Crema - Italy

Dublin May 18th – 20th 2005

Background

• The prevalence and impact on public health of chronic obstructive pulmonary disease (COPD) are rising.

• Individuals living with COPD require skills and information necessary to make changes in their behaviour in order to stay healthy and avoid further deteriorations.

PROJECTED CHANGES IN WORLD-WIDE MORTALITY 1990-2020

• Ischemic heart disease

• Cerebrovascular disease

• Lower respiratory infection

• Diarroheal disease

• Perinatal disorders

• COPD

• Tuberculosis

• Measles

• Road traffic accidents

• Lung cancer

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8 K stomach

9 9 HIV

10 10 suicide

WHO Global Burden of disease study

Classification of COPD (GOLD 2003)

Stage 0: At Risk

Stage I: Mild COPD

Stage II: Moderate COPD

Stage III: Severe COPD

Stage IV: Very Severe COPD

Lung function is still normal

FEV1/FVC < 70% but FEV1 ≥ 80% predicted)

50% ≤ FEV1 < 80% predicted

30% ≤ FEV1 < 50% predicted

Exacerbations of symptoms, which have an impact on a patient’s QoL

FEV1 < 30% predicted or FEV1 < 50% predicted plus CRF

NON INVASIVE VENTILATION

• Non-invasive ventilation (NIV) is gaining increasing popularity after good evidence has shown that

– not only patients with decompensated, hypercapnic COPD,

– but also patients with acute respiratory failure may benefit from the early institution of non invasive positive pressure ventilation (NPPV).

Mehta S., Hill NS.Non invasive Ventilation. State of the Art.

Am J Respir Crit Care Med 2001; 163: 540-577

Goals of NIMV

• To keep under control the evolution of CRF• To increase quality of life: reduction No. and

severity of exacerbations; • To increase social and physical function and

quality of sleep; • To slow the progression of the underlying disease• To reduce morbidity and increase survival; • To reduce health costs of these patients.

Hill N, Leger P, Criner G.: Consensus conference report.

Chest. 1999;116:521-534

Aim of our study

• To report our experience on patients suffering from COPD Stage III & IV associated with chronic respiratory failure (CRF), dismissed from our Unit in Non-Invasive Mechanical Ventilation after an in-hospital management approach

• To verify if our multidisciplinary intervention would have resulted in a better compliance to the prescribe therapy regimen

DEMOGRAPHICS

• 48 COPD patients, stage III /

IV with Hypercapnic CRF

• April ‘99 - December ‘04

• M/F ratio 1,4:1

• Mean age 62 years

Patients assessment - 1

• Smoking history:– Ex-smokers – Non-smokers

• Arterial blood gases:pH - pO2 - PCO2

• Vital Parameters– Blood Pressure– Heart Rate – Respiratory rate

• PFT– FEV1 pre – post

bronchodilator– FVC - FRC (He)– DLCO– MIP - MEP

• Dyspnea indexBorg’s scale VAS

• Exercise test– Walking test– Cycloergometer test

Patients assessment - 2

• Nocturnal Pulsoxymetry

• Full night Cardiorespiratory monitoring or Polysomnography

• Choosing the ventilator• Choosing the best interface• Setting the ventilator to the

correct parameters:

– IPAP – EPAP values

– Rise time

– I/E ratio

– Back up R.R.

• Fixing FiO2 (when needed)

Choice of ventilator and setting

• An individualized approach to the choice of ventilator and ventilator setting for each patient is mandatory.

• The ventilator type should be determined by each patient’s degree of comfort, coupled with the ability to increase minute ventilation, improve gas exchange, and diminish the work of breathing.

Interfaces in NIMV

• The interface between patient and ventilator is a crucial issue

• An uncomfortable mask may be the reason to refuse NIMV and its inappropriate fitting may cause a reduction in its efficacy

• Proper sizing and fitting of the mask may require several attempts owing to the facial architecture

Spectrum of interfaces in NIMV

• Approximately 15–20 types of commercial or custom-made nasal and face masks are on the market.

• Both nasal and facial masks show advantages and disadvantages.

Advantages & disadvantages of masks

Main problems with NIMV

• Mask leak

• Mouth leak

• The ventilator itself cannot distinguish mask leak and/or mouth leak

• Both types of leak and their deleterious effects tend to go unrecognised (i.e. complete loss of supplemental O2)

Mask Leak

• can be highly irritating to the patient or cause conjunctivitis

• high leak can produce a reduction of pressure delivered

• headgear needs to be regularly inspected and replaced when overstretched

• If a leak is intractable, another size or style of mask should be tried

Mouth leak

• Can lead to severe nasal symptoms with burning, drying, rhinorrhoea, and congestion which in turn lead to increased nasal resistance and causes severe sleep fragmentation.

• Mouth leak can lead to a loss of 50% of effective pressure delivered.

• A chin strap may help reduce mouth leak, but typically only reduces it by some 50%.

Side-effects of NIMV

The commonest are due to:

1. The interface: nose and face mask

2. Aerophagia

3. Nasal dryness/congestion or bleeding and dry mouth in the morning

4. Conjunctivitis

Side-effects

• A poorly fitting mask can produce not only discomfort but severe pain with: – redness – abrasion – ulceration of the bridge of the nose

• Aerophagia: High pressures (> 20 cmH2O) will result in the stomach filling with air, which is unpleasant and increases the elastic work of breathing, thereby leading to higher pressures being delivered.

Side-effects: Nose – Mouth - Eyes

• Nasal dryness/congestion or bleeding and dry mouth in the morning are largely symptoms of mouth leak, which also severely impair delivery of effective therapy.

• Conjunctivitis: is due to mask leak, and should be treated with a change in mask size, fitting, style, or headgear.

HumidificationHumidification

Drying of the nasal mucosa, rhinorrhoea, congestion, and increased nasal resistance can be prevented by humidification:

• a cold humidification increases the relative humidity by only 6–9% and has scarce effects on the above symptoms

• a hot water bath humidifier increases the relative humidity to 97% and does eliminate symptoms and abolish nasal resistance

Educational Sessions

Together with their caregivers, all patients attended multi-disciplinary personalized, and group educational sessions and training on:

– home management of their condition

– how to handle and to clean their ventilator, tubes, mask, and oxygen supplier

– how to keep a diary of their condition (symptoms and signs) and malfunctioning of their devices

NIMV at Home: what to consider

• A domiciliary plan for routine servicing/cleaning and preventive maintenance schedule

• Once home, patients will be contacted during the first week, and later periodically, in order to check the ventilator for proper functioning

• The home-care company should perform preventive maintenance, and must guarantee a 24-h technical service consisting of – inspection of the ventilator– replacement of tubing, mask, and filters

Going home: the discharge planning

A follow up schedule was set at 1, 3, 6 months, and subsequently every 6 months, if no exacerbations, consisting in:– Clinical visit – BGA – Educational reinforcement sessions – Monitoring of:

• Compliance• Requests of technical support; • Non scheduled visit or ER visits; • Admissions to hospital.

Compliance

• Compliance is very high in end-stage COPD pts who are ventilator dependent, but can be very disappointing in patients with obesity-hypoventilation syndrome or hypercapnic CRF at earlier stages.

• A ventilator should have an hour-meter, so that compliance can be monitored, particularly during the first weeks of therapy.

Compliance

• A recent paper investigated the efficacy and compliance with long-term NIMV in 40 patients with CRF.

• After initial evaluation, 34 patients received NIMV via PTV (i.e. BiPAP) and only six patients via VTV.

• During the 6 months follow-up 14 patients discontinued NIMV due to poor compliance. In the compliant patients blood gases and functional status improved in the long term.

Criner GJ, Brennan K, Travaline JM, Kreimer D.

Chest 1999; 116: 667–675.

Compliance

Low compliance

Identify the causes

Educate the patient and family

Decreased compliance can be due to:

1. Poor mask fitting 2. Mouth leaks 3. Mask leaks 4. Ventilator noise 5. Claustrophobia 6. Poor patient-ventilator

synchronization

Our ResultsOur Results

• All 48 pts attended the scheduled follow up controls.

• To date, 7 pts had died: 4 M, 3 F

• Compliance to treatment: good > 85% time prescribed

• Routine servicing/cleaning and preventative maintenance

schedule: good performed by caregivers

• Requests of technical assistance = 107% than scheduled

• Non scheduled visit (E.R./Respiratory Clinics) = 104%

• Hospital readmissions for respiratory problems: mean 0.8/year

for each patient

Pneumologist

Patient&

caregivers Psychologist

Primary CarePhysician

ConsultantsSpecialists

Dietitian

PFT’s Technician

SpecializedNurse

Respiratory Therapist

Pulmonary RehabilitationPulmonary RehabilitationTEAMTEAM

+

Home assistance network

Conclusions

Our multidisciplinary approach to patients in HNIMV, based on holistic system care, shows

• good compliance to treatment• low hospital readmission ratio• low emergency visit requests Globally, good patient’s and caregivers’

satisfaction

as a consequence of a good health educational approach during hospital stay and at follow up and a good management of their condition at home.

S. Martha’s Team