Adapting to the Worsening of the LTMV Patient

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1 14 èmes Journées Internationales de Ventilation à Domicile LYON, mars 2015 Adapting to the Worsening of the LTMV Patient Andrea Vianello Fisiopatologia e Terapia Intensiva Respiratoria Ospedale-Università di Padova

2 Diseases than can benefit from LTMV Robert, Critical care 2007

3 Clinical Course according to Underlying Disease Category The concept of the traffic light ventilator dependency Acute exacerbation Life expectancy Neuromuscular Thoracic cage Lung/Airway

4 Clinical Course according to Baseline Disease LTMV Type II Glycogenosis DMD ALS

5 Follow-up after acclimatization to NIV 1. Regular clinical review of patient to determine compliance and response to therapy; 2. Assessment of cough and swallowing; 3. PSG or nocturnal respiratory monitoring based on clinical progression and blood gas levels.

6 Advanced care initiatives in progressive NMD 1. Prompt response to intercurrent exacerbation; 2. Hospital at home as an alternative to hospitalization; 3. Full time NIV use for 24-hrs ventilator dependent patients.

7 Prompt response to intercurrent exacerbation

8 Criteria that should define transition from home to acute care setting Acute loss of clinical stability; Need for escalating medical/health care that cannot be provided in home environment; The patient s and family s wishes for full intervention for reversible condition.

9 Efficacy of NIPPV plus assisted coughing on exacerbated NMD patients Study Design N o of patients (age) Interventions Main Results Limit Vianello 2000 prospective case-control 14 patients (38,8+ 23 yrs) versus 14 historical controls E= NIPPV + CM C= MV via ETI Mortality and treatment failure significantly lower in the NPPV group Severe bulbar involvement Servera 2005 prospective cohort study 17 patients (48,7+ 20 yrs) NIPPV + MI-E Successful in averting death and ETI in 79.2% of the acute episodes Severe bulbar involvement Vianello 2005 prospective case-control 11 patients (34,9+ 17,3 yrs) versus 16 historical controls E= NIPPV + MI-E+ CPT C= NIPPV+ CPT Treatment failure was significantly lower in the experimental group Padman 1994 Retrospective study 11 NMD patients(+ 4 cystic fibrosis patients) with acute on chronic respiratory failure (4-21 yrs) NIPPV ü Treatment failure = 6,6% ü Significant RR and PaCO2 improvement ü Number of intubated patients=1 Niranjan 1998 Retrospective study 10 patients (13-21 yrs) NIPPV + MI-E Avoidance of ETI Bach 2000 Retrospective study 11 children suffering from SMA type 1 (6 26 months) 28 distinct episodes of ARF Immediately upon extubation the patients received NIPPV + MI-E NIPPV was to a large extent successful even in very young children with severe skeletal and bulbar muscle weakness. Piastra 2006 Retrospective study 10 children (3month-12yrs) NIPPV + CPT The treatment was successful in 8 of 10 patients E, Experimental ; C, Control; NIPPV, Non invasive positive pressure ventilation CM, Cricothyroid-mini-tracheostomy; MV, mechanical ventilation; ETI, endotracheal intubation; CPT, chest physical treatments ; MI-E, mechanical insufflation exsufflation; NMD, neuromuscolare disease; RR, respiratory rate; ARF, acute respiratory failure; SMA, spinal muscular atrophy

10 NIV in NMD patients in the acute setting Extreme ventilator dependency Severe inability to cough Severe risk of inhalation Invasive mechanical ventilation

11 DMD, 24 yrs, administered HMV. He developed bilateral CAP. Ineffective NIV approach endotracheal intubation

12 Weaning process Treatment of ARF Assessing readiness to wean Extubation Suspicion SBT Re-intubation Admit Discharge Tobin MJ. Role and interpretation of weaning predictors. 5 International Consesus Conference in Intensive Care Medicine: Weaning from Mechanical Ventilation. Hosted by ERS, Ats, ESICM, SCCM and SRLF; Budapest April 28-29, 2005

13 Wean the patient from endotracheal tube and avoid tracheostomy!

14 PCF : 80 L/min MEP: 20 cmh 2 O MIP: -18 cmh 2 O

15 Assessing readiness to wean Clinical assessment Adequate cough Absence of excessive tracheobronchial secretion Resolution of disease acute phase Objective measurements Clinical stability - Stable CV status (FC 140, sbp mmhg) - Stable metabolic staus Adeguate oxygenation - SatO 2 >90% on FiO 2 40% or PatO 2 / FiO mmhg - PEEP 8 cmh 2 O Adequate pulmonary function - f R 35 breaths/min - MIP cmh 2 O, V T >5 ml/kg, VC >10 ml/kg - No significant respiratory acidosis Adeguate mentation - No sedation or stable neurologic patient Boles, Eur Respir J 2007

16

17 First attempt extubation success rate was 95%; Six of 7 patients who initially failed extubation succeeded on subsequent attempts; Only one patient underwent tracheostomy.

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20 Protocol: 1. NIV delivered immediately after extubation; 2. Man and/or mech assisted coughing to clear secretions.

21 1. Preventive use of NIV plus assisted coughing is effective to avert the need for reintubation. 2. Subjects with substantial swallowing dysfunction may still encounter particular difficulties

22 Disadvantages of hospitalization for NMD patients 1. Lack specific facilities for patients with physical disabilities and for their carers / family to stay; 2. Need of adequate family support to allow daily attendance; 3. Not appropriate for patients likely to experience problems with acclimatisation; 4. Risk of nosocomial infections. Greater satisfaction with home care

23 May a Hospital at Home model be as effective as hospitalization for the management of exacerbation in NMD patients?

24 Hospital at home : definition A service that provides active treatment by health care professionals, in the patient s home, of a condition that otherwise would require hospitalization.

25 Aim of the study To evaluate the efficacy and safety of a hospital-at-home model for the management of Respiratory Tract Infections in NMD patients.

26 Patients Study group: 26 NMD subjects suffering from severe respiratory tract infection treated with a hospital-at-home program; Control group: 27 subjects who were hospitalized Inclusion criteria: Respiratory tract infection: one or more of the following symptoms or signs: fever, throat irritation or sore throat, hoarseness, and cough diagnosis of pneumonia: concomitant presence of infiltrates on chest x-ray Urgent need for hospitalization: difficulty in breathing need for continuous noninvasive ventilatory support oxyhemoglobin desaturation with need for assisted cough Exclusion criteria: requirement for critical care with 24-hour surveillance living outside the geographic area covered by our district nurse service no non-professional caregivers or caregiver networks at home

27 Anthropometric, Clinical, Pulmonary Function, and Blood Gas Data at Study Entry

28 Non-Invasive Ventilation Portable ventilator Interventions Continuous use, except for min periods of rest Oronasal mask Manually and/or Mechanically Assisted Cough whenever SpO2, decreased, the ventilator peak inspiratory pressure increased, or the subject had an increase in dyspnea or sense of retained secretions. first 3 days: administered by a respiratory therapist who visited the subjects each morning; subsequently: administered by trained nonprofessional caregivers Continuous SpO2 Monitoring Standard pharmacologic treatment Pulmonology Visit at Home first 3 days: each morning subsequently: at the discretion of the district nurses or patient s GP District Nurse Visit at Home assessment of the subject s adherence and response to treatment requirement for a pulmonology visit each morning and afternoon until recovery from exacerbation. Telephone access to the pulmonologists of our division

29 Results In the hospital-at-home group, 18 (69.2%) responded well, with an uncomplicated course, and 8 required hospitalization.

30 Outcomes and Direct Costs of Healthcare of Subjects Treated With the Hospital-at- Home Model Versus Hospitalized Subjects

31 By multivariate analysis, hospital-at-home failure was independently correlated with type of NMD, with an odds ratio of failure of 17.3 for subjects with ALS. None of the other covariates had any significant effect on hospital-at-home failure. Anthropometric, Clinical, Pulmonary Function, and Blood Gas Data at Study Entry of Subjects Successfully Treated With the Hospitalat- Home Model Versus Those Who Required Hospital Admission

32 Hospital at home for exacerbated NMD patients Conclusions 1. Management at home is a viable option 2. Careful home monitoring is mandatory 3. Patients at risk of failing at home should be timely identified 4. Hospital at home can be problematic or even ineffective in ALS subjects 5. Non-professional caregivers play a critical role in the transition of the care from hospital to home 6. The cost of hospital-at-home can be impressively lower than hospital care

33 From Nocturnal to Full Time NIV use

34 When is full time MV required? 1. Worsening of the symptoms and dyspnoea during the day; 2. Excessive increases in PaCO2 ; 3. VC mL. Extension is empirically driven Toussaint, Chronic Respiratory Disease 2007

35 Ventilator-dependent patient: the one who requires ventilation for 18 hours/day

36 Potential Disadvantages of Long-Term Tracheostomy Expense of procedure Higher risk of respiratory infection Formation of granulation tissue Airway stenosis / malacia Tracheoinnominate-artery fistula Tracheoesophageal fistula Impairs speech and swallowing Skilled assistance for suctioning Increased carer burden Social issues around stoma and tracheostomy tube

37 To be successful with continuous NIV, the ventilator user must realise three goals: Optimise and maintain respiratory system compliance by frequent full insufflation Able to use a variety of interfaces which are alternated night and day Able to practice techniques to enhance peak cough flows.

38 Requirements for Home Full-time Ventilation Carefully selected and motivated individuals; Intact upper airway function; Access to centres with expertise in nocturnal and diurnal ventilation; Access to adequate levels of carers who are skilled in NIV and assisted coughing techniques. Toussaint, Chronic Respiratory Disease 2007

39 Outcome of patients on continuous NIV P Soudon, Chron Respir Dis 2008

40 Outcome of patients on continuous NIV Morbidity in 42 patients receiving ventilation either via tracheostomy (TR) or noninvasive interface (NI). P Soudon, Chron Respir Dis 2008

41 A Fatal Complication of Noninvasive Ventilation The patient was a previously healthy 53-year-old man with amyotrophic lateral sclerosis who was started on nocturnal noninvasive positive-pressure ventilation (inspiratory pressure, 10 cm of water; expiratory pressure, 2 cm of water). He tolerated this well and decided that he did not want invasive mechanical ventilation in the future. The patient's disease progressed, but he continued to work full-time and used noninvasive positive-pressure ventilation all night and most of the day. He obtained a second ventilator, which he kept at work. Noah Lechtzin, M.D., M.H.S. Charles M. Weiner, M.D. Lora Clawson, M.S.N., C.R.N.P. Johns Hopkins University School of Medicine NEJM 344: Number 7 Baltimore, MD 21287

42 More than a year after noninvasive ventilation was initiated, the patient's ventilating unit failed. The machine's error code indicated that there had been a power-supply failure. Respiratory distress quickly developed, and the patient was taken to a local hospital but died of respiratory failure before ventilation could be reinstituted. NEJM 344: Number 7

43 Full-time NIV user: minimizing the risk 2 ventilators if use of NIV in day > 4hrs. Service & Maintenance Cough machine: indications reduced cough (PF <160), poor clearance of secretions despite assisted cough techniques, physio on NIV, ambu bag Continued caregiver training and support [ventilator function, back-up battery systems, back-up ventilator function,action skills for emergencies]. Problem solving approach Clear advance directives

44 Adapting to the Worsening of the LTMV Patient: Take home messages Clinicians should remain vigilant to any potential change in patients clinical status; All settings, interfaces, and strategies should be employed to achieve goals of good health and optimized quality of life; Every patient is unique!

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