Home Mechanical Ventilation

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1 The International Convention Centre (ICC), Birmingham September 2017 Home Mechanical Ventilation Martin Latham Nurse Specialist in Sleep Disordered Breathing St James s University Hospital Leeds

2 What s New in Home Mechanical Ventilation Specialist Commissioning - current thinking? Hot HMV and recent research. Novel modes of ventilation. Changing demographic.

3 NHS England Specialist commissioning for home ventilation A suggested hub and spoke arrangement between local services and specialist centres: Local Service Local Service Specialist Service Local Service Specialist care Shared care Local care Local Service Local Service With sleep service With sleep service

4 NHS England complex home ventilation criteria for specialist centres Patients who meet the following criteria; Assisted invasive ventilation via tracheostomy. Patients treated with NIV who are transitioning from Paediatric Services. Individuals treated with NIV who have complex requirements necessitating repeated specialist multidisciplinary input (e.g. Neurology, Cardiology DMD, spinal muscular atrophy, Becker s muscular dystrophy, Limb Girdle Muscle Dystrophy, and Myotonic Dystrophy). Individuals treated with NIV (or at risk of ventilatory failure due to the progressive nature of the disease concerned) who require expert, multidisciplinary physiotherapy input (e.g. provision of cough-assist advice and devices in those for example with Muscular Dystrophies and MND). Assisted non-invasive ventilation in patients with a requirement for complex ventilation assessment and/ or management. e.g: Patients who require assisted ventilation for 14 hours or more during a 24 hour period are at risk of significant clinical harm if ventilation is interrupted. Back-up ventilators and consumables are required.

5 NHS England proposed complex home ventilation patient matrix Specialist centre Shared care Local service

6 Possible specialist centres Numbers of Patients (Tracheostomised) 2016 Manchester 2000 (30) Liverpool Stoke 900 Birmingham Oxford 700 Bristol Newcastle 560 (30) Leeds 1000 (55) Hull 215 Sheffield Nottingham Leicester 450 (60) Papworth 1500 Brompton Lane Fox 1800 Plymouth 400 (80) Southampton

7 NHS England Specialist commissioning for home ventilation where next? No new money Establish a national (England) register - talks ongoing Zero tariff contracting?

8 HOT HMV Reduced early readmission rates with HOT HMV v HOT alone in persistent hypercapnoea Murphy et al (2016)

9 HOT HMV Reduced early readmission rates with HOT HMV v HOT alone in persistent hypercapnoea Murphy et al (2016) Patients who remain hypercapnic (PaCO2 greater than 7 kpa) at 2 to 6 weeks post discharge after receiving NIV acutely for an AECOPD benefit from domiciliary NIV in terms of reducing the risk of readmission.

10 Dutch Rescue study Struik FM, Sprooten RTM, Kerstjens HAM,et al. Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after ventilator support for acute respiratory failure: a randomised, controlled, parallel-group study. Thorax 2014;69: Dutch RESCUE trial confirmed the long-standing observation that blood gases may improve post-discharge. Like LTOT we should not usually be sending patients home from hospital with a ventilator following an acute exacerbation of COPD. Like LTOT there will of course be some patients who never reach clinical stability and then one just has to get on and do it.

11 HMV & COPD The Leeds view Some patients will fail to wean after acute NIV and will proceed straight to HMV (NCEPOD = 7.2%). ABG should be done shortly (24 to 48 hours) before discharge and if PaCO2 > 7 kpa, they tolerated NIV well and would be willing to use it long term at home patient to be seen 2 weeks post discharge for repeat ABG. The patient who hated NIV and did not use it acutely is not going to be a good candidate for HMV but should still be reviewed. NCEPOD (2017) Acute Non-Invasive Ventilation: Inspiring Change

12 OHS & HMV Howard ME, Piper AJ, Stevens B, Et Al. A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome. Thorax 2016; 0: 1-8

13 OHS & HMV Howard ME, Piper AJ, Stevens B, Et Al. A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome. Thorax 2016; 0: 1-8 Patients stabilised first with NIV if needed, once ph normal randomised to CPAP or HMV. CPAP & HMV equally well tolerated with similar failure rates. CPAP group had slightly higher CO 2 at 1 month. Severity of failure at presentation only predictor of continuing failure at 3 months.

14 Novel modes of ventilation Targeted volume modes +/- auto EPAP Assisted Servo Ventilation Smart Devices

15 The changing demographic In 1999 there were 141 children on home ventilation Jardine, E. et al.. (1999) Current status of long term ventilation of children in the United Kingdom: Questionnaire survey. British Medical Journal. 318 By 2010 there were about 2000 children under 16 on home ventilation. Wallis, C. et al.. (2010) Children on long-term ventilatory support: 10 years of progress. Archives of Disease in Childhood. 96,11

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