(BQ) Part 1 book “Principles and practice of mechanical ventilation” has contents: Historical background, physical basis of mechanical ventilation, indications, conventional methods of ventilatory support, alternative methods of ventilator support, noninvasive methods of ventilator support,… and other contents.
Principles and Practice of Mechanical Ventilation Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, 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Sareen, Damien, Kate, and Kieran This page intentionally left blank CONTENTS Contributors xi Preface xxi Pressure-Controlled and Inverse-Ratio Ventilation 227 Marcelo B P Amato and John J Marini I HISTORICAL BACKGROUND 10 Positive End-Expiratory Pressure 253 Paolo Navalesi and Salvatore Maurizio Maggiore Historical Perspective on the Development of Mechanical Ventilation V Gene L Colice II PHYSICAL BASIS OF MECHANICAL VENTILATION 43 Classification of Mechanical Ventilators and Modes of Ventilation 45 Robert L Chatburn 11 Airway Pressure Release Ventilation 305 Christian Putensen 12 Proportional-Assist Ventilation 315 Magdy Younes 13 Neurally Adjusted Ventilatory Assist 351 Basic Principles of Ventilator Design 65 Robert L Chatburn and Eduardo Mireles-Cabodevila III INDICATIONS 99 Indications for Mechanical Ventilation 101 Franco Laghi and Martin J Tobin IV CONVENTIONAL METHODS OF VENTILATORY SUPPORT 137 Setting the Ventilator ALTERNATIVE METHODS OF VENTILATOR SUPPORT 303 139 Steven R Holets and Rolf D Hubmayr Assist-Control Ventilation 159 Jordi Mancebo Intermittent Mandatory Ventilation 175 Catherine S Sassoon Christer Sinderby and Jennifer C Beck 14 Permissive Hypercapnia 377 John G Laffey and Brian P Kavanagh 15 Feedback Enhancements on Conventional Ventilator Breaths 403 Neil MacIntyre and Richard D Branson VI NONINVASIVE METHODS OF VENTILATOR SUPPORT 415 16 Negative-Pressure Ventilation 417 Antonio Corrado and Massimo Gorini 17 Noninvasive Respiratory Aids: Rocking Bed, Pneumobelt, and Glossopharyngeal Breathing 435 Nicholas S Hill 18 Noninvasive Positive-Pressure Ventilation 447 Nicholas S Hill Pressure-Support Ventilation 199 Laurent J Brochard and Francois Lellouche vii viii Contents VII UNCONVENTIONAL METHODS OF VENTILATOR SUPPORT 493 Ahmet Baydur 19 High-Frequency Ventilation 495 33 Chronic Ventilator Facilities 777 Alison B Froese and Niall D Ferguson Stefano Nava and Michele Vitacca 20 Extracorporeal Life Support for Cardiopulmonary Failure 517 34 Noninvasive Ventilation on a General Ward Heidi J Dalton and Pamela C Garcia-Filion 21 Extracorporeal Carbon Dioxide Removal 32 Mechanical Ventilation in Neuromuscular Disease 761 543 Antonio Pesenti, Luciano Gattinoni, and Michela Bombino IX PHYSIOLOGIC EFFECT OF MECHANICAL VENTILATION 803 22 Transtracheal Gas Insufflation, Transtracheal Oxygen Therapy, Emergency Transtracheal Ventilation 555 35 Effects of Mechanical Ventilation on Control of Breathing 805 Umberto Lucangelo, Avi Nahum, and Lluis Blanch Dimitris Georgopoulos VIII VENTILATOR SUPPORT IN SPECIFIC SETTINGS 571 36 Effect of Mechanical Ventilation on Heart–Lung Interactions 821 Hernando Gomez and Michael R Pinsky 23 Mechanical Ventilation in the Neonatal and Pediatric Setting 573 37 Effect of Mechanical Ventilation on Gas Exchange 851 Peter C Rimensberger and Jürg Hammer Roberto Rodriguez-Roisin and Antoni Ferrer 24 Mechanical Ventilation during General Anesthesia 597 Paolo Pelosi, Claudia Brusasco, and Marcelo Gama de Abreu X ARTIFICIAL AIRWAYS AND MANAGEMENT 869 25 Independent Lung Ventilation 629 38 Airway Management 871 David V Tuxen Aaron M Joffe and Steven Deem 26 Mechanical Ventilation during Resuscitation 655 39 Complications of Translaryngeal Intubation Holger Herff and Volker Wenzel John L Stauffer 27 Transport of the Ventilator-Supported Patient 669 40 Care of the Mechanically Ventilated Patient with a Tracheotomy 941 Richard D Branson, Phillip E Mason, and Jay A Johannigman 28 Home Mechanical Ventilation 683 John E Heffner and David L Hotchkin Wolfram Windisch 29 Mechanical Ventilation in the Acute Respiratory Distress Syndrome 699 COMPLICATIONS IN XI VENTILATOR-SUPPORTED PATIENTS 971 John J Marini 30 Mechanical Ventilation for Severe Asthma 727 41 Complications Associated with Mechanical Ventilation 973 James W Leatherman Karin A Provost and Ali A El-Solh 31 Mechanical Ventilation in Chronic Obstructive Pulmonary Disease 741 42 Ventilator-Induced Lung Injury Franco Laghi 793 Mark W Elliott 995 Didier Dreyfuss, Nicolas de Prost, Jean-Damien Ricard, and Georges Saumon 895 ix Contents 43 Ventilator-Induced Diaphragmatic Dysfunction 1025 56 Ventilator-Supported Speech 1281 Jeannette D Hoit, Robert B Banzett, and Robert Brown Theodoros Vassilakopoulos 57 Sleep in the Ventilator-Supported Patient 1293 44 Barotrauma and Bronchopleural Fistula 1041 Patrick J Hanly Andrew M Luks and David J Pierson 58 Weaning from Mechanical Ventilation 45 Oxygen Toxicity 1065 1307 Martin J Tobin and Amal Jubran Robert F Lodato 59 Extubation 46 Pneumonia in the Ventilator-Dependent Patient 1091 Jean E Chastre, Charles-Edouard Luyt, and Jean-Yves Fagon 47 Sinus Infections in the Ventilated Patient 1123 Jean-Jacques Rouby and Qin Lu 1353 Martin J Tobin and Franco Laghi XIV ADJUNCTIVE THERAPY 1373 60 Surfactant 1375 James F Lewis and Valeria Puntorieri EVALUATION AND MONITORING XII OF VENTILATOR-SUPPORTED PATIENTS 1137 48 Monitoring during Mechanical Ventilation 1139 Amal Jubran and Martin J Tobin 61 Nitric Oxide as an Adjunct 1389 Klaus Lewandowski 62 Diaphragmatic Pacing 1405 Anthony F DiMarco 63 Bronchodilator Therapy 1419 MANAGEMENT OF VENTILATORXIII SUPPORTED PATIENTS 1167 49 Prone Positioning in Acute Respiratory Failure 1169 Luciano Gattinoni, Paolo Taccone, Daniele Mascheroni, Franco Valenza, and Paolo Pelosi 50 Pain Control, Sedation, and Neuromuscular Blockade 1183 John P Kress and Jesse B Hall 51 Humidification Rajiv Dhand 64 Inhaled Antibiotic Therapy 1447 Jean-Jacques Rouby, Ivan Goldstein, and Qin Lu 65 Fluid Management in the Ventilated Patient 1459 Andrew D Bersten XV ETHICS AND ECONOMICS 1471 66 The Ethics of Withholding and Withdrawing Mechanical Ventilation 1473 1199 Jean-Damien Ricard and Didier Dreyfuss Michael E Wilson and Elie Azoulay 52 Airway Secretions and Suctioning 1213 67 Economics of Ventilator Care Gianluigi Li Bassi 53 Fighting the Ventilator 1237 Martin J Tobin, Amal Jubran, and Franco Laghi 54 Psychological Problems in the Ventilated Patient 1259 Yoanna Skrobik 55 Addressing Respiratory Discomfort in the Ventilated Patient 1267 Robert B Banzett, Thomas Similowski, and Robert Brown Shannon S Carson 68 Long-Term Outcomes after Mechanical Ventilation 1501 Margaret Sutherland Herridge Index 1517 1489 788 Part VIII Ventilator Support in Specific Settings oxygen therapy who never required ICU admission After discharge, cognition and mobility improved to levels found in stable COPD patients on oxygen therapy PROBLEMS UNIQUE TO CHRONIC FACILITIES Finances Comparison between studies of different centers and different periods may be inappropriate because weaning success seems strongly related to patient complexity and comorbidities, hospital organization and personnel expertise, availability of early physiotherapy, use of weaning management techniques, patient autonomy, and family preparation for home discharge with a ventilator Published data based on small samples, different clinical histories, costs based on patients in a single hospital, different reimbursements, variations in care habits among different countries, and differences in interventions, equipment, and staff involvement reduce the generalizability of cost assessment In all studies, lower costs principally arise from a lower staffing ratio; other reductions are related to decreased room charges, lower overheads, simpler (usually noninvasive) monitoring, and changes in the pattern of diagnostics and therapeutics Costs are likely to change across years, particularly for admissions and related provisions because reimbursement based on DRG does not necessarily reflect real costs of individual treatment In this respect, CVFs have a peculiar system of reimbursement that deserves special attention.119 As shown in Table 33-6, most observational studies estimate that the daily cost of care for ventilator-dependent patients is lower in a CVF than in an ICU Indeed, the difference in health care systems between the United States and most other industrialized countries (i.e., near universal health insurance coverage)122 makes any comparison between different countries futile Proposed modalities of reimbursements in the United States include: (a) single payment for all patients within a DRG with specific weight severity; (b) payment according to variability of units dedicated to prolonged mechanical ventilation; (c) reduced payment for short length of stay; (d) ability to balance with very long stay costs; and (e) bonuses for unweanable patients Familiarity with correct reimbursement codes for documentation of time spent caring for patients and appropriate documentation has been advocated for physicians involved in CVFs123 because of the complexity of the encounter with subsequent different payments To address the problem of underreimbursement, some CVFs are now licensed as DRGgrouping-exempt,56 and are required by the Health Care Financial Administration to maintain a mean length of stay more than 25 days and usually fewer than 90 days In the United States, long-term acute care facilities are reimbursed under regulations of the Tax Equity and Fiscal Responsibility Act (TEFRA)124 for care provided to Medicare patients Charges are reimbursed up to the annual maximum cap for the facility, calculated during a 12-month period designated as the base year Hospitals incur penalties when charges for Medicare exceed the discharge target amount and receive incentives if charges are reduced in the subsequent years This policy, unfortunately, has led, as it did for rehabilitation hospitals, to substantial extra costs, including increases in payments to hospitals and doctors and numbers of hospital days for the average patient.124 In most European countries, the health care system is funded primarily by government Therefore, the vast majority of public hospitals and some private hospitals receive most of their funds through a national health service Most beds are devoted to the treatment of acutely ill patients, independent of the baseline disease (i.e., medical or surgical), and are reimbursed through TABLE 33-6: COSTS PER DAY FOR A VENTILATOR-DEPENDENT PATIENT ADMITTED TO AN INTENSIVE CARE UNIT OR TO A CHRONIC VENTILATOR FACILITY Authors (Ref) Sheinhorn72 Latriano58 Bagley74 Nava120 Gracey56 Engoren116 Seneff103 Linsday87 Halpern1 Pilcher62 O’Connor21 Carpene121 Kahn27 Year of Publication 1994 1996 1997 1997 2000 2000 2000 2004 2004 2005 2009 2010 2010 Year of Analysis ? ? 1995 1995 1998 ? ? ? 2000 1997 to 2000 2002 to 2003 2008 to 2009 1997 to 2006 Type of Unit WC (outside acute care H) Nonmonitored care floor (inside acute care H) WC (outside acute care H) RICU (outside acute care H) CVDU (inside acute care H) Cardiac stepdown unit (inside acute care H) ICU Nursing home Daily cost per patient admitted to a critical care bed Cost per day Cost per day Mean cost saving per patient Mean cost per patient Note: Reference is the actual daily cost of a critical care bed in year 2000 in the United States Abbreviations: CVDU, chronic ventilator-dependent unit; H, hospital; RICU, respiratory intensive-care unit; WC, weaning center Daily Costs $980 $453 $630 $865 $1084 $439 $4174 $303 $2647 €1350 $1054 €39.8452 $21.766 Chapter 33 Chronic Ventilator Facilities a DRG-based system A minor share is devoted to the care of chronically ill patients The latter beds are located inside rehabilitation wards of acute care hospitals or within independently structured rehabilitation hospitals For acute care, the DRG-based reimbursement per case is applied For chronic care, reimbursement is on a per diem basis, allowing for some increase according to DRG classification This per diem fee applies for only a limited number of days (40 to 60), after which the fee is curtailed drastically Mean duration of stay in CVFs differs considerably between patients with an impressively high standard deviation Nasraway et al37 reported the duration of hospital stay to range from to 2125 days Because the time spent in CVFs differs so greatly, it is clear that exemption from the DRGbased payment system is granted to avoid massive losses The per diem reimbursement up to relatively small ceiling of days, however, may not achieve reasonable reimbursement Staffing CVFs, especially those outside acute care hospitals, are still characterized by heterogeneous staffing Most of the centers share common views about the equipment to be used (i.e., ventilators and monitoring systems) and the overall multidisciplinary organization, aimed at improving the autonomy of patients, privacy, and environment There is, however, considerable discrepancy concerning the training of personnel, especially of nurses The availability of skilled nurses in extended care facilities in the Boston area, as determined by an informal survey.37 Marked differences exist in the care that each center provides to long-term ventilated patients The authors37 state that “some facilities may accept ventilator-dependent patients but may not be able to provide for all their needs, especially when serious infections or other setbacks ensue.” Nurses working in a CVF should be specifically trained not only in acute lifesaving procedures, such as resuscitation, but also in specific “chronic” procedures, such as bronchial toilet, prevention of sores at the tracheotomy site, and positioning of the tracheal cannula Vitacca et al125 studied the allocation of nursing time in a respiratory unit belonging to a rehabilitation center In the first days after admission, time devoted to care of a ventilator-dependent patient consumed approximately 45% of a nursing shift Respiratory therapists should be skilled in weaning protocols that shorten the duration of mechanical ventilation The hospital team should be trained in clinical tests (i.e., bronchoscopy, fluoroscopy, assessment of respiratory muscle function) that may help the clinicians decide whether or not a patient can have the tracheotomy removed.21 Special attention should be paid to the diagnosis of ICU-acquired neuromuscular abnormalities, which increase the time to weaning Diagnosis may require electrophysiologic studies and needle electromyography of the limb and respiratory muscles.126,127 The global economic crisis in recent years may induce administrators to reduce the number of hospital employees, 789 especially outside critical care settings In the past, however, a reduction of hospital staff caused a worsening in clinical performance For example, studies show a lower mortality and length of stay with high-intensity physician staffing.128 Dara and Afessa observed a longer stay during the periods with less intensivists in a medical ICU.129 Differences in the intensivist-to-ICU-bed ratio, ranging from 1:7.5 to 1:15, were not associated with differences in ICU or hospital mortality, although a ratio of 1:15 was associated with an increased ICU length of stay.129 An Italian multicenter study revealed a progressive decrease in the doctor-to-patient ratio secondary to a reduction of medical personnel consequent to the recent restriction in the reimbursement policy of the National Health Care System.115 The negative influence of reduced medical staff availability on weaning success rate, home discharge, and length of stay has been previously demonstrated,115 providing empirical evidence for a link between organization and outcome in dedicated weaning facilities CONCLUSION Over the past 15 years, the availability of ICU beds, new technology, and improved levels of care have produced a new population of patients termed survivors of catastrophic illness These patients commonly require prolonged weaning The rate of achieving complete ventilator independence in specific and dedicated weaning units is generally high It has been demonstrated that these units are cost-saving alternatives to an ICU for carefully selected patients Survivors have an acceptable long-term quality of life Weaning success, however, does not in itself solve other severe problems, such as the heavy financial and human burdens that the high level of dependency imposes on families, caregivers, and health service organizations once these patients are discharged from a protected environment Long-term acute care hospitals play an increasingly important role in patients with chronic critical illness Yet few data exist to guide decision making about transfer or to inform policy decisions about whether to support or restrict this rapidly growing cost center.27 The different international medical systems need to adopt new organizational innovations and highlight the need for a diverse program of comparative effectiveness research to determine the optimal organization of care for patients recovering from critical illness, including the best way to maximize survival and control costs for this high-risk patient group.27 For these reasons, rigorous studies on structural factors relating to the outcome of patients with mechanical ventilation are mandatory With increased efforts to reduce health care costs, patients will be shifted away from ICUs toward other clinical settings, such as dedicated weaning facilities, to care for more, and increasingly complex, patients.130 It is imperative that we critically evaluate these changes as they occur More research is needed on the impact of weaning facilities on costs and outcomes In particular, the following questions should be assessed: (a) whether weaning facilities best operate as units within hospitals or as 790 Part VIII Ventilator Support in Specific Settings stand-alone hospitals; (b) the optimum nurse, physician, and ancillary staffing of weaning facilities; and (c) the spillover effects of weaning facilities on critical care.130 In conclusion, the main benefits of chronic ventilator facilities are (a) the possibility of relieving congestion of ICU beds, (b) maintaining a high level of nursing assistance, (c) responding to sudden changes in a patient’s clinical condition, (d) allowing enough 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unit: development and outcomes Chest 1997;111:1024–1029 75 Votto J, Brancifort JM, Scalise PJ, et al COPD and other diseases in chronically ventilated patients in a prolonged respiratory care unit: a retrospective 20-year survival study Chest 1998;113:86–90 76 Scalise PJ, Gerardi DA, Wollschlager CM, Votto JJ A regional weaning center for patients requiring mechanical ventilation: an 18 month experience Conn Med 1997;61:387–389 77 Campbell S HCFA clamping down on long-term acute care “hospitals within hospitals.” Health Care Strateg Manage 1997;15:12–23 78 Nava S, Rubini F, Zanotti E, et al Survival and prediction of successful ventilator weaning in COPD patients requiring mechanical ventilation for more than 21 days Eur Respir J 1994;7:1645–1652 79 Vitacca M, Clini E, Scalvini S, et al Cardiopulmonary intermediate intensive unit: time course of two years activity Monaldi Arch Chest Dis 1993;48:296–300 80 Carson SS, Bach PB, Brzozowski L, Leff A Outcomes after long-term acute care: an 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Shifting care of chronic ventilator-dependent patients from the intensive care unit to nursing home Jt Comm J Qual Saf 2004;30:257–265 88 Frutos-Vivar F, Esteban A, Apezteguía C, et al Outcome of mechanically ventilated patients who require a tracheostomy Crit Care Med 2005;33:290–298 89 Cox CE, Carson SS, Holmes GM, et al Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993–2002 Crit Care Med 2004;32:2219–2226 90 Perren A, Conte P, De Bitonti N, et al From the ICU to the ward: cross-checking of the physician’s transfer report by intensive care nurses Intensive Care Med 2008;34(11):2054–2056 91 Weaning program for mechanically ventilated patients, Montreal Chest Institute, MUHC Updated June 7, 2000 http//www.meakins mcgill.ca/respdiv/ 92 LeGall JR, Lomeshow S, Saulnier F A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study JAMA 1993;270:2957–2963 93 Knaus WA, Wagner DP, Draper EA, et al The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults Chest 1991;100:1619–1636 94 Cullen DJ, Nemeskal AR, Zaslavsky AM Intermediate TISS: a new therapeutic intervention scoring system for non-ICU patients Crit Care Med 1994;22:1406–1411 95 Zimmerman JE, Wagner DP, Knaus WA, et al The use of risk predictions to identify candidates for intermediate care units: implications for intensive care utilization and costs Chest 1995;108:490–499 792 Part VIII Ventilator Support in Specific Settings 96 Gillespie DJ, Marsh HM, Divertie MB, Meadows JA 3rd Clinical outcome of respiratory failure in patients requiring prolonged (>24 hours) mechanical ventilation Chest 1986;90:364–369 97 Vincent JL, Burchardi H Do we need intermediate care units? Intensive Care Med 1999;25:1345–1349 98 Robson V, Poynter J, Lawler PG, Baudouin SV The need for a regional weaning centre, a one-year survey of intensive care weaning delay in northern region of England Anaesthesia 2003;58:161–182 99 Franklin CM, Rackow EC, Mamdani B, et al Decreases in mortality in a large urban medical service by facilitating access to critical care: an alternative to rationing Arch Intern Med 1988;148:1403–1405 100 Heyland DK, Konopad E, Noseworthy TW, et al Is it “worth-while” to continue treating patients with a prolonged stay (>14 days) in the ICU? An economic evaluation Chest 1998;114:192–198 101 Engoren M, Arslanan-Engoren C, Fenn-Buderer N Hospital and long-term outcome after tracheostomy for respiratory failure Chest 2004;125:220–227 102 Rudy E, Daly B, Douglas S, et al Patient outcomes for chronically ill: special care unit versus intensive care unit Nurs Res 1995;44: 324–331 103 Seneff MG, Wagner D, Thompson D, et al The impact of long-term acute care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation Crit Care Med 2000; 28:342–350 104 Kahn JM, Rubenfeld GD, Rohrbach J, Fuchs BD Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients Med Care 2008;46:1226–1233 105 Engoren M, Arslanian-Engoren C Hospital and long-term outcome of trauma patients with tracheostomy for respiratory failure Am Surg 2005;71(2):123–127 106 Scheinhorn DJ, Hassenpflug MS, Votto JJ, et al for the Ventilation Outcomes Study Group Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation Chest 2007;131(1): 76–84 107 Vitacca M, Callegari G, Sarva M, et al Physiological effects of meals in difficult-to-wean tracheostomised patients with chronic obstructive pulmonary disease Intensive Care Med 2005;31:236–242 108 Freichels T Financial implications and recommendations for care of ventilator dependent patients J Nurs Adm 1993;23:16–20 109 De Vivo MJ, Ivie CS Life expectancy of ventilator dependent persons with spinal cord injuries Chest 1995;108:226–232 110 Escarrabill J, Estopá R, Farrero E, et al Long term mechanical ventilation in amyotrophic lateral sclerosis Respir Med 1998;92: 438–441 111 Modawal A, Candadai NP, Mandell KM, et al Weaning success among ventilator-dependent patients in a rehabilitation facility Arch Phys Med Rehabil 2002;83:154–157 112 Stoller JK, Xu M, Masha E, Rice R Long-term outcomes for patients discharged from a long term hospital based weaning unit Chest 2003;124:1892–1899 113 Ceriana P, Delmastro M, Rampulla C, Nava S Demographics and clinical outcomes of patients admitted to a respiratory intensive care unit located in a rehabilitation centre Respir Care 2003;48:670–676 114 Chadwich R, Nadig V, Oscroft NS, et al Weaning from prolonged invasive ventilation in motor neuron disease: analysis of outcomes and survival J Neurol Psychiatry 2011;82(6):643–645 115 Polverino E, Nava S, Ferrer M, et al Patients’ characterization, hospital course and clinical outcomes in five Italian respiratory intensive care units Intensive Care Med 2010;36:137–142 116 Engoren M Marginal cost of liberating ventilator dependent patients after cardiac surgery in a stepdown unit Ann Thorac Surg 2000; 70:182–185 117 Ambrosino N, Bruletti G, Scala V, et al Cognitive and perceived health status in patients recovering from an acute exacerbation of COPD: a controlled study Intensive Care Med 2002;28:170–177 118 Chatila W, Kreimer DT, Criner GJ Quality of life in survivors of prolonged mechanical ventilatory support Crit Care Med 2001;29: 737–742 119 Understanding costs and cost-effectiveness in critical care Report from the second American Thoracic Society workshop on outcomes research Am J Respir Crit Care Med 2002;165:540–550 120 Nava S, Evangelisti I, Rampulla C, et al Human and financial costs of noninvasive mechanical ventilation in patients affected by COPD and acute respiratory failure Chest 1997;111:1631–1638 121 Carpene N, Vagheggini G, Panait E, et al A proposal of a new model for long-term weaning: respiratory intensive care unit and weaning centre Respir Med 2010;104:1505–1511 122 Davis K Slowing the growth of health care costs—learning from international experience N Engl J Med 2008;359:1751–1755 123 White AC, O’Connor HH, Kirby K Prolonged mechanical ventilation Review of care settings and an update on professional reimbursement Chest 2008;133:539–545 124 Chan L, Koepsell DT, Deyo R, et al The effect of Medicare’s payment system for rehabilitation hospitals on length of stay, charges and total payments N Engl J Med 1997;337:978–985 125 Vitacca M, Clini E, Porta R, Ambrosino N Preliminary results on nursing workload in a dedicated weaning centre Intensive Care Med 2000;26:796–799 126 Mahler J, Rutledge F, Remtulla H, et al Neuromuscular disorders associated with failure to wean from the ventilator Intensive Care Med 1995;21:737–743 127 De Jonghe B, Bastuji-Garin S, Sharshar T, et al Does ICU-acquired paresis lengthen weaning from mechanical ventilation Intensive Care Med 2004;30:1117–1121 128 Pronovost PJ, Angus DC, Dorman T, et al Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review JAMA 2002;288:2151–2162 129 Dara SI, Afessa B Intensivist-to-bed ratio: association with outcomes in the medical ICU Chest 2005;128:567–572 130 Kahn JM The evolving role of dedicated weaning facilities in critical care Intensive Care Med 2010;36:8–10 NONINVASIVE VENTILATION ON A GENERAL WARD 34 Mark W Elliott EVIDENCE AND RATIONALE FOR NONINVASIVE VENTILATION ON A GENERAL WARD Acute Noninvasive Ventilation Elective Ventilation for Chronic Ventilatory Failure SELECTION OF PATIENTS FOR NONINVASIVE VENTILATION IN A GENERAL WARD Acute Respiratory Failure WHERE SHOULD NONINVASIVE VENTILATION BE PERFORMED? Acute Noninvasive Ventilation: ICU or General Ward? Elective Noninvasive Ventilation: General Ward or Chronic Care Facility? The Advantage of the General Ward ECONOMIC CONSIDERATIONS In any discussion about location of a noninvasive ventilation (NIV) service, it is important to note that the model of hospital care differs between countries and that there may be significant differences even between hospitals within the same country There will be variations in staffing levels; the skills of doctors, nurses, and paramedical staff; and the sophistication of monitoring The terms intensive care unit (ICU), highdependency unit (HDU), and general ward have a different meaning to different people Care therefore must be taken when extrapolating experience and results obtained in one environment to other hospitals and countries The United Kingdom’s King’s Fund panel1 defines intensive care as “a service for patients with potentially recoverable diseases who can benefit from more detailed observation and treatment than is generally available in the standard wards and departments.” The definition of HDU is less clear, with some HDUs allowing invasive monitoring, whereas in others only noninvasive monitoring is performed In some countries, specific respiratory ICUs and intermediate ICUs have been developed.2,3 Specifically, within the King’s Fund definition is the consideration of intensive care as a service rather than a place; critical care is provided within a continuum of primary, secondary, and tertiary care, and patients are categorized on the basis of their needs4 (Table 34-1) Movement through the different levels usually means transfer from one location to another Critical care outreach teams can advise on care as patients cross organizational boundaries and also facilitate transfer when this is needed.5,6 Although most acute NIV services are situated in a specific clinical area, a peripatetic model has been described and has some advantages.7,8 For the purposes of this chapter, the following definitions are used: IMPLICATIONS FOR STAFFING AND TRAINING THE FUTURE AND IMPORTANT UNKNOWNS CONCLUSION • Intensive care High ratio of staff to patients, facility for invasive ventilation and sophisticated monitoring • Intermediate respiratory ICU or HDU Continuous monitoring of vital signs, with a staffing ratio intermediate between an ICU and a general ward, in a specified clinical area Intubated patients (unless with tracheostomy) usually are not cared for in this environment • General ward Takes unselected emergency admission, and although most wards will have a particular speciality interest, it is likely that because of the unpredictability of demand, patients with a variety of conditions and degrees of severity will be cared for in the same clinical area Nurse staffing levels vary, but the intensity of nursing input available in HDUs and ICUs is not possible Only basic monitoring is available Another important issue when considering NIV in different locations is the severity and acuteness of the insult leading to ventilatory failure Ventilatory failure can be considered acute when it occurs on a background of normal function, acute-on-chronic when there is a sudden deterioration on a background of impaired function, or chronic when there is ventilatory failure but with no precipitating acute event Assisted ventilation can be considered necessary when 793 794 Part VIII Ventilator Support in Specific Settings TABLE 34-1: CLASSIFICATION OF INDIVIDUAL PATIENT DEPENDENCY Level 0: Patients whose needs can be met through normal ward care in an acute hospital Level 1: Patients at risk of their condition deteriorating or patients recently relocated from higher levels of care whose needs can be met in an acute ward with additional advice and support from the critical care team Level 2: Patients requiring more detailed observation or intervention, including support for a single failing organ system or postoperative care, and those stepping down from higher levels of care Level 3: Patients requiring advanced respiratory support alone or basic respiratory support, together with the support of at least two organ systems This level includes all complex patients requiring support for multiorgan failure without it death will ensue over a few hours or desirable when the primary aim is to improve quality of life and also to improve survival over the longer term EVIDENCE AND RATIONALE FOR NONINVASIVE VENTILATION ON A GENERAL WARD For additional information about noninvasive ventilation, see Chapter 18 Acute Noninvasive Ventilation CHRONIC OBSTRUCTIVE PULMONARY DISEASE NIV first became established as a viable technique for patients with acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease (COPD) in the ICU The most striking finding from the early randomized, controlled trials (RCTs) comparing NIV with conventional therapy was a reduction in the need for intubation,9,10 which in the largest study translated into improved survival and reduced length of both ICU and hospital stays.9 Complications, particularly pneumonia and other infectious complications, were reduced markedly.9,11–15 It is striking that NIV was administered for only a relatively small proportion (mean: hours) of each day9 or at modest levels for a longer period.10 With NIV, paralysis and sedation are not needed, and ventilation outside the ICU is an option Given the considerable pressure on ICU beds in some countries, the high costs, and that for some patients admission to ICU is a distressing experience,16 this is an attractive option There have been seven prospective, randomized, controlled studies of NIV outside the ICU either on general wards, in an intermediate unit, or in the emergency department.17–23 A more rapid improvement in abnormal physiology is a consistent finding, but it was only in the largest,22 adequately powered, study that a benefit in terms of outcome was seen Plant et al22 recruited 236 patients with an acute exacerbation of COPD, who were still hypercapnic, with a pH less than 7.35, and respiratory rate greater than 23 breaths/min on arrival on the ward A proportion of patients will improve just with medical therapy In a 1-year-period prevalence study24 of patients with acute exacerbations of COPD, 20% of 954 patients were acidotic on arrival in the emergency department; of these, 25% had completely corrected their pH by the time of arrival on the ward There was a weak relationship between partial pressure of arterial oxygen (Pa O2) on arrival at hospital and the presence of acidosis, suggesting that, in at least some patients, respiratory acidosis had been precipitated by high-flow oxygen therapy administered on the way to hospital The study was performed on general respiratory wards in thirteen centers NIV was applied, by the usual ward staff, using a bilevel device in spontaneous mode according to a simple protocol “Treatment failure,” a surrogate for the need for intubation, defined by a priori criteria, was reduced from 27% to 15% by NIV In-hospital mortality was reduced from 20% to 10% This study suggests that with adequate staff training, NIV can be applied with benefit outside the ICU by the usual ward staff and that early introduction of NIV in a general ward results in better outcomes than providing no ventilator support for acidotic patients outside the ICU A recent national audit in the United Kingdom,25 however, raised significant concerns about the provision of NIV in the “real” world Although it was not recorded in the audit, it is likely that the majority of patients received NIV outside of ICUs, mostly on general wards Two hundred and thirtytwo hospital units collected data on 9716 patients of whom 1077 received NIV Of concern 30% of patients with persisting respiratory acidosis did not receive NIV The mortality was higher in all acidotic groups receiving NIV than in those treated without Patients who had late-onset acidosis had a particularly poor prognosis confirming the results of an earlier case series.26 Interestingly, 11% of acidotic admissions had a pure metabolic acidosis There is a challenge in translating the results of RCTs into everyday clinical practice, especially when the particular technique involves significant technical expertise It reinforces the need for ongoing audit to ensure that standards are maintained CONDITIONS OTHER THAN CHRONIC OBSTRUCTIVE PULMONARY DISEASE Trials in acute exacerbations of COPD provide the biggest body of evidence on NIV NIV, however, is also used in other conditions, often on the basis of what has been learned in COPD Hypoxemic and Hypercapnic Respiratory Failure Obesity Obese patients may present with acute or acute-onchronic respiratory failure In numerical terms this patient group is increasing; the number of patients requiring home ventilation because of obesity-hypoventilation syndrome Chapter 34 Noninvasive Ventilation on a General Ward is increasing year on year, and in one study, patients with obesity now comprise the largest single group.27 For obese patients requiring ventilator support acutely, the outcome from invasive ventilation is generally poor.28 There are major practical problems associated with nursing critically ill obese patients, often requiring many pairs of hands and specialized lifting equipment for basic tasks There are no RCTs of the use of NIV in patients with ventilatory failure secondary to obesity A case series in which patients who received NIV were compared with those who refused it showed a survival advantage for those receiving NIV (97% vs 42%)29; this was not controlled and there may have been other reasons for the difference Very obese patients may have upper airway obstruction during sleep and because the impedance to inflation may be very high may require different ventilator modes.30 Neuromuscular Disease and Chest Wall Deformity Patients with acute respiratory failure secondary to neuromuscular disease and chest wall deformity are not widely studied because they are small in number Because of markedly reduced respiratory reserve, however, these patients are often challenging to wean from invasive ventilation and endotracheal intubation is best avoided if possible Ideally, at-risk patients should already be under follow-up in a specialist unit and have been warned of the symptoms of evolving respiratory failure and of the necessity to present to hospital early in case of changes in their condition Some patients will already have experienced a trial of domiciliary NIV As such they represent good candidates for NIV outside the ICU In addition to staff skilled in the delivery of NIV, therapists with expertise in secretion clearance techniques, including the use of mechanical insufflators or exsufflators,31,32 are vital in the management of these patients Cardiogenic Pulmonary Edema Cardiogenic pulmonary edema (CPE) represents a special case because the onset and recovery are usually both rapid Most patients present to the emergency room, but some develop CPE in the ward There have been seven systematic reviews (meta-analyses) on noninvasive ventilator assistance in CPE published since 2005.33–40 Overall, there was a significant reduction in mortality for those patients treated with continuous positive airway pressure (CPAP) and a trend toward improved survival with NIV.34 Both CPAP and NIV showed benefit when intubation was an outcome There was no difference in any outcome when CPAP and NIV were compared There was a trend toward an increase in myocardial infarction rate with NIV, but this was largely caused by the weighting of one study.41 Two recent trials may result in the reappraisal of the role of NIV in acute CPE.42,43 In the 3CPO trial,42 a multicenter, open, prospective RCT, patients were randomized to standard oxygen therapy, CPAP, or bilevel ventilation There was no difference between 7-day mortality for standard oxygen therapy (9.8%) and NIV (CPAP and bilevel ventilation, 9.5%; P = 0.87) The combined end point of 7-day death or intubation rate was 795 similar irrespective of NIV modality (11.7% vs 11.1%, CPAP vs bilevel ventilation respectively; P = 0.81) In comparison to standard oxygen therapy, NIV was associated with greater reductions in breathlessness scores, heart rate, acidosis, and hypercapnia at hour There were no treatment-related adverse events There were no differences in other secondary outcomes, such as myocardial infarction rate, intubation, length of hospital stay, or ICU admission rate In another trial,43 120 patients were enrolled in three French emergency departments to either CPAP or NIV There was no difference between interventions for any outcome Respiratory distress and physiology improved in both arms Only 3% of patients required intubation and one died within the first 24 hours These outcomes are different from the outcomes in the above meta-analyses, despite similar improvements in physiologic and gas exchange variables The 3CPO trial was adequately powered and recruited more patients than the total of all the studies included in the meta-analyses The discrepancy between results from one large, multicenter RCT and previous pooled data are not unique and the limitations of meta-analysis are well known.44 Individual trials were composed of small treatment group sizes that varied between nine and sixty-five patients with recruitment rates of only 10% to 30% (compared to 62% randomized in the 3CPO trial) In the meta-analyses, the small total number of outcome events was well below the recommended threshold of 200,45 limiting the generalizability of the findings The 3CPO trial may have failed to reveal a difference because the intervention was ineffectively delivered Mean pressures for both CPAP (10 cm H2O) and noninvasive positive pressure ventilation (IPAP 14/EPAP cm H2O) are comparable with previous studies, and improvements in physiologic variables are similar There was crossover between interventions in all three arms of the 3CPO trial and these were analyzed on an intention-to-treat basis There were differing reasons with respiratory distress and hypoxia being more likely in the control arm and lack of patient tolerance in the two intervention arms After these patients were removed from primary outcome analysis, there remained no significant difference between groups, although mortality rates were lower Previous trials have indicated that the physiologic improvement seen with NIV is translated into a reduction in tracheal intubation rates.33,34 In contrast, the 3CPO trial found no benefit in reducing intubation rates by NIV Reasons for this are unclear but may reflect the differing patient populations, concomitant therapies, and thresholds for intubation and mechanical ventilation Intubations rates in the standard therapy arms vary from 35% to 65% in early trials to 5% to 7% for recent trials in emergency department settings, despite similar severity of illness Intubation rate in the intervention arms have fallen considerably over time, with some initial trials reporting intubation rates of up to 35% whereas recent reports have consistently suggested rates of around 5% The recent trial43 from France reported a 3% intubation rate, almost identical to that in the 3CPO trial It is difficult 796 Part VIII Ventilator Support in Specific Settings to make direct comparisons because studies differ in the time at which mortality is recorded, but, if anything, survival has probably improved as intubation rates have fallen, suggesting better overall management One danger of NIV is that other aspects of medical therapy may be forgotten because the focus is on the application of NIV Nitrates are key and the total dose delivered has been shown to be an important predictor of outcome.46,47 Positive pressure is beneficial to the failing heart and has some similarities to the effects of nitrates (preload and afterload reduction); if medical management is suboptimal, ventilation will have a beneficial effect on the failing heart, which may be lost if these effects have already been achieved with medication Finally, the patients recruited may have been less unwell than those in other studies There was no difference in survival between recruited and nonrecruited patients, and no interaction with disease severity making this unlikely The physiologic disturbance in these patients put them at the sickest end of the spectrum of patients studied, and, indeed, in contrast to other studies, acidosis (mean pH: 7.22) and hypercapnia (mean partial pressure of arterial carbon dioxide [Pa CO2]: 7.6 kPa) were invariable Despite these negative findings, a reduction in dyspnea, which was very intense, was a striking feature in patients receiving ventilator support, and this alone is sufficient reason to utilize ventilation in CPE There is a trade-off between the beneficial effects of this reduction in dyspnea against discomfort from the mask and other factors Hypoxemic Respiratory Failure There are no RCTs of NIV outside the ICU in hypoxemic respiratory failure An RCT in the ICU12 showed that patients receiving NIV had significantly lower rates of serious complications, and those treated successfully with NIV had shorter ICU stays Post hoc analysis of patients grouped according to the Simplified Acute Physiology Score (SAPS) showed that NIV was superior to conventional mechanical ventilation in patients with a SAPS less than 16 In patients with a SAPS equal to or greater than 16, outcome was similar irrespective of the type of ventilation Another study,48 in immunocompromised patients, introduced NIV at a much lower level of physiologic compromise than would be required for invasive ventilation, and the sequential strategy (predefined periods on and off NIV) suggests that these patients could manage periods of spontaneous breathing safely Further data are needed but it is reasonable for selected patients to have a trial of NIV in an experienced noninvasive unit outside the ICU; rapid access to intubation and mechanical ventilation must be available Elective Ventilation for Chronic Ventilatory Failure This subject is dealt with in more detail in Chapters 28 and 33 In summary, there is no prospective RCT evidence to support the chronic use of NIV in any patient group Most practitioners, however, would consider it unethical not to offer NIV to patients with chest wall deformity and neuromuscular disease, and it is unlikely that there will ever be any RCTs of NIV in these conditions Chronic NIV is not appropriate for most patients with COPD; RCTs are ongoing WHERE SHOULD NONINVASIVE VENTILATION BE PERFORMED? Acute Noninvasive Ventilation: ICU or General Ward? There have been no direct comparisons of outcome with NIV delivered in the ICU, in intermediate units, and in a general ward It should be appreciated that while there is some overlap, the skills needed for NIV are different from those required for invasive ventilation Familiarity with and confidence in NIV by all members of the multidisciplinary team is the most important factor Nurses, physiotherapists, or respiratory therapists may be the primary caregiver; this will depend on local availability, enthusiasm, and expertise The outcome from NIV is likely to be better on a general ward where the staff has a lot of experience of NIV than in an ICU with high nurse-to-patient, therapist-to-patient, and doctor-to-patient ratios, and a high level of monitoring, but little experience of NIV The less intensive atmosphere of a noninvasive unit may not be as distressing for patients and their relatives NIV may be quite time-consuming in the early stages, and patients may benefit from extra attention, more likely in an ICU compared with less-well-staffed areas Staffing is usually less at night, but a study in an ICU revealed no difference between patients failing NIV during the day and the night49; because of the greater number of patients under the care of an individual nurse, this may not be true on a general ward and should be evaluated further Assuming that the skills to deliver NIV are equal in the various possible locations, there are a number of other factors to be considered These include whether or not intubation is considered appropriate should NIV fail, the presence of other system failure, comorbidity, severity of the respiratory failure, and likelihood of success with NIV (Fig 34-1) Patients who cannot sustain ventilation for more than a few minutes when acutely unwell require continuous observation This level of support is more likely to be available in the ICU than in other ward environments Although there are no published data, anecdotally there may be a tendency to abandon NIV more readily in an ICU because intubation is easily available, and in some ways it is easier for staff to manage a paralyzed, sedated patient than one who is struggling with NIV When intubation is not immediately an option, there is a need to keep going a little longer, and a number of patients who at first sight appear to be failing can be managed successfully with persistence It certainly has been the experience of the author that problems have been solved between the time that the ICU staff has been contacted and its arrival in the ward to intubate and/or transfer the patient (10 to 15 minutes) Chapter 34 Noninvasive Ventilation on a General Ward Intensive Care Lower pH Comorbidities Acute Chronic Need for intensive monitoring NIV technically difficult Invasive ventilation deemed appropriate if NIV fails 797 General Ward Higher pH No comorbidities NIV technically easier Invasive ventilation not deemed appropriate NIV the ceiling of intervention Advantages Advantages Higher nurse-to-patient ratio More monitoring Ready access to invasive ventilation Cost saving compared with ICU Specific interest and/or expertise in lung disease Absence of immediate, easy intubation encourages greater persistence and problem solving More “pleasant” enviroment Disadvantages Disadvantages Cost Less pleasant environment Easier to abandon NIV and intubate Low nurse-to-patient ratio Care needs of other patients may be neglected Lack of ready access to invasive ventilation FIGURE 34-1 The spectrum of provision for an acute NIV service Another important difference between the ICU and the general ward is the complexity of monitoring and the types of ventilators available Monitoring serves two roles: (a) safety and (b) optimization of ventilator settings ICU ventilators differ from the portable devices designed primarily for home use but frequently used in general wards The principal limitation to the use of home ventilators during acute respiratory failure is the lack of direct online monitoring of pressure, volume, and flow provided by these devices The evaluation of patient–ventilator asynchrony is easier with visualization of flow and pressure waveforms.50 This may be important, particularly during the initiation of ventilation, when it is important to assess patient–ventilator interaction, respiratory mechanics, and the expired tidal volume.51 Further work is needed to establish which variables should be monitored to optimize NIV It should be appreciated that high-technology monitoring is never a substitute for good clinical observation.52 For safety, it is recommended that all patients receiving NIV for acute ventilatory failure should have continuous monitoring of oxygen saturation (SO2) by pulse oximetry, regular assessments of arterial blood-gas tensions (because there is no accurate and reliable noninvasive measure of PCO2 or, more importantly, of pH), and respiratory rate.53,54 The SO2 should be maintained at around 88% to 92%55,56 to avoid the twin dangers of dangerous hypoxia and the risk of worsening hypercapnia secondary to altering the dead-space-to-tidal-volume ratio.57 There is no reason why this level of monitoring cannot be provided in a general ward (Table 34-2) If NIV is only to be provided in the ICU, the number of patients needing ICU care will increase, and this may not be necessary or appropriate The study of Plant et al22 showed that NIV is an option outside the ICU, but the outcome for patients with a pH of less than 7.30 was not as good as that seen for comparable patients in the studies performed in a higher-dependency setting Also, for reasons of training, throughput, quality of service, and skill retention, NIV is best performed in a single location.24 An intermediate unit with ready access to an ICU is probably the best compromise.58 A study3 of 756 consecutive patients admitted to twenty-six respiratory intermediate care units in Italy showed a better outcome than that expected on the basis of Acute Physiology and Chronic Health Evaluation (APACHE) II scores The predicted inpatient mortality was 22.1%, whereas the actual mortality was 16% All but forty-eight patients had chronic respiratory disease, mainly COPD (n = 451) Patients with acute CPE should usually receive ventilator support where they are, because by the time arrangements have been made and transfer effected, most patients will have either improved or deteriorated to the point at which intubation is needed Sufficient patients will attend the emergency room with CPE or develop it in the coronary care unit to make staff training in NIV in these areas worthwhile and to TABLE 34-2: MONITORING DURING NONINVASIVE VENTILATION Essential • Regular clinical observation • Continuous pulse oximetry • Arterial blood gases after to hours of NIV and after hour of any change in ventilator settings or fractional inspired oxygen concentration (FiO2) • Respiratory rate—continuous or intermittent Desirable • Electrocardiogram • More detailed physiologic information such as leak, expired tidal volume, and measure of ventilator–patient asynchrony 798 Part VIII Ventilator Support in Specific Settings ensure enough throughput to maintain skills When patients develop CPE outside these areas (e.g., in a surgical ward), it is likely to be sufficiently infrequent that it is not worth training the staff, or if trained, staff will not have had sufficient opportunity to use and develop their skills This is a situation in which the peripatetic NIV team or critical care outreach service may have a role There may also be a role for CPAP delivered by helmet as it is easier to train staff in its use; it has been used successfully in the prehospital setting.59 It is important that personnel are able to recognize and treat arrhythmias and myocardial ischemia.60 Elective Noninvasive Ventilation: General Ward or Chronic Care Facility? The onset of established chronic ventilatory failure is usually insidious Patients at risk are best seen and regularly reviewed in specialist centers so that the onset of significant nocturnal hypoventilation and the development of diurnal ventilatory failure can be anticipated As a result, NIV usually should be instituted before the patient becomes critically ill It is advisable to acclimatize patients to NIV at an early stage once the development of significant ventilatory failure becomes likely In one study, 90% of patients without daytime hypercapnia but with a rise in transcutaneous CO2 during sleep required NIV within year.61 Decompensation may occur with an intercurrent event, most commonly respiratory tract infection NIV is much easier in the acute situation if the patient has experienced it previously when reasonably well In such patients, if they are clinically stable, there is no need for assisted ventilation to “work” immediately; indeed, it does not matter if the patient is hardly able to use the ventilator at all initially There is little reason to admit these patients to the ICU, and it is questionable whether, with appropriate teams in place, the patient even needs admission to hospital Similar outcomes were seen in an RCT of inpatient versus outpatient initiation of home ventilation in patients with neuromuscular disease and chest wall deformity The mean (SD) inpatient stay was 3.8 (1.0) days, and the outpatient attendance sessions 1.2 (0.4) Health care professional contact time, including telephone calls, was: inpatient 17799 minutes versus outpatient 18860 minutes (p = NS) Two-month ventilator compliance was: inpatient 4.32 hours per night7 versus outpatient 3.928 (p = NS) hours per night.62 Some patients, particularly those with severe neuromuscular disease, have complex nursing needs, and their home environment may be better adapted to their needs than a hospital ward It is more pleasant for relatives and caregivers to stay in their own home Particular issues for that patient concerning positioning of equipment, ensuring adequate access to electrical power, and so on can be addressed.63 If the patient is to be admitted to hospital, the choice may be between a chronic care facility and a general ward As for acute NIV, staff expertise is the most important factor determining the best location (Table 34-3) Staffing and expertise being equal, advantages of the general ward include access to the ICU if things go wrong, and more ready access to other specialist teams because some of these patients have other complex needs, which the need to start NIV brings into focus These advantages, however, are generalizations; depending on the nature of the chronic care facility, it may be better suited than a general ward for providing the care and support for the other needs of patients Regardless of location, adequate control of nocturnal hypoventilation needs to be confirmed For some patients, overnight oximetry may suffice; for others, particularly those receiving supplemental oxygen, monitoring of PCO2 is necessary Patients also will need intermittent arterial blood-gas analyses Increasingly, it is possible to interrogate, including remotely, the home NIV ventilator, which can give important insights into why ventilation is poorly tolerated or supoptimal? Many days’ data are recorded, important in a technique with which problems may be intermittent and subject to night-to-night variation More detailed respiratory variable monitoring, including chest wall and abdominal motion, may provide important insights,64 but is not of itself a reason for admission to hospital The Advantage of the General Ward An acute and a chronic NIV service depends critically on local factors, particularly the skill levels of doctors, nurses, and therapists The major advantage of the general ward is that it sits in the middle of the spectrum of locations for NIV provision and is likely to treat the greatest number of patients Use of skills is a key factor in developing and retaining them The skills learned looking after patients needing NIV acutely are equally relevant for patients being started electively on NIV Familiarity with the nonrespiratory needs of patients with complex neuromuscular or musculoskeletal disorders, learned when patients are admitted electively to start NIV, are transferable to the care of such patients needing NIV acutely or for weaning Continuity of care is also important Some patients start home ventilation after an acute event, and the option of dealing with both aspects in the same place and with the same care team probably is advantageous to the patient and caregivers If NIV is the ceiling of TABLE 34-3: ELECTIVE VENTILATION FOR CHRONIC VENTILATORY FAILURE There is likely to be great local variation Factors that determine the best location • Enthusiastic and trained staff • Possibility of colocating with acute NIV unit • Access to expertise in the management of nonrespiratory aspects of care • Diagnostics, e.g., sleep laboratory • Access to ICU Chapter 34 Noninvasive Ventilation on a General Ward treatment, admission to an ICU is not necessary; if NIV is failing, the patient may be allowed to die in a less hightech environment than that afforded by most ICUs There is an emerging role for NIV in the management of patients with end-stage COPD It is well recognized that these patients receive suboptimal palliative care toward the end of life65; in part, this relates to the great difficulty in recognizing when the end is near The boundary between life-sustaining therapy and palliation can move on a daily basis during an exacerbation as a patient’s condition improves and then deteriorates again.66 One of the biggest challenges facing doctors now and in the future is knowing when “enough is enough.”67 NIV provides a useful alternative to life-sustaining therapy, with limited palliative care, that is, invasive ventilation, or to treatment that may not be sufficient to sustain life, but does allow effective palliative care, that is, medical therapy alone With NIV, patients retain a real say in their care, and, because assisted ventilation is not all or nothing, it is possible to move relatively easily between life sustaining and palliative care as the patient’s situation changes 799 support, with either CPAP or NIV, if they already have symptoms of excessive daytime sleepiness or peripheral edema before admission The patient should be reassessed post discharge because a significant proportion will be able to change their mode of ventilation or even need no ongoing ventilator support.29 NIV certainly should not be delayed until acidosis occurs in patients with neuromuscular disease; by the time these patients become hypercapnic, respiratory reserve is very reduced and they are at high risk NIV should be considered even if the patient is normocapnic if he or she is also tachypneic; these patients will tire out and the Pa CO2 will start to rise NIV will prevent this and also offload the respiratory muscles providing relief from dyspnea Although it is less clear cut, the same principles apply to patients with chest wall deformity; chronic hypercapnia is an indication to start domiciliary NIV,76 and there is therefore no reason not to start NIV if the patient is admitted to hospital with respiratory disease, even if not accompanied by acidosis These patients not require admission to an ICU HYPOXEMIC RESPIRATORY FAILURE SELECTION OF PATIENTS FOR NONINVASIVE VENTILATION IN A GENERAL WARD Acute Respiratory Failure CHRONIC OBSTRUCTIVE PULMONARY DISEASE The pH at the time NIV is initiated is the best single predictor of severity and the likelihood of success with the noninvasive approach.68 Moreover, changes in pH and respiratory rate are easily measurable and useful in predicting the likelihood of a successful outcome from NIV.9,17,69–73 Arterial blood gases should be checked at baseline and after to hours Data from the largest study74 showed that hydrogen ion concentration at enrollment (odds ratio 1.22 per nmol/L) and Pa CO2 (odds ratio 1.14 per kPa) were associated with treatment failure After hours of therapy, improvement in acidosis (odds ratio 0.89 per nmol/L) and/or fall in respiratory rate (odds ratio 0.92 per breath per minute) were associated with success If at least one of these two variables was improving, successful NIV was likely pH, therefore, is useful in determining, first, who should receive NIV, second, in what location, and, finally, when the patient can move to a more or less intensive location Generally speaking, the lower the pH, the greater is the risk to the patient of needing invasive ventilation if NIV is not offered or, if it is attempted, of failure The more acidotic the patient, the greater is the need for that patient to be managed in an ICU because the risk of failure of NIV and the potential need for endotracheal intubation is higher.75 The same criteria can be extended to other patients with acute-on-chronic hypercapnic respiratory failure, for instance those with obesity The pH criterion is less important as some of these patients will require chronic ventilator These patients are best managed in an ICU because the risks of failure are higher and because the major problem is inadequate oxygenation Patients are more likely to need prompt invasive ventilation if they are deteriorating or have other organ failure; moreover, ventilators usually used on general wards are those designed primarily for home use, and a high FIO2 cannot be delivered One further consideration was highlighted by Delclaux et al77 in a study on the use of noninvasive CPAP in patients with hypoxemic respiratory failure; there was a trend toward more cardiorespiratory arrests in the CPAP group The increase was attributed to the improvement in oxygenation and other physiologic parameters while the patients were using CPAP, which led to a false sense of security; when patients take the mask off, even for a short period, SO2 may fall rapidly, putting them at high risk Any patient who desaturates within seconds of removing a mask should be monitored very carefully, usually in an ICU, and probably this should be considered an indication for intubation IMPLICATIONS FOR STAFFING AND TRAINING Table 34-4 lists key training requirements NIV has been reported to be a time-consuming procedure.78 As with any new technique, there is a learning curve, and the same authors subsequently published more encouraging results.79 A number of ICU studies have shown that a significant amount of time is required to establish the patient on NIV, but this drops off substantially in subsequent days.10,80,81 It is possible, therefore, that NIV may have a much greater impact on nursing workload outside the ICU, where nurses have responsibility for a larger number of patients In the study of Plant et al,22 NIV resulted in a modest increase 800 Part VIII Ventilator Support in Specific Settings TABLE 34-4: KEY TRAINING REQUIREMENTS Understanding the rationale for assisted ventilation Mask and headgear selection and fitting Ventilator circuit assembly Theory of operation and adjusting ventilation to achieve desired outcome Principles and practice of humidification Inhaled therapy for the patient receiving NIV Cleaning and general maintenance Understanding how to monitor progress Ethical issues relevant to the care of patients with incurable disease Problem solving—the ability to recognize serious situations and act accordingly in nursing workload, assessed using an end-of-bed log, in the first hours of the admission, equivalent to 26 minutes, but no difference was identified thereafter No data exist, however, on the effect NIV on the care of other patients on the ward, nor whether outcome would have been better had nurses spent more time with patients receiving NIV Most of the centers that participated in the study had little or no previous experience of NIV and therefore required training in mask fitting and application of NIV Formal training in the first months of opening a ward by a research doctor and nurse was 7.6 hours (SD 3.6) Thereafter, each center received 0.9 hour per month (SD 0.82) to maintain skills It should be appreciated that there was no need to make subtle adjustments to ventilator settings, which all was done according to protocol Much more training would be needed if sophisticated ventilators are used This underlines the fact, however, that NIV, in whatever location, is not just a question of purchasing the necessary equipment but also of staff training Although considerable input is likely when a unit commences to provide an NIV service, thereafter, as long as a critical mass remain, new staff will gain the necessary skills from their colleagues Given that NIV in the more severely ill patient may require as much input as an invasively ventilated patient,81 there usually should be one nurse responsible for no more than three or four patients, although this will depend on the other care needs of the patients In the less severely affected patient, NIV can be successful with a lower level of staffing.22 ECONOMIC CONSIDERATIONS Although the findings are not consistent, some of the larger studies show that NIV can shorten length of an ICU and/or hospital stay compared, for example, with medical therapy or invasive ventilation.9,10,12,13,48,82 In no study has NIV been shown to lengthen hospital stay Although not the primary aim of the studies, the finding of reduced length of stay creates or saves resources and thereby indicates a cost benefit from NIV In a North American cost-effectiveness analysis83 in which NIV was delivered in the ICU, the authors concluded that NIV was more effective than standard treatment in reducing hospital mortality and also less expensive, with a cost saving of about $2500 per patient admission Intensive care is also expensive care Intermediate units provide an alternative to the classic ICU at reduced cost.58 The daily costs of a ventilated patient may be reduced by two-thirds when NIV is performed in a specialized respiratory unit rather than in an ICU.84 These costs can be reduced still further when NIV is performed on a general ward,85 although effectiveness may not be as good as in higher-dependency settings Carlucci et al86 showed that over time practice changes They found that after a few years, patients with more severe acidosis were ventilated successfully with NIV; more patients received NIV on general wards, with significant cost savings, compared with when they first started providing an acute NIV service THE FUTURE AND IMPORTANT UNKNOWNS As the population ages, the pressure on ICU beds will increase and alternatives to intensive care will need to be developed further, even in health care systems that currently enjoy high levels of ICU provision It is likely that, as has been seen in COPD, the management of more patients with NIV will take place outside of the ICU The challenge will be to ensure that standards are maintained and that the real-world experience in the United Kingdom is avoided.25 Technology will play a part, but staff training will remain key The effect of provision of NIV upon the care of other patients on the general ward is an important consideration CONCLUSION Staff training and experience are more important than location Adequate numbers of staff, skilled in NIV, must be available throughout 24 hours Because of the demands of looking after acutely ill patients, and to aid training and skill retention, acute NIV usually is best carried out in one single-sex location with one nurse responsible for three to four patients Basic monitoring, at least pulse oximetry and facilities for arterial blood-gas analysis, should be available Because the skills, both for NIV and for the other care needs of the patient population likely to need NIV, are transferable, there are significant advantages to locating both the acute and elective NIV service in the same place, but there must be ready access to invasive ventilation The best location for both an acute and chronic NIV service will vary from institution to institution, and local expertise, enthusiasm, and hospital geography will be the major determinants of where the service should be located and how it is delivered 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The Ethics of Withholding and Withdrawing Mechanical Ventilation 14 73 11 99 Jean-Damien Ricard and Didier Dreyfuss Michael E Wilson and Elie Azoulay 52 Airway Secretions and Suctioning 12 13 67 Economics... markedly enhance patient comfort and survival A comparison of the third and first editions of Principles and Practice of Mechanical Ventilation provides proof of the tremendous progress in this