Hospital Monitoring, Setting and Training for Home NIV

8/11/2019 Hospital Monitoring, Setting and Training for Home NIV

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Monaldi Arch Chest Dis2003; 59: 2, 119-122 REVIEW

Hospital monitoring, setting and trainingfor home non invasive ventilation

D. Fiorenza, M. Vitacca, E. Clini

In recent years, guidelines were published todefine indications, applications and delivery oflong-term mechanical ventilation (MV) [1, 2].

Non-invasive positive pressure ventilation(NPPV) has been increasingly used in the manage-

ment of chronic respiratory insufficiency resultingfrom neuromuscular and restrictive chest wall dis-eases [3] and, also in chronic obstructive pul-monary disease (COPD) [4] with controversial re-sults.

Side-effects due to the interface may impactthe follow-up of these patients in 20-50% of cases[5-7] and they account for an important problemwhen dealing with discontinuation and lack ofcompliance. Nonetheless, the selection of patients[2], mode of ventilation [8], types of ventilator [9],ventilator setting [10, 11] and apparatus needed forMV [12-14] have claimed to account for theseconflicting results.

There is a lack of information regarding in-hospital assessment and the plans to initiate andprescribe NPPV. The present review proposes anoperative flow chart for optimisation of homeNPPV prescription which has been used since2001 in two Italian rehabilitative centres.

As stressed in recent guidelines [2] the physicianneeds to strictly test the correct indication for NPPVin terms of correct diagnosis (neuromuscular disor-ders or chest wall deformities rather than COPD)and in terms of patients stability (see figure 1). Pa-tients stability refers to general conditions, to respi-ratory status in absence of any factor associated with

exacerbation, and to the psycho-social ability to copewith a long-term MV [2] programme. In particular,stability in COPD patients, has been defined as anarterial pH > 7.35 and absence of acute exacerba-

tions in the four weeks preceding recruitment [4]. Atthe same time, another key point is to accurately ex-plain the in-hospital training and home NPPV pro-grams to the patient and care-giver(s) in terms of;a) expected results

b) outcomec) necessity of program adherence andd) strict long term follow up [2].

The second step of the ideal training process(figure 1) requires the careful choice of: 1) venti-lator, 2) mask, 3) apparatus (in terms of circuit andexpiratory valve) 4) mode of MV and 5) setting upof MV.

Home NPPV is often prescribed after in-hospi-tal practice sessions have been performed with thecommercial ventilators available at the moment(often a single one), which may be not necessarilythe same one used by the patient at home. Thislimits the possibility to select the best ventilatortailored for the patient. Although the large ma-

jority of the so-called home care ventilators canoffer performances similar to those of the tradi-tional and more expensive ICU ventilators [10,15], it has been demonstrated that, at least in benchstudies, each ventilator may perform differently[16-18]. One study has compared patients compli-ance in the commonly prescribed commercial ven-tilators [8]: however, no specific comparisons onthe physiological effects among these ventilatorshave been reported yet.

In our laboratory we undertook a study [19] tocompare patient-ventilator interaction and patient

comfort with five different commercial bi-levelpressure home ventilators, all set on the basis of themaximal tolerated Inspiratory Positive AirwayPressure (IPAP). These ventilators were delivered

ABSTRACT:Hospital monitoring, setting and training for homenon invasive ventilation. D. Fiorenza, M. Vitacca, E. Clini.

Although in recent years guidelines have been pub-lished in order to define indications, applications and de-livery of long-term home non invasive mechanical ventila-tion (HNMV), there is lack of information with regards toin-hospital assessment, planning and training to initiateand prescribe it.

Discontinuation and lack of compliance versus HNMVmay affect the follow-up of these patients adding a costlyburden for care.

The present review proposes an operative flow chartfor optimisation of HNMV prescription from initial pa-tients selection to post discharge follow up including;1. assessment of the correct choice of ventilator, inter-

faces, ventilation setting2. Timing for different physiological monitoring (arteri-

al gases, mechanics, sleep)3. Timing for clinical evaluation, machine adaptation,

carer training and long term follow-up.

Monaldi Arch Chest Dis 2003; 59: 2, 119-122.

Keywords: Non invasive ventilation, home care, training.

Fondazione Salvatore Maugeri IRCCS, Gussago (BS) and Fondazione Villa Pineta ONLUS, Pavullo (MO).

Correspondence: Domenico Fiorenza, MD; Via Pinidolo 24; 25064 Gussago BS, Italy: e-mail: [email protected]


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to 28 obstructed or restricted patients with chronicventilatory failure; we concluded that (despite agreat inter-subject variability in comfort) all theseventilators are well tolerated, and produce similarphysiological effects thus fulfilling the aims of me-chanical ventilation [2]. These findings suggestthat, in order to make informed decision when pre-

scribing a ventilator for NPPV to the individual pa-tient, it is necessary to understand how the ventila-tor tested actually performs in that patient, and howit is accepted by the patient him/her self. For thatreason the choice of ventilator for home NPPVshould be made after comparing different ventila-tors which are suitable to the individual patient.

Serious attention is also necessary to test dif-ferent masks in order to minimize leaks and sideeffects and also to obtain the best comfort. Never-theless, poor literature is available in this specificfield: Navalesi and colleagues [12] demonstratedthat during application of NPPV the best comfortis found with the use of nasal masks, whereas the

best improvements in minute ventilation and Pa-CO2 are obtained using the facial mask.

The use of an appropriate exhalation device forhome ventilatory assistance to avoid significantCO2 re-breathing is mandatory. Controversies re-main if this goal may be obtained only with an ap-propriate exhalation device (such as the plateauexpiratory valve) without compromising the deliv-ered pressures and tidal volume [13] or also withthe traditional exhalation valve [14] Recent work[2] shows that the majority of authors use pressureassisted modalities rather than volume controlledones; in particular, the pressure support modality

has been demonstrated to be the most comfortablemethod to chronically ventilate COPD patientswith respiratory failure [4, 8].

In clinical practice, home NPPV for COPD pa-tients is prescribed as Nasal Pressure Support Ven-tilation (NPSV), and it is set to achieve a decreasein PaCO2 and an optimal patients compliance(usual setting). However, targeting the setting tothese objects gives no information on the respira-tory muscle unloading and the intrinsic positiveend expiratory pressure (PEEPi) counterbalancing(physiological setting). The application of ex-trinsic positive end expiratory pressure (PEEPe) inthese patients has been shown to be the best to un-

load the diaphragm with an adequate titration [i.e.80-90% of intrinsic dynamic positive end-expira-tory pressure (PEEPi dyn)], whilst an incorrect set-ting (for example in the case of over assistance)may lead to further increase hyperinflation [20].The usual setting and the physiological settingmight have different implications in clinical prac-tice as demonstrated in a recent study performedon stable COPD patients with chronic hypercapnia[11]. This study supports the notion that NPSV seteither at patients comfort or tailored to the physi-ological measurements provides similar improve-ment in arterial blood gases (ABG) and unloading

of the respiratory muscles. However, the physio-logical setting of inspiratory assistance and PEEPe(with the need to use an invasive evaluation oflung mechanics and respiratory muscles function)

may result in a reduction of inspiratory ineffectiveefforts, which relate to the patient-ventilator dis-synchrony [11]. Figure 1 shows in details themodality of the settings more used in literature.

Figure 1 also indicates that clinical monitoringof patients comfort, patient-ventilator interactionand arterial saturation (SatO2) is necessary from

the beginning of MV [2]. In particular, ABG to testthe effect of the ventilation, the assessment of pa-tient comfort and the appearance of any technicalproblems (leaks, high pressure limit) are recom-mended 60 minutes after MV application [2]. Atthis stage patients co-operation, rather than imme-diate clinical results, is the main aim.

Two different results are possible in the patientunder evaluation (see figure 1): arterial blood gases(ABG) improvement or ABG unchanged/worsening:1. If ABG is worsened and MV discomfort ap-

pears, then there is the possibility to changeapparatus (see above) and/or to add flow, vol-ume and airway pressure by continuous moni-

toring (by means of a flow transducer); thesechanges may therefore help physician to opti-mise setting and to improve the patients com-pliance [11]. Only in selected situations [11]evaluation of lung mechanics (by means of oe-sophageal balloon) may substantially lead toimprove the patient-ventilator interaction, toavoid ineffective efforts, to physiologically re-duce intrinsic PEEP (PEEPi dyn) and work ofbreathing (WOB).

2. If an acceptable level of patient comfort with agood response in terms of ABG is found, diur-nal adaptation to MV can start. The recom-

mended protocol of application is targeted toreach no less than four hours per day and noless than two consecutive days of positiveadaptation [2]. Thereafter, nocturnal ventila-tion may be tested: the assessment of nocturnalcompliance and SatO2 monitoring at the 3rdconsecutive night is usually performed. ABGon spontaneous breathing with usual O2 supplyat waking up is assessed to evaluate the defin-itive impact of MV during sleep. Question-naires on sleep quality can also be adminis-tered. Only in selected situations a full-nightpolysomnography might be useful to assessapnoeas, snoring or arousals and possibly, to

normalise them after proper setting.Only when both diurnal and nocturnal adapta-

tions are acceptable, can in-hospital training forthe patient and the carer be proposed [2]. Thetraining consists of at least 6 lessons (by medicaldoctors and nurses) lasting 30 to 45 minutes to il-lustrate the use of mask, circuit, comfort flaps,ventilator and cleaning procedures. Finally, it is al-so essential to test the ability of the care-giver andfamily members to collaborate with the home MVprogramme.

Only at this step can a definitive prescriptionof MV be assured to complete the discharge plan-

ning. A strict follow-up including clinical signs (i.e. gastric inflation, coughing, etc.), mask and/orventilator discomfort and technical problems (i. e.leaks) needs also to be planned.

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In conclusion, the prescription of home NPPVis a hard task for doctors and it represents a kind ofchallenge for a multidisciplinary team consistingnot only of the doctor himself, the nurse, the respi-ratory therapist, the psychologist, but also of thepatients family and care-giver. Acceptance andmotivation to co-operate are essential and should

be proportional to the patients dependency.The main goals of NPPV are to control symp-toms linked to nocturnal hypo-ventilation, to im-prove the patients quality of life and to reducemorbidity and, (possibly) mortality in a cost-effec-tive way. In-hospital assessment and planning arenecessary to initiate NPPV. A documented diagno-sis and indications, an adequate setting and the pa-tients compliance are essential for prescription.The follow-up monitoring is also essential to con-firm prescription each year; moreover, a re-evalu-ation about the correct indication for NPPV and/oralternative indication for tracheotomy and changeto invasive MV may be considered at this stage .

The process to properly assess and plan homeMV is the correct way to improve and stabilizelung function, to increase the quality of life and toprevent acute episodes of hypercapnia which areoften fatal recurrences in these kind of patientswith advanced respiratory disease.

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