RESUMO
DESIGN: Randomised crossover trial with 6 months of standard best practice clinical care (control group) and 6 months with the addition of telemonitoring. PARTICIPANTS: 68 patients with chronic lung disease (38 with COPD; 30 with chronic respiratory failure due to other causes), who had a hospital admission for an exacerbation within 6 months of randomisation and either used long-term oxygen therapy or had an arterial oxygen saturation (SpO2) of <90% on air during the previous admission. Individuals received telemonitoring (second-generation system) via broadband link to a hospital-based care team. OUTCOME MEASURES: Primary outcome measure was time to first hospital admission for an acute exacerbation. Secondary outcome measures were hospital admissions, general practitioner (GP) consultations and home visits by nurses, quality of life measured by EuroQol-5D and hospital anxiety and depression (HAD) scale, and self-efficacy score (Stanford). RESULTS: Median (IQR) number of days to first admission showed no difference between the two groups77 (114) telemonitoring, 77.5 (61) control ( p=0.189). Hospital admission rate at 6 months increased (0.63 telemonitoring vs 0.32 control p=0.026). Home visits increased during telemonitoring; GP consultations were unchanged. Self-efficacy fell, while HAD depression score improved marginally during telemonitoring. CONCLUSIONS: Telemonitoring added to standard care did not alter time to next acute hospital admission, increased hospital admissions and home visits overall, and did not improve quality of life in chronic respiratory patients. TRIAL REGISTRATION NUMBER: NCT02180919 (ClinicalTrials.gov).
Assuntos
Oxigenoterapia , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Telemedicina , Idoso , Doença Crônica , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/métodos , Qualidade de Vida , Fatores de Risco , Resultado do TratamentoRESUMO
Risk management is an important aspect of home ventilation (HV). We examined the nature of calls to a home support helpline to identify patient/equipment problems and strategies to minimise risk for patients, healthcare teams and manufacturers. From 1,211 adult and paediatric patients with neuromuscular disease, chronic obstructive pulmonary disease or chest wall disease receiving HV, all calls to a dedicated respiratory support telephone hotline between January 1, 2006 and June 30, 2006 were analysed. 1,199 patients received noninvasive ventilation, 12 tracheostomy ventilation; 149 had two ventilators for 24-h ventilator dependency. There was a mean of 528 daytime calls per month and 14 calls a month at night. Following 188 calls, a home visit was performed; these identified a technical problem that could either be solved in the patient's home in 64% or required replacement or new parts in 22% of cases. In 25 calls in which no mechanical fault was identified, 13 patients were either found to be unwell or required hospital admission. Patients using HV have a substantial requirement for assistance, with most technical problems being resolved simply. Where no fault can be found during an equipment check, the patient themselves may be unwell and should receive early clinical evaluation. The patient may have mistaken clinical deterioration for an equipment problem.
Assuntos
Serviços de Assistência Domiciliar , Respiração Artificial/métodos , Insuficiência Respiratória/terapia , Ventiladores Mecânicos , Adulto , Idoso , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Neuromusculares/terapia , Traqueostomia , Resultado do TratamentoRESUMO
Pandemics and acute emergencies raise pressing medical, ethical and organisational challenges. These include global governance, priority setting, triaging of patients, allocation of scarce resources and restricting individual liberty in the interests of public health. We will focus particularly on an issue of direct relevance to all respiratory team members, i.e. what is the duty of the healthcare worker to continue working in the face of personal risk, and draw lessons from guidelines, ethical considerations, past pandemics and evolving experience with H1N1 swine influenza.
Assuntos
Desastres , Surtos de Doenças , Ética Médica , Influenza Humana/terapia , Pneumologia/ética , Tomada de Decisões/ética , Emergências , Serviços Médicos de Emergência/ética , Pessoal de Saúde/ética , Humanos , Vírus da Influenza A Subtipo H1N1/metabolismo , Exposição Ocupacional , Recusa em Tratar/ética , Risco , Síndrome Respiratória Aguda Grave/terapiaRESUMO
The aim of the present study was to compare the efficacy of automatic titration of noninvasive ventilation (NIV) with conventional NIV in stable neuromuscular and chest wall disorder patients established on long-term ventilatory support. In total, 20 neuromuscular and chest wall disease patients with nocturnal hypoventilation treated with long-term NIV completed a randomised crossover trial comparing two noninvasive pressure support ventilators: a standard bilevel ventilator (VPAP III) and a novel autotitrating bilevel ventilator (AutoVPAP). Baseline physiological measurements, overnight polysomnography and Holter monitoring were repeated at the end of each 1-month treatment period. Nocturnal oxygenation was comparable between the autotitrating device and standard ventilator, as were sleep efficiency, arousals and heart rate variability. However, there was a small significant increase in mean overnight transcutaneous carbon dioxide tension (median (interquartile range) 7.2 (6.7-7.7) versus 6.7 (6.1-7.0) kPa) and a decrease in percentage stage 1 sleep (mean+/-sd 16+/-9 versus 19+/-10%) on autotitrating NIV compared with conventional NIV. Autotitrating noninvasive ventilation using AutoVPAP produced comparable control of nocturnal oxygenation to standard nonivasive ventilation, without compromising sleep quality in stable neuromuscular and chest wall disease patients requiring long-term ventilatory support for nocturnal hypoventilation.
Assuntos
Ventilação Pulmonar , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Adulto , Automação , Dióxido de Carbono/metabolismo , Estudos Cross-Over , Feminino , Frequência Cardíaca , Humanos , Hipoventilação , Masculino , Pessoa de Meia-Idade , Oxigênio/química , Respiração com Pressão Positiva/instrumentação , Respiração com Pressão Positiva/métodos , Fatores de TempoRESUMO
The Congenital Myasthenic Syndromes (CMS), a group of heterogeneous genetic disorders of neuromuscular transmission, are often misdiagnosed as congenital muscular dystrophy (CMD) or myopathies and present particular management problems. We present our experience of 46 children with CMS, referred to us between 1992-2007 with provisional diagnoses of congenital myopathy (22/46), CMS or limb-girdle myasthenia (9/46), central hypotonia or neurometabolic disease (5/46), myasthenia gravis (4/46), limb-girdle or congenital muscular dystrophy (4/46) and SMA (2/46). Diagnosis was often considerably delayed (up to 18y4 m), despite the early symptoms in most cases. Diagnostic clues in the neonates were feeding difficulties (29/46), hypotonia with or without limb weakness (21/46), ptosis (19/46), respiratory insufficiency (12/46), contractures (4/46) and stridor (6/46). Twenty-five children had delayed motor milestones. Fatigability developed in 43 and a variable degree of ptosis was eventually present in 40. Over the period of the study, the mainstay of EMG diagnosis evolved from repetitive nerve stimulation to stimulation single fibre EMG. The patients were studied by several different operators. 66 EMGs were performed in 40 children, 29 showed a neuromuscular junction abnormality, 7 were myopathic, 2 had possible neurogenic changes and 28 were normal or inconclusive. A repetitive CMAP was detected in only one of seven children with a COLQ mutation and neither of the two children with Slow Channel Syndrome mutations. Mutations have been identified so far in 32/46 children: 10 RAPSN, 7 COLQ, 6 CHRNE, 7 DOK7, 1 CHRNA1 and 1 CHAT. 24 of 25 muscle biopsies showed myopathic changes with fibre size variation; 14 had type-1 fibre predominance. Three cases showed small type-1 fibres resembling fibre type disproportion, and four showed core-like lesions. No specific myopathic features were associated with any of the genes. Twenty children responded to Pyridostigmine treatment alone, 11 to Pyridostigmine with either 3, 4 DAP or Ephedrine and five to Ephedrine alone. Twenty one children required acute or chronic respiratory support, with tracheostomy in 4 and nocturnal or emergency non-invasive ventilation in 9. Eight children had gastrostomy. Another 11 were underweight for height indicative of failure to thrive and required dietetic input. A high index of clinical suspicion, repeat EMG by an experienced electromyographer and, if necessary, a therapeutic trial of Pyridostigmine facilitates the diagnosis of CMS with subsequent molecular genetic confirmation. This guides rational therapy and multidisciplinary management, which may be crucial for survival, particularly in pedigrees where previous deaths have occurred in infancy.
Assuntos
Síndromes Miastênicas Congênitas/diagnóstico , Síndromes Miastênicas Congênitas/terapia , Adolescente , Idade de Início , Biópsia/métodos , Criança , Pré-Escolar , Análise Mutacional de DNA , Eletromiografia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Proteínas Musculares/genética , Proteínas Musculares/metabolismo , Músculo Esquelético/patologia , Mutação , Síndromes Miastênicas Congênitas/classificação , Síndromes Miastênicas Congênitas/fisiopatologia , Respiração , Estudos RetrospectivosRESUMO
BACKGROUND: Sleep disordered breathing (SDB) is common in severe chronic heart failure (CHF) and is associated with increased morbidity and mortality. The prevalence of SDB in mild symptomatic CHF is unknown. AIM: The aim of this study was to determine the prevalence and characteristics of SDB in male patients with NYHA class II symptoms of CHF. METHODS AND RESULTS: 55 male patients with mild symptomatic CHF underwent assessment of quality of life, echocardiography, cardiopulmonary exercise, chemoreflex testing and polysomnography. 53% of the patients had SDB. 38% had central sleep apnoea (CSA) and 15% had obstructive sleep apnoea. SDB patients had steeper VE/VCO(2) slope [median (inter-quartile range) 31.1 (28-37) vs. 28.1 (27-30) respectively; p=0.04], enhanced chemoreflexes to carbon dioxide during wakefulness [mean+/-sd: 2.4+/-1.6 vs. 1.5+/-0.7 %VE Max/mmHg CO(2) respectively; p=0.03], and significantly higher levels of brain natriuretic peptide and endothelin-1 compared to patients without SDB. No differences in left ventricular ejection fraction, percent predicted peak oxygen uptake, or symptoms of SDB were observed. CONCLUSIONS: A high prevalence of SDB was found in men with mild symptomatic CHF. Patients with SDB could not be differentiated by symptoms or by routine cardiac assessment making clinical diagnosis of SDB in CHF difficult.
Assuntos
Insuficiência Cardíaca/complicações , Apneia do Sono Tipo Central/fisiopatologia , Apneia Obstrutiva do Sono/fisiopatologia , Disfunção Ventricular Esquerda/complicações , Idoso , Estudos de Coortes , Teste de Esforço , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Qualidade de Vida , Apneia do Sono Tipo Central/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Estatísticas não Paramétricas , Ultrassonografia , Disfunção Ventricular Esquerda/fisiopatologiaAssuntos
Medicina Aeroespacial , Aeronaves , Pneumopatias/terapia , Aptidão Física , Viagem , Adulto , Altitude , Asma/terapia , Pressão Atmosférica , Doenças Cardiovasculares/terapia , Criança , Pré-Escolar , Comorbidade , Medicina Baseada em Evidências , Humanos , Lactente , Infecções/terapia , Pneumopatias/diagnóstico , Pneumopatias/fisiopatologia , Nebulizadores e Vaporizadores , Oxigênio/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração Artificial , Testes de Função Respiratória , Medição de Risco , Fatores de Risco , Sociedades Médicas , Resultado do Tratamento , Reino UnidoAssuntos
Pneumologia/tendências , Doenças Respiratórias/diagnóstico , Doenças Respiratórias/terapia , Asma/terapia , Doença Crônica , União Europeia , Feminino , Promoção da Saúde/métodos , Humanos , Masculino , Pneumonia/terapia , Doença Pulmonar Obstrutiva Crônica/terapia , Pneumologia/métodos , Doenças Respiratórias/epidemiologia , Infecções Respiratórias/terapia , Fumar/efeitos adversosAssuntos
Pneumologia/educação , Pneumologia/métodos , Currículo , Educação Médica Continuada/organização & administração , Educação de Pós-Graduação em Medicina/organização & administração , Europa (Continente) , Feminino , Humanos , Masculino , Desenvolvimento de Programas , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/terapiaRESUMO
STUDY OBJECTIVE: Severe idiopathic scoliosis is associated with respiratory failure. This usually is secondary to restrictive airway disease and reduced vital capacity. Patients may also suffer from an increase in airway resistance when severe kyphoscoliosis is present. SETTING: Three patients (two of whom required assisted ventilation) with varying degrees of kyphoscoliosis presented with moderate to severe breathing difficulties. INTERVENTION: Bronchoscopic examination of these patients showed evidence of torsion with secondary obstruction of the central airways. RESULTS: The airway obstruction was notable for its slit-like appearance, for the normality of the mucosa at the site of the obstruction, for the relative ease through which an instrument could traverse the obstruction, and once the retained secretions had been cleared, for the preservation of normal anatomy of the distal airways. The insertion of metal prostheses to stent the areas of obstruction prompted an impressive improvement in respiratory status, radiologic findings, and spirometric criteria in each case. Improvement has been maintained over a maximum follow-up period of 4 years. CONCLUSION: Severe kyphoscoliosis can lead to bronchial torsion and obstruction of the central airways. Patients should be assessed by bronchoscopy to exclude this deformity or any other cause of obstruction. The use of a metal endobronchial stent has been effective in both the immediate and long-term period.
Assuntos
Broncopatias/etiologia , Cifose/complicações , Escoliose/complicações , Adulto , Obstrução das Vias Respiratórias/etiologia , Feminino , Humanos , Anormalidade TorcionalRESUMO
We investigated the effect of age on breathing and total pulmonary resistance (RL) during sleep by studying elderly (>65 yr) and young (25-38 yr) people without sleep apnea (EN and YN, respectively) matched for body mass index (BMI). To determine the impact of sleep apnea on age-related changes in breathing, we studied elderly and young apneic patients (EA and YA, respectively) matched for apnea and BMI. In all groups (n = 11), breathing during periods of stable sleep was analyzed to evaluate the intrinsic variability of respiratory control mechanisms. In the absence of sleep apnea, the variability of the breathing was similar in the elderly and young [mean (+/- SD) coefficient of variation (CV) of tidal volume (VT); wake: EN 21.0 +/- 14.9%, YN 14.7 +/- 5.5%; sleep: EN 14.0 +/- 6.0%; YN 11.5 +/- 6.4%]. In patients with sleep apnea, breathing during stable sleep was more irregular, but there were no age-related differences (CV of VT; wake: EA 22.0 +/- 11.6%, YA 16.7 +/- 11.3%; sleep: EA 32.8 +/- 24.9%, YA 25.2 +/- 16.3%). In addition, EN tended to have a higher RL (n = 6, RL midinspiration, wake: EN 7.1 +/- 3.0; YN 9.1 +/- 6.4 cmH(2)O. l(-1). s, sleep: EN 17.5 +/- 11.7; YN 9.8 +/- 2.0 cmH(2)O. l(-1). s). We conclude that aging per se does not contribute to the intrinsic variability of respiratory control mechanisms, although there may be a lower probability of finding elderly people without respiratory instability.
Assuntos
Envelhecimento/fisiologia , Resistência das Vias Respiratórias/fisiologia , Mecânica Respiratória/fisiologia , Síndromes da Apneia do Sono/fisiopatologia , Sono/fisiologia , Adulto , Idoso , Pressão Sanguínea , Índice de Massa Corporal , Eletroencefalografia , Eletromiografia , Feminino , Humanos , Masculino , Variações Dependentes do Observador , Valores de Referência , Vigília/fisiologiaRESUMO
There are a limited number of reports in the literature cocerning lung volume reduction surgery in patients receiving mechanical ventilation. We present a case in which a ventilator-dependent patient with apparent endstage pulmonary emphysema underwent lung volume reduction with a successful outcome. Although the role of this procedure for selected nonventilated patients has been widely discussed its use in ventilated patients is still not clearly defined. We show that lung volume reduction surgery may facilitate ventilatory weaning in such cases and improve functional status.
Assuntos
Pneumonectomia , Enfisema Pulmonar/cirurgia , Respiração Artificial , Feminino , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de DoençaRESUMO
Arousals from sleep result in hyperventilation and hypocapnia that can lead to sleep apnoea. We have investigated whether sleep apnoea in the elderly is associated with more arousals compared with younger people. Additionally, the impact of arousals on daytime symptoms was noted. Four groups (n = 11) of elderly (> 65 years) and young (< 39 years) apnoeic (EA and YA), and age-matched non-apnoeics (EN and YN) were studied. The arousal index (AI) and apnoea/hypopnoea index were determined from polysomnography. Sleepiness (Epworth Sleepiness Scale) and Quality of life (QoL, SF-36) were assessed. The mean (SD) AI was: EN 23.1 (7.6), EA 46.5 (8.8), YN 13.2 (6.6), YA 38.5 (12.1) events/h. AI was higher in the elderly (P = 0.002) and in apnoeics (P = 0.001); however, the increase in AI associated with sleep apnoea was not age dependent (P = 0.73). The influence of sleep apnoea on sleepiness was similar in both age groups. YA but not EA reported reduced physical functioning (P = 0.04), vitality (P = 0.007) and general health (P = 0.04) compared to non-apnoeics. We conclude that (1) the effect of sleep apnoea on arousal is no greater in the elderly compared to the young (2) despite similar levels of sleepiness, elderly apneoics perceive a reduced loss of QoL compared to younger patients.
Assuntos
Síndromes da Apneia do Sono/fisiopatologia , Vigília/fisiologia , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Polissonografia , Qualidade de VidaRESUMO
The short- and long-term physiological, functional and economic benefits of NIPPV in patients with chronic chest wall and stable neuromuscular disease have been confirmed and its advantages over non-invasive negative pressure ventilation outlined. Current research should help provide guidelines for patient selection and the most appropriate use of NIPPV in progressive neuromuscular disorders.
Assuntos
Serviços de Assistência Domiciliar , Ventilação com Pressão Positiva Intermitente/métodos , Doenças Neuromusculares/complicações , Insuficiência Respiratória/terapia , Doenças Torácicas/complicações , Humanos , Insuficiência Respiratória/etiologia , Desmame do Respirador , Ventiladores MecânicosRESUMO
While much evidence has been gained over the last decade to support the use of non-invasive ventilation (NIV) in a series of acute and chronic applications, some issues still need to be addressed, particularly regarding the timing of initiation of NIV and the best methods of implementation. This article discusses the role of NIV, if any, in preventing respiratory decline, as a physiotherapy adjunct, and in perioperative care for adults and children with neuromuscular disease.
Assuntos
Doenças Neuromusculares/complicações , Respiração Artificial , Insuficiência Respiratória/etiologia , Criança , Humanos , Doenças Neuromusculares/fisiopatologia , Doenças Neuromusculares/cirurgia , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapia , Escoliose/complicações , Atrofias Musculares Espinais da Infância/complicaçõesRESUMO
All units providing ventilatory support will experience patients with weaning difficulties. The factors which contribute to weaning problems include the pathophysiology of the illness, the extent of underlying chronic disease, and equipment, physician-related and organisational issues. In this article ways to resolve these problems are outlined.
Assuntos
Desmame do Respirador , Feminino , Humanos , Masculino , Respiração Artificial/métodos , Fatores de Risco , Fatores SexuaisRESUMO
A nihilistic approach to ventilatory support in progressive neuromuscular disorders is no longer acceptable. Noninvasive ventilation may improve survival and quality of life in some patients. In other situations, worthwhile palliation of symptoms of nocturnal hypoventilation and dyspnoea may be achieved. Noninvasive ventilation combined with cough assistance may obviate the need for tracheostomy ventilation, or can be employed as part of a staged approach. Individual titration of ventilatory support to meet the needs of the individual and family is vital. The participation of the patient, family and carers in decision-making is crucial and advanced directives are likely to be used increasingly.
Assuntos
Esclerose Lateral Amiotrófica/terapia , Distrofia Muscular de Duchenne/terapia , Respiração Artificial , Adolescente , Adulto , Tomada de Decisões , Progressão da Doença , Humanos , Hipercapnia/etiologia , Hipercapnia/terapia , Ventilação com Pressão Positiva Intermitente , Distrofia Muscular de Duchenne/complicaçõesRESUMO
Non-invasive ventilation refers to the technique of providing ventilatory support to a patient without an endo/orotracheal airway. It is a promising and rapidly upcoming new technique and is being used as first line therapy in a wide variety of conditions causing respiratory failure. The major indications for its use include respiratory failure due to a variety of causes (chest wall abnormalities, neuromuscular disease, COPD), weaning and stabilization of cardio-respiratory status before and after surgery. Patients who are candidates for this modality usually have a hypercapnic respiratory failure but are able to protect the airway and cooperate with treatment. The biggest advantage of the technique is its simplicity and avoidance of complications of intubation like trauma, infection and delayed complications like tracheal stenosis. Patient comfort is significantly improved and important functions like speech, swallowing and cough are preserved. Several purpose built ventilators are available for use including pressure preset and volume present machines, each of which have their own advantages and disadvantages in clinical practice. A range of patient interfaces is available. The initiation of non-invasive ventilation is much easier as compared to invasive ventilation and can be done for most patients in an intermediary care unit thereby cutting down treatment costs and saving precious intensive care beds. Titration of ventilatory parameters can usually be done using simple tests like oxymetry and blood gases. Several technique related problems like skin pressure sores, nasal symptoms and abdominal distension can be managed with simple measures. Non invasive ventilation has got a special and evolving role in management of COPD, both in acute exacerbations and chronic respiratory failure. In short, the advantages of this form of ventilation are numerous and physicians must familiarize themselves with this new technique, facilities for which should be available in all hospitals admitting patients with respiratory failure.