A qualitative study of patient and carer experiences with home respiratory therapies: Long-term oxygen therapy and home mechanical ventilation.

Studies exploring the experience of patients receiving home respiratory therapies (HRT), such as long-term oxygen therapy (LTOT) and home mechanical ventilation (HMV), are still limited. This study focused on patients' and carers' experience with LTOT and HMV. An exploratory, cross-sectional qualitative study, using semi-structured focus groups, was carried out with 18 patients receiving HRT (median 71y, 78% male, 56% on both LTOT and HMV) and 6 carers (median age 67y, 67% female). Three focus groups were conducted in three regions of Portugal. Thematic analysis was performed by two independent researchers. Patients' and carers' experience was reflected in seven major topics, linked to specific time points and settings of the treatment: Initial symptoms/circumstances (n = 41), Prescription (n = 232), Implementation (n = 184), Carer involvement (n = 34), Quality of life impact (n = 301), Health care support/navigability (n = 173) and Suggestions (n = 14). Our findings demonstrate a general good perception of the HRT by patients and carers recognizing a significative quality of life impact improvement, while identifying specific points where improvements in healthcare are needed, particularly about navigability issues, articulation between the hospital, primary care and homecare teams, especially regardingprescriptionrenewal. This knowledge is crucial to promote a long-term HRT adherence and to optimize HRT delivery in line with patients' experience, needs, and values. Moreover, these key points can inform the development of a specific patient-reported experience measure (PREM) for patients on HRT, which is not currently available, and foster a more integrated respiratory care model.

The Portuguese Model of Home Respiratory Care: Healthcare Professionals' Perspective.

Patients' and carers' views regarding the Portuguese model of home respiratory care were recently described, yet the complementary perspective of healthcare professionals (HCPs) is still to be investigated. Thus, this study explored HCPs experience in the management of patients needing home respiratory therapies (HRT), and their perspective about the Portuguese model. A phenomenological descriptive study, using focus groups, was carried out with 28 HCPs (median 42 y, 68% female) with distinct backgrounds (57% pulmonologists, 29% clinical physiologists, 7% physiotherapists, 7% nurses). Three focus groups were conducted in three regions of Portugal. Thematic analysis was performed by two independent researchers. HCPs have in general a positive view about the organization of the Portuguese model of home respiratory care, which was revealed in four major topics: Prescription (number of references, n = 171), Implementation and maintenance (n = 162), Carer involvement (n = 65) and Quality of healthcare (n = 247). Improvements needed were related to patients' late referral, HRT prescription (usability of the medical electronic prescription system and renewals burden), patients' education, access to hospital care team, lack of multidisciplinary work and articulation between hospital, primary and home care teams. This study describes the perspective of HCPs about the Portuguese model of home respiratory care and identifies specific points where improvements and reflections are needed. This knowledge may be useful to decision makers improve the current healthcare model.

Enhance Access to Pulmonary Rehabilitation with a Structured and Personalized Home-Based Program-reabilitAR: Protocol for Real-World Setting.

Home-based models represent one of the solutions to respond to the poor accessibility of pulmonary rehabilitation (PR) services in patients with chronic respiratory disease (CRD). The main goal of this protocol is to present the implementation of the first nationwide home-based PR program-reabilitAR-in Portugal and the strategies to assess its benefits in patients with CRD. The program consists of 2 phases: a 12-week intensive phase and a 40-week maintenance phase (total: 52 weeks, 1 year). The intervention in both phases is composed of presential home visits and phone-call follow ups, including exercise training and the self-management educational program Living Well with COPD. Dyspnea, impact of the disease, emotional status, and level of dyspnea during activities of daily living are used as patient-reported outcomes measures. A one-minute sit-to-stand test is used as a functional outcome, and the number of steps as a measure of physical activity. To ensure safety, fall risk and the cognitive function are assessed. Data are collected at baseline, at 12 weeks, at 26 weeks and at 52 weeks. This is the first nationwide protocol on enhancing access to PR, providing appropriate responses to CRD patients' needs through a structured and personalized home-based program in Portugal.

Home Mechanical Ventilation Practices in Spain and Portugal.

Introduction: Home mechanical ventilation (HMV) practice has changed with publication of new evidence and introduction of new technologies, and varies between countries. This study investigated current HMV use and practices in Spain and Portugal. Methods: 94 healthcare professionals identified as regularly performing HMV-related activities were sent an e-mail link to an online questionnaire. The questionnaire included 40 items relating to responder demographics, non-invasive ventilation (NIV) care structure, ventilated patient profile, work habits, and potential future practice improvements. Results: 66 questionnaires (70%) were returned (Spain, 36; Portugal, 30). The majority of respondents were physicians (Spain, 95%; Portugal, 63%). Overall, 83% of hospitals had a dedicated NIV unit (Spain, 100%; Portugal, 63%). The most common indication for HMV was neuromuscular disorders in Spain and obstructive diseases in Portugal. Homecare providers (HCPs) and pulmonologists were usually responsible for managing HMV; HCPs were involved more often in Portugal. Choice of ventilator was most often based on usage hours/day; the most important device features were 'ease of use' (Spain) and 'adjustment range' (Portugal). HMV monitoring practices varied between countries. Telemonitoring was used more often in Portugal (20%; vs. Spain, 3%). Follow-up frequency and practices also differed markedly between Spain and Portugal. Respondents highlighted identification of new patient groups and patient phenotyping to optimize treatment and personalize therapy as future HMV strategies. Conclusions: Important differences in the management of HMV were observed between two similar European countries. Better understanding of clinical practices can facilitate targeted education and training to ensure optimal management of patients using HMV.

Introducción: El manejo de la ventilación mecánica domiciliaria (VMD) ha cambiado tras la publicación de información nueva y la introducción de nuevas tecnologías, y varía entre países. Este estudio investigó el uso y el manejo actuales de la VMD en España y Portugal. Métodos: Noventa y cuatro profesionales de la salud que realizaban actividades relacionadas con la VMD con regularidad recibieron un enlace mediante correo electrónico a un cuestionario en línea. El cuestionario incluyó 40 ítems relacionados con la demografía de los encuestados, la estructura de cuidados de la ventilación no invasiva (VNI), el perfil del paciente ventilado, los hábitos de trabajo y las posibles mejoras en el futuro manejo de la VMD. Resultados: Se respondieron 66 cuestionarios (70%) (España, 36; Portugal, 30). La mayoría de los encuestados eran médicos (España, 95%; Portugal, 63%). En total, el 83% de los hospitales tenían una unidad dedicada a la VNI (España, 100%; Portugal, 63%). La indicación más frecuente de VMD fueron los trastornos neuromusculares en España y las enfermedades obstructivas en Portugal. Los prestadores de servicios médicos domiciliarios (SMD) y los neumólogos generalmente fueron los responsables del manejo de la VMD. Los SMD participaron con mayor frecuencia en Portugal. La elección del ventilador se basó con mayor frecuencia en las horas de uso/día; las características más importantes del dispositivo fueron «facilidad de uso¼ (en España) y «rango de ajuste¼ (en Portugal). El manejo del seguimiento de la VMD varió entre países. La telemonitorización se utilizó con mayor frecuencia en Portugal (20%; frente a España, 3%). La frecuencia y la forma de seguimiento también difirieron notablemente entre España y Portugal. Los encuestados destacaron la identificación de nuevos grupos de pacientes y el fenotipado de los pacientes para optimizar el tratamiento y personalizar la terapia como estrategias futuras en la VMD. Conclusiones: Se observaron diferencias importantes en el manejo de la VMD entre dos países europeos similares. Una mejor comprensión de las prácticas clínicas puede facilitar la educación y la formación específicas para garantizar un manejo óptimo de los pacientes que utilizan VMD.

¿Podemos usar terapias respiratorias no invasivas en la pandemia COVID-19? / Can we use noninvasive respiratory therapies in COVID-19 pandemic?

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Effects on Humidification and Ventilatory Parameters of Three Single-limb Heated-wired Circuits for Non-invasive Ventilation: A Bench Study / Efectos sobre la humidificación y los parámetros de ventilación de 3 circuitos de ramal único con cable calefactado para la ventilación mecánica no invasiva: estudio experimental

Background: The objective of this study was to evaluate the effects of three single-limb heated wired circuits (SLHWC) for NIV, on ventilatory parameters and humidification performance in a simulation lung model. Methods: Three SLHWC compatible with the MR-850 Heated Humidifier (HH) (Fisher & Paykel, Auckland, New Zealand) were tested: RT-319 (FP) (Fisher & Paykel, Auckland, New Zealand), Respironics 1045770 (RP) (DEAS, Castel Bolognese, Italy) and Intersurgical B/SYS 5809001 (IT) (Intersurgical, Wokingham, UK). A Bipap Vision ventilator (Philips Respironics, Murrysville, PA, USA) in pressure control ventilation (PCV) connected to a test lung was used for simulation. Each SHWC performance was evaluated in four ventilatory conditions: IPAP of 15 cm H2O with FiO2 0.3 and 1, respectively; and, IPAP of 25 cm H2O with FiO2 0.3 and 1, respectively. EPAP was set at 5 cm H2O. Hygrometric and ventilatory measurements including: relative humidity (RH), temperature (T), Pplat, PIP, PEEP, peak inspiratory flow (PIF), and tidal volume (Vt) were measured. Results: In each FiO2 group absolute humidity (AH) was similar with FP regardless of the IPAP level employed compared to IT and RP (P<.001). Except for RP at FiO2 0.3, AH increased significantly in IT and RP groups as IPAP increased (P < .001). PIP, Pplat, PEEP, PIF, and Vt values were significantly higher with FP and RP in each FiO2 group compared to IT (P < .001). Conclusions: Humidification performance varied significantly among the three circuits, being FP the only one able to maintain stable AH values during the study with no influence on ventilatory parameters

Introducción: El objetivo de este estudio fue evaluar los efectos de 3 circuitos de ramal único (SLHWC) para la ventilación mecánica no invasiva (VNI) en los parámetros de ventilación y la humidificación en un modelo de simulación pulmonar. Métodos: Se evaluaron 3 SLHWC compatibles con el humidificador calefactado MR-850 (HH) (Fisher & Paykel, Auckland, Nueva Zelanda): RT-319 (FP) (Fisher & Paykel, Auckland, Nueva Zelanda), Respironics 1045770 (RP) (DEAS, Castel Bolognese, Italia) y Intersurgical B/SYS 5809001 (IT) (Intersurgical, Wokingham, Reino Unido). Para la simulación se empleó un ventilador Bipap Vision (Philips Respironics, Murrysville, PA, EE. UU.) con ventilación controlada por presión (PCV) conectado a un simulador pulmonar. El rendimiento de cada SHWC se evaluó en 4 condiciones ventilatorias: IPAP de 15 cm H2O con FiO2 igual a 0,3 o igual a 1; IPAP de 25 cm H2O con FiO2 igual a 0,3 o igual a 1. La EPAP se estableció en 5 cm H2O. Las medidas ventilatorias e higrométricas incluyeron: humedad relativa (HR) humedad absoluta (AH), temperature (T), Pplat, PIP, PEEP, pico de flujo inspiratorio (PIF) y volumen tidal (Vt). Resultados: Para cada grupo de FiO2 FP detectó valores similares de humedad absoluta (HA) en comparación con IT y RP (p<0,001), independientemente del nivel IPAP utilizado. Se registró un incremento significativo de la HA en todos los grupos medidos con IT y RP conforme aumentaron los valores de IPAP (p<0,001), excepto en el grupo de FiO2, igual a 0,3 medido con RP. Los valores de PIP, Pplat, PEEP, PIF y Vt resultaron significativamente más elevados con FP y RP en cada grupo FiO2 en comparación con IT (p < 0 ,001). Conclusiones: La evaluación de la humidificación varió significativamente entre los 3 circuitos, siendo FP el único capaz de mantener estables los valores de HA durante el estudio sin influencia alguna de los parámetros ventilatorios

Effects on Humidification and Ventilatory Parameters of Three Single-limb Heated-wired Circuits for Non-invasive Ventilation: A Bench Study.

BACKGROUND: The objective of this study was to evaluate the effects of three single-limb heated wired circuits (SLHWC) for NIV, on ventilatory parameters and humidification performance in a simulation lung model. METHODS: Three SLHWC compatible with the MR-850 Heated Humidifier (HH) (Fisher & Paykel, Auckland, New Zealand) were tested: RT-319 (FP) (Fisher & Paykel, Auckland, New Zealand), Respironics 1045770 (RP) (DEAS, Castel Bolognese, Italy) and Intersurgical B/SYS 5809001 (IT) (Intersurgical, Wokingham, UK). A Bipap Vision ventilator (Philips Respironics, Murrysville, PA, USA) in pressure control ventilation (PCV) connected to a test lung was used for simulation. Each SHWC performance was evaluated in four ventilatory conditions: IPAP of 15cmH2O with FiO2 0.3 and 1, respectively; and, IPAP of 25cmH2O with FiO2 0.3 and 1, respectively. EPAP was set at 5cmH2O. Hygrometric and ventilatory measurements including: relative humidity (RH), temperature (T), Pplat, PIP, PEEP, peak inspiratory flow (PIF), and tidal volume (Vt) were measured. RESULTS: In each FiO2 group absolute humidity (AH) was similar with FP regardless of the IPAP level employed compared to IT and RP (P<.001). Except for RP at FiO2 0.3, AH increased significantly in IT and RP groups as IPAP increased (P<.001). PIP, Pplat, PEEP, PIF, and Vt values were significantly higher with FP and RP in each FiO2 group compared to IT (P<.001). CONCLUSIONS: Humidification performance varied significantly among the three circuits, being FP the only one able to maintain stable AH values during the study with no influence on ventilatory parameters.

Virulence and resistance determinants of Klebsiella pneumoniae isolated from a Portuguese tertiary university hospital centre over a 31-year period / Determinantes de virulencia y resistencia en Klebsiella pneumoniae aisladas en un centro hospitalario universitario en Portugal durante 31 años

INTRODUCTION: The rapid and complex evolution of bacterial resistance mechanisms in Klebsiella pneumoniae producing extended-spectrum β-lactamases and carbapenemases in Klebsiella pneumoniae is one of the most significant threats to public health. However, questions and controversies regarding the interactions between resistance and virulence in multidrug-resistant K. pneumoniae isolates remain unclear. METHODS: A retrospective cohort study was performed with 100 K. pneumoniae isolates recovered from a tertiary care university hospital centre in Lisbon over a 31-year period. Resistance and virulence determinants were screened using molecular methods (PCR, M13-PCR and MLST). RESULTS: The predominant virulence profile (fimH, mrkDv1, khe) was shared by all isolates, indicative of an important role of type 1 and 3 fimbrial adhesins and haemolysin, regardless of the type of β-lactamase produced. However, accumulation of virulence factors was identified in KPC-3-producers, with a higher frequency (p < 0.05) of capsular serotype K2 and iucC aerobactin when compared with non-KPC-3 Beta-lactamases or carbapenemases. Additionally, 9 different virulence profiles were found, indicating that the KPC-3 carbapenemase producers seem to adapt successfully to the host environment and maintain virulence via several pathways. CONCLUSION: This study describes an overlapping of multidrug-resistance and virulence determinants in ST-14K2 KPC-3 K. pneumoniae clinical isolates that may impose an additional challenge in the treatment of infections caused by this pathogen

INTRODUCCIÓN: La rápida y compleja evolución de los mecanismos de resistencia de Klebsiella pneumoniae productora de beta-lactamasas de espectro extendido y carbapenemasas en Klebsiella pneumoniae es una de las amenazas más importantes para la salud pública. Sin embargo, aun existe controversia sobre la interacción entre la resistencia y la virulencia en aislados de K. pneumoniae resistentes a múltiples antimicrobianos. MÉTODOS: Se realizó un estudio de cohorte retrospectivo con 100 aislados de Klebsiella pneumoniae de un centro hospitalario universitario en Lisboa durante 31 años. Los determinantes de la resistencia y virulencia se rastrearon utilizando métodos moleculares (PCR, M13-PCR y MLST). RESULTADOS: Todos los aislados compartían un perfil de virulencia predominante (fimH, mrkDv1, khe), lo que indica un papel importante de las adhesinas fimbriales de tipo 1 y 3, y de la hemolisina, independientemente del tipo de β-lactamasa producida. Sin embargo, la acumulación de factores de virulencia del serotipo capsular K2 y la aerobactina iucC se identificó con una mayor frecuencia en las cepas productoras de KPC-3 (p < 0,05) en comparación con las productoras de otras Beta-lactamasas o carbapenemasas. Además, se encontraron 9 perfiles de virulencia diferentes, indicativos de que las cepas productoras de carbapenemasa KPC-3 parecen adaptarse con éxito al entorno y mantener la virulencia por varias vías. CONCLUSIÓN: Este estudio describe la unión de resistencia a múltiples antimicrobianos junto con determinantes de virulencia en aislados clínicos de K. pneumoniae ST-14K2 KPC-3 lo que puede suponer un desafío adicional en el tratamiento de infecciones causadas por este patógeno

Nuevas perspectivas en la titulación de la oxigenoterapia: ¿es la titulación automática el futuro? / New Perspectives in Oxygen Therapy Titration: Is Automatic Titration the Future?

La oxigenoterapia, como todos los tratamientos que dependen de la tecnología, no para de evolucionar. No hay dudas respecto a su eficacia en el tratamiento de la insuficiencia respiratoria aguda y crónica en diferentes escenarios clínicos. Sin embargo, su dosificación terapéutica no es tan estricta como la de otros tratamientos. El uso de flujos más altos de lo necesario y por periodos demasiado prolongados, derivados de la percepción de «terapia salvavidas con pocos efectos secundarios» por parte del clínico, ha conllevado un uso bastante liberal de este medicamento, pese a la evidencia de que tanto su uso en exceso como su ajuste subóptimo tienen efectos nocivos. La titulación de la oxigenoterapia ha demostrado efectos beneficiosos en los pacientes. Tradicionalmente, se ha realizado de forma manual. Recientemente, se han desarrollado nuevos dispositivos para ajustar automáticamente las tasas de flujo de oxígeno a las necesidades de cada paciente, con el objetivo de mantener las saturaciones de oxígeno estables. Estos sistemas de suministro de oxígeno de circuito cerrado tienen el potencial de reducir el error médico, mejorar la morbimortalidad y reducir los costes del cuidado. Dar a conocer estos nuevos avances tecnológicos ayudará a concienciar a la comunidad médica de los riesgos del uso inadecuado del tratamiento con oxígeno. Este trabajo pretende ser una puesta al día de las recientes novedades en relación con la titulación de la oxigenoterapia

Oxygen therapy, like all technology-based treatments, is continuously evolving. There are no doubts as to its effectiveness in the treatment of acute and respiratory failure in different clinical scenarios. However, the dosing guidelines for oxygen therapy are not as strict as for other treatments. The use of higher than necessary flows over excessively long periods, derived from the clinician's perception of it as a ‘life-saving treatment with few side effects’, has led to a rather liberal use of this intervention, despite evidence that overuse and suboptimal adjustment can be harmful. The titration of oxygen therapy, which is traditionally performed manually, has been shown to be beneficial. Recently, new devices have been developed that automatically adjust oxygen flow rates to the needs of each patient, in order to maintain stable oxygen saturation levels. These closed-loop oxygen supply systems can potentially reduce medical error, improve morbidity and mortality, and reduce care costs. Familiarizing the medical community with these technological advances will improve awareness of the risks of the inappropriate use of oxygen therapy. The aim of this paper is to provide an update of recent developments in oxygen therapy titration

Nuevas perspectivas en la titulación de la oxigenoterapia: ¿es la titulación automática el futuro? / New Perspectives in Oxygen Therapy Titration: Is Automatic Titration the Future?

La oxigenoterapia, como todos los tratamientos que dependen de la tecnología, no para de evolucionar. No hay dudas respecto a su eficacia en el tratamiento de la insuficiencia respiratoria aguda y crónica en diferentes escenarios clínicos. Sin embargo, su dosificación terapéutica no es tan estricta como la de otros tratamientos. El uso de flujos más altos de lo necesario y por periodos demasiado prolongados, derivados de la percepción de «terapia salvavidas con pocos efectos secundarios» por parte del clínico, ha conllevado un uso bastante liberal de este medicamento, pese a la evidencia de que tanto su uso en exceso como su ajuste subóptimo tienen efectos nocivos. La titulación de la oxigenoterapia ha demostrado efectos beneficiosos en los pacientes. Tradicionalmente, se ha realizado de forma manual. Recientemente, se han desarrollado nuevos dispositivos para ajustar automáticamente las tasas de flujo de oxígeno a las necesidades de cada paciente, con el objetivo de mantener las saturaciones de oxígeno estables. Estos sistemas de suministro de oxígeno de circuito cerrado tienen el potencial de reducir el error médico, mejorar la morbimortalidad y reducir los costes del cuidado. Dar a conocer estos nuevos avances tecnológicos ayudará a concienciar a la comunidad médica de los riesgos del uso inadecuado del tratamiento con oxígeno. Este trabajo pretende ser una puesta al día de las recientes novedades en relación con la titulación de la oxigenoterapia

Oxygen therapy, like all technology-based treatments, is continuously evolving. There are no doubts as to its effectiveness in the treatment of acute and respiratory failure in different clinical scenarios. However, the dosing guidelines for oxygen therapy are not as strict as for other treatments. The use of higher than necessary flows over excessively long periods, derived from the clinician's perception of it as a ‘life-saving treatment with few side effects’, has led to a rather liberal use of this intervention, despite evidence that overuse and suboptimal adjustment can be harmful. The titration of oxygen therapy, which is traditionally performed manually, has been shown to be beneficial. Recently, new devices have been developed that automatically adjust oxygen flow rates to the needs of each patient, in order to maintain stable oxygen saturation levels. These closed-loop oxygen supply systems can potentially reduce medical error, improve morbidity and mortality, and reduce care costs. Familiarizing the medical community with these technological advances will improve awareness of the risks of the inappropriate use of oxygen therapy. The aim of this paper is to provide an update of recent developments in oxygen therapy titration

A telephone-based survey of current trends, habits and beliefs in patients receiving portable oxygen therapy in Madrid, Spain.

Portable oxygen therapy is a major challenge for patients and clinicians. Additionally, the available evidence on this subject is poor considering that only a few studies have been published and the results have not been encouraging. We explored the current trends, habits and beliefs among patients receiving portable oxygen therapy in a geographical area of Madrid, Spain (4 051 862 inhabitants). A telephone-based survey was conducted among patients selected from a database who were undergoing portable oxygen therapy. The number of patients on home respiratory therapies on December 31, 2017 was 81 559 (prevalence 2013.30 per 100 000 inhabitants). A total of 19 492 patients were on home oxygen therapy (HOT) (prevalence 481.16 per 100 000 inhabitants). Of these, 4015 patients (20% of the total of patients on HOT) received ambulatory oxygen therapy. In the analysed period, 1942 patients were selected (57.31% male and 42.69% female). The mean±sd age was 73.89±11.67 years. Most of patients had portable oxygen concentrators (99.59%). The survey was completed by 1777 patients. Most of patients thought they had been prescribed HOT for respiratory failure. 55% of the participants surveyed reported having carried out a walking test with oxygen to know the amount of oxygen they needed. 71% of the participants reported leaving the home for between 1 and 3 h a day. Most of them were carrying portable devices in a wheeled cart (51.94%). Our study data obtained from a large sample of oxygen-dependent individuals provide valuable information regarding domiciliary and portable oxygen usage in Madrid.

Terapia combinada en pacientes con insuficiencia respiratoria aguda: alto flujo por cánula nasal y ventilación mecánica no invasiva / Combination Therapy in Patients with Acute Respiratory Failure: High-Flow Nasal Cannula and Non-Invasive Mechanical Ventilation

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