Provision of palliative care for people with chronic obstructive pulmonary disease: a narrative review.

BACKGROUND AND OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is characterized by persistent and progressive airflow restriction and is the third leading cause of death and disability, globally. People with severe COPD generally experience long-term functional decline punctuated by periods of acute exacerbation. Symptom burden can be severe and debilitating, and typically includes breathlessness, cough, fatigue, pain, anxiety, depression, and overall reduced quality of life. Understanding current palliative care needs and provisions in this group is an essential step to expanding access in future. METHODS: A narrative review of specialist and generalist (primary) palliative care provisions for people with COPD, with an emphasis on breathlessness symptom management. This paper aims to examine the current landscape of palliative care provision and highlight barriers and facilitators to palliative care access for people with severe COPD. KEY CONTENT AND FINDINGS: People living with severe COPD, as well as the people who care for them, are routinely under-serviced in best-practice end-of-life care, despite having symptom burden that is comparable to that of people with advanced cancer. Barriers to palliative care in this group include lack of specialist palliative care resources, uncertainty surrounding prognostication, and poor recognition of need from both patients and clinicians. Routine early palliative care involvement, including integration of specialist palliative care into respiratory services and upskilling of other healthcare providers to adopt palliative care principals within usual care (primary palliative care), have been shown to improve outcomes indicative of high-quality end-of-life care in this group, including symptom control, place of death, and legal preparations. Ongoing integration of specialist palliative care and professional education for generalist and non-palliative care specialist healthcare providers in the recognition and management of unmet palliative care needs is required to increase capacity beyond traditional specialist palliative care models. CONCLUSIONS: Despite high level of symptom burden, many people with COPD miss out on palliative care. Expanding capacity of traditional specialist palliative care by upskilling generalist healthcare providers and integrating specialist palliative care into existing respiratory services is necessary to improve access for people with COPD.

Implementing High-Flow Nasal Oxygen Therapy in Medical Wards: A Scoping Review to Understand Hospital Protocols and Procedures.

Acute hypoxemic respiratory failure (ARF) is a common cause for hospital admission. High-flow nasal oxygen (HFNO) is increasingly used as a first-line treatment for patients with ARF, including in medical wards. Clinical guidance is crucial when providing HFNO, and health services use local health guidance documents (LHGDs) to achieve this. It is unknown what hospital LHGDs recommend regarding ward administration of HFNO. This study examined Australian hospitals' LHGDs regarding ward-based HFNO administration to determine content that may affect safe delivery. A scoping review was undertaken on 2 May 2022 and updated on 29 January 2024 to identify public hospitals' LHGDs regarding delivery of HFNO to adults with ARF in medical wards in two Australian states. Data were extracted and analysed regarding HFNO initiation, monitoring, maintenance and weaning, and management of clinical deterioration. Of the twenty-six included LHGDs, five documents referenced Australian Oxygen Guidelines. Twenty LHGDs did not define a threshold level of hypoxaemia where HFNO use was recommended over conventional oxygen therapy. Thirteen did not provide target oxygen saturation ranges whilst utilising HFNO. Recommendations varied regarding maximal levels of inspired oxygen and flow rates in the medical ward. Eight LHGDs did not specify any system to identify and manage deteriorating patients. Five LHGDs did not provide guidance for weaning patients from HFNO. There was substantial variation in the LHGDs regarding HFNO care for adult patients with ARF in Australian hospitals. These findings have implications for the delivery of high-quality, safe clinical care in hospitals.

Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'.

Oxygen is a life-saving therapy but, when given inappropriately, may also be hazardous. Therefore, in the acute medical setting, oxygen should only be given as treatment for hypoxaemia and requires appropriate prescription, monitoring and review. This update to the Thoracic Society of Australia and New Zealand (TSANZ) guidance on acute oxygen therapy is a brief and practical resource for all healthcare workers involved with administering oxygen therapy to adults in the acute medical setting. It does not apply to intubated or paediatric patients. Recommendations are made in the following six clinical areas: assessment of hypoxaemia (including use of arterial blood gases); prescription of oxygen; peripheral oxygen saturation targets; delivery, including non-invasive ventilation and humidified high-flow nasal cannulae; the significance of high oxygen requirements; and acute hypercapnic respiratory failure. There are three sections which provide (1) a brief summary, (2) recommendations in detail with practice points and (3) a detailed explanation of the reasoning and evidence behind the recommendations. It is anticipated that these recommendations will be disseminated widely in structured programmes across Australia and New Zealand.

Therapeutic benefits and limitations of participatory photography for adults with mental health problems: A systematic search and literature review.

WHAT IS KNOWN ON THE SUBJECT?: Participatory photography has been reported to have therapeutic benefits for participants, such as a sense of empowerment and increased self-knowledge. No known review has examined the potential of participatory photography as a therapeutic intervention in people with mental health problems. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Participatory photography can have many therapeutic benefits for people with mental health problems. It can be used to work through problematic issues, can promote a sense of empowerment and strengthen therapeutic relationships. The most significant potential drawback of the process is the ethical issues that may arise with taking photographs of identifiable people. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Participatory photography can be a helpful therapeutic intervention for some adults with mental health problems, though not all. Further research is required for the effectiveness of this intervention before it can be considered as evidence-based. ABSTRACT: Introduction Participatory photography (PP) has been reported to have therapeutic benefits for its participants, such as empowerment and critical reflection. No known review has examined this potential exclusively in people with mental health problems. Aim To identify what therapeutic benefits and limitation adults with mental health problems have experienced through PP. Method Six academic databases were systematically searched. Eleven articles met inclusion/exclusion criteria and were of medium to high quality. Themes were extracted using thematic analysis. Results Seven themes were identified: empowerment, mental processing, enhanced therapeutic relationships, peer support, creative expression, sense of achievement and enjoyment, and limitations. Discussion The limited evidence base prevents firm conclusions. PP projects higher in personal relevance and intensity were linked with the greater therapeutic benefits. Most identified themes are supported by the wider literature on PP. The limitations indicate that PP is not suitable for all and requires adaptation for individuals and the potential seriousness of ethical issues. Implications for practice Participatory photography can be a helpful therapeutic intervention for some adults with mental health problems, though not all. Further research is required to develop the limited evidence base, particularly quantitative research that would enable comparisons to be made with other interventions.

Domiciliary non-invasive ventilation post lung transplantation.

BACKGROUND AND OBJECTIVE: The benefits of domiciliary non-invasive ventilation (NIV) post lung transplantation (LTx) have not previously been described. This was a single-centre retrospective audit of patients requiring domiciliary NIV post-LTx. Our aim was to describe indications for NIV and outcomes in chronic lung allograft dysfunction (CLAD) and diaphragmatic palsy. METHODS: All patients requiring domiciliary NIV post-LTx between 2010 and June 2016 were assessed. NIV indications, respiratory function and patient outcomes were collected. RESULTS: Out of 488 LTx recipients, 20 patients were identified as requiring NIV over the 6.5-year study period. The most common indications for NIV were CLAD and diaphragmatic palsy. Hypercapnia improved significantly with NIV. Patient outcomes were poor with nine (45%) patients dying, four (20%) undergoing redo-LTx, four (20%) continuing domiciliary NIV and only three (15%) patients weaned off NIV. CONCLUSION: This is the first case series to describe the use of domiciliary NIV post-LTx. Patients commenced on NIV post-LTx had severely impaired lung function and severe hypercapnia. Patients with diaphragmatic palsy often recovered. The mortality rate was high in chronic allograft dysfunction.

Models of care for non-invasive ventilation in the Acute COPD Comparison of three Tertiary hospitals (ACT3) study.

BACKGROUND AND OBJECTIVE: Non-invasive ventilation (NIV) improves clinical outcomes in hypercapnic acute exacerbations of COPD (AECOPD), but the optimal model of care remains unknown. METHODS: We conducted a prospective observational non-inferiority study comparing three models of NIV care: general ward (Ward) (1:4 nurse to patient ratio, thrice weekly consultant ward round), a high dependency unit (HDU) (1:2 ratio, twice daily ward round) and an intensive care unit (ICU) (1:1 ratio, twice daily ward round) model in three similar teaching tertiary hospitals. Changes in arterial blood gases (ABG) and clinical outcomes were compared and corrected for differences in AECOPD severity (Blood urea > 9 mmol/L, Altered mental status (Glasgow coma scale (GCS) < 14), Pulse > 109 bpm, age > 65 (BAP-65)) and co-morbidities. An economic analysis was also undertaken. RESULTS: There was no significant difference in age (70 ± 10 years), forced expiratory volume in 1 s (FEV1 ) (0.84 ± 0.35 L), initial pH (7.29 ± 0.08), partial pressure of CO2 in arterial blood (PaCO2 ) (72 ± 22 mm Hg) or BAP-65 scores (2.9 ± 1.01) across the three models. The Ward achieved an increase in pH (0.12 ± 0.07) and a decrease in PaCO2 (12 ± 18 mm Hg) that was equivalent to HDU and ICU. However, the Ward treated more patients (38 vs 28 vs 15, P < 0.001), for a longer duration in the first 24 h (12.3 ± 4.8 vs 7.9 ± 4.1 vs 8.4 ± 5.3 h, P < 0.05) and was more cost-effective per treatment day ($AUD 1231 ± 382 vs 1745 ± 2673 vs 2386 ± 1120, P < 0.05) than HDU and ICU. ICU had a longer hospital stay (9 ± 11 vs 7 ± 7 vs 13 ± 28 days, P < 0.002) compared with the Ward and HDU. There was no significant difference in intubation rate or survival. CONCLUSION: In acute hypercapnic Chronic obstructive pulmonary disease (COPD) patients, the Ward model of NIV care achieved equivalent clinical outcomes, whilst being more cost-effective than HDU or ICU models.

A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome.

BACKGROUND: Obesity hypoventilation syndrome (OHS) is the most common indication for home ventilation, although the optimal therapy remains unclear, particularly for severe disease. We compared Bi-level and continuous positive airways pressure (Bi-level positive airway pressure (PAP); CPAP) for treatment of severe OHS. METHODS: We conducted a multicentre, parallel, double-blind trial for initial treatment of OHS, with participants randomised to nocturnal Bi-level PAP or CPAP for 3 months. The primary outcome was frequency of treatment failure (hospital admission, persistent ventilatory failure or non-adherence); secondary outcomes included health-related quality of life (HRQoL) and sleepiness. RESULTS: Sixty participants were randomised; 57 completed follow-up and were included in analysis (mean age 53 years, body mass index 55 kg/m2, PaCO2 60 mm Hg). There was no difference in treatment failure between groups (Bi-level PAP, 14.8% vs CPAP, 13.3%, p=0.87). Treatment adherence and wake PaCO2 were similar after 3 months (5.3 hours/night Bi-level PAP, 5.0 hours/night CPAP, p=0.62; PaCO2 44.2 and 45.9 mm Hg, respectively, p=0.60). Between-group differences in improvement in sleepiness (Epworth Sleepiness Scale 0.3 (95% CI -2.8, 3.4), p=0.86) and HRQoL (Short Form (SF)36-SF6d 0.025 (95% CI -0.039, 0.088), p=0.45) were not significant. Baseline severity of ventilatory failure (PaCO2) was the only significant predictor of persistent ventilatory failure at 3 months (OR 2.3, p=0.03). CONCLUSIONS: In newly diagnosed severe OHS, Bi-level PAP and CPAP resulted in similar improvements in ventilatory failure, HRQoL and adherence. Baseline PaCO2 predicted persistent ventilatory failure on treatment. Long-term studies are required to determine whether these treatments have different cost-effectiveness or impact on mortality. TRIAL REGISTRATION NUMBER: ACTRN12611000874910, results.

The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA.

STUDY OBJECTIVES: The study aimed to document the neurobehavioral outcomes of patients referred to and treated by a sleep medicine service for moderate to severe obstructive sleep apnea (OSA). In particular, we aimed to establish the proportion of patients who, while appearing to have optimal continuous positive airway pressure (CPAP) adherence, did not normalize their daytime sleepiness or neurocognitive function after 3 months of CPAP therapy despite effective control of OSA. DESIGN: Multicenter clinical-effectiveness study. SETTING: Three academic sleep centers in Australia. PARTICIPANTS: Patients referred to a sleep medicine service with moderate to severe OSA (n = 174). INTERVENTION: CPAP. MEASUREMENTS AND RESULTS: Participants were assessed pretreatment and again after 3 months of CPAP therapy. At the beginning and at the conclusion of the trial, participants completed a day of testing that included measures of objective and subjective daytime sleepiness, neurocognitive function, and quality of life. In patients with symptomatic moderate to severe OSA (i.e., apnea-hypopnea index > 30/h), we found a treatment dose-response effect for CPAP in terms of Epworth Sleepiness Scale scores (P < 0.001). Several key indexes of neurobehavior (e.g., Functional Outcomes of Sleep Questionnaire, Epworth Sleepiness Scale) currently used to assess treatment response failed to normalize in a substantial group of patients after 3 months of CPAP treatment, even in those who were maximally compliant with treatment. Forty percent of patients in this trial had an abnormal Epworth Sleepiness Scale score at the conclusion of the trial. In addition, we showed no dose-response effect with the Maintenance of Wakefulness Test, raising doubts as to the clinical utility of the Maintenance of Wakefulness Test in assessing treatment response to CPAP in patients with OSA. CONCLUSIONS: Our study suggests that a greater percentage of patients achieve normal functioning with longer nightly CPAP duration of use, but a substantial proportion of patients will not normalize neurobehavioral responses despite seemingly adequate CPAP use. It is thus crucial to adequately assess patients after CPAP therapy and seek alternate etiologies and treatments for any residual abnormalities.

A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea.

RATIONALE: Obstructive sleep apnea (OSA) is a prevalent disease. Often limited clinical resources result in long patient waiting lists. Simpler validated methods of care are needed. OBJECTIVES: To demonstrate that a nurse-led model of care can produce health outcomes in symptomatic moderate-severe OSA not inferior to physician-led care. METHODS: A randomized controlled multicenter noninferiority clinical trial was performed. Of 1,427 potentially eligible patients at 3 centers, 882 consented to the trial. Of these, 263 were excluded on the basis of clinical criteria. Of the remaining 619, 195 met home oximetry criteria for high-probability moderate-severe OSA and were randomized to 2 models of care: model A, the simplified model, using home autoadjusting positive airway pressure to set therapeutic continuous positive airway pressure (CPAP), with all care supervised by an experienced nurse; and model B, involving two laboratory polysomnograms to diagnose and treat OSA, with clinical care supervised by a sleep physician. The primary end point was change in Epworth Sleepiness Scale (ESS) score after 3 months of CPAP. Other outcome measures were collected. MEASUREMENTS AND MAIN RESULTS: For the primary outcome change in ESS score, nurse-led management was no worse than physician-led management (4.02 vs. 4.15; difference, -0.13; 95% confidence interval: -1.52, 1.25) given a prespecified noninferiority margin of -2 for the lower 95% confidence interval. There were also no differences between both groups in CPAP adherence at 3 months or other outcome measures. Within-trial costs were significantly less in model A. CONCLUSIONS: A simplified nurse-led model of care has demonstrated noninferior results to physician-directed care in the management of symptomatic moderate-severe OSA, while being less costly. Clinical trial registered with http://www.anzctr.org.au (ACTRN012605000064606).

The use of noninvasive mechanical ventilation in COPD with severe hypercapnic acidosis.

STUDY OBJECTIVES: To compare the effect of noninvasive mechanical ventilation (NIV) in severely acidotic with mildly acidotic patients with acute hypercapnic chronic obstructive lung disease (COPD). DESIGN: Comparison of NIV in consecutively enrolled patients with acute hypercapnic COPD with mild (pH 7.25-7.35) or severe (pH<7.25) acidosis on time to normalise pH and improve PaCO(2), duration of NIV treatment, length of stay in hospital and survival. Results (meadian (IQR)): Twenty-nine patients had 36 episodes of acute hypercapnic respiratory failure: Seventeen with pH<7.25 and 19 with pH 7.25-7.34. Compared with the mildly acidotic group, the severely acidotic group took a similar length of time for pH to normalise and PaCO(2) improve (12 (6-34) vs 12 (4-28)h, respectively, P=0.42), with similar duration of NIV treatment (60 (35-96) vs 68 (36-48)h, respectively, P=0.25) and hospital length of stay (8 (7-18) vs 9 (5-17) days, respectively, P=0.61). Overall survival was 89%, with 95% in the mild and 82% in the severely acidotic groups. CONCLUSIONS: Noninvasive ventilation is effective in the treatment of patients with severe acidosis due to acute hypercapnic COPD.

Efficacy of a heated passover humidifier during noninvasive ventilation: a bench study.

BACKGROUND: Noninvasive positive-pressure ventilation (NPPV) delivers air at a high flow, which is associated with airway mucosal drying and impaired airway functioning. OBJECTIVES: To examine the effects of mechanical ventilation parameters on relative humidity and absolute humidity during NPPV, and to evaluate the effect of a heated passover humidifier on relative humidity, absolute humidity, and ventilator performance during NPPV. METHODS: We performed a bench study to assess the effects of inspiratory positive airway pressure (IPAP) of 10 cm H(2)O, 15 cm H(2)O, and 20 cm H(2)O, respiratory rates of 12 breaths/min and 24 breaths/min, and inspiratory-expiratory ratios of 1:2 and 1:3 on relative and absolute humidity. The measurements were obtained on room air and with a heated humidifier at medium and maximum heater settings. RESULTS: Without humidification, the relative humidity in the NPPV circuit (range 16.3-26.5%) was substantially lower than the ambient relative humidity (27.6-31.5%) at all ventilatory settings. Increasing the IPAP decreased the relative humidity (Spearman's rho = 0.67, p < 0.001). Changing the respiratory rate or inspiratory-expiratory ratio had no significant effect. Both relative and absolute humidity increased with humidification, and the air was fully saturated at the maximum heater setting. Delivered IPAP was reduced by 0.5-1 cm H(2)O during humidification. CONCLUSIONS: NPPV delivers air with a low relative humidity, especially with high inspiratory pressure. Addition of a heated humidifier increases the relative and absolute humidity to levels acceptable for nonintubated patients, with minimal effect on delivered pressure. Consideration should be given to heated humidification during NPPV, especially when airway drying and secretion retention are of concern.