Long-term survival following initiation of home non-invasive ventilation: a European study.

INTRODUCTION: Although home non-invasive ventilation (NIV) is increasingly used to manage patients with chronic ventilatory failure, there are limited data on the long-term outcome of these patients. Our aim was to report on home NIV populations and the long-term outcome from two European centres. METHODS: Cohort analysis including all patients established on home NIV from two European centres between 2008 and 2014. RESULTS: Home NIV was initiated in 1746 patients to treat chronic ventilatory failure caused by (1) obesity hypoventilation syndrome±obstructive sleep apnoea (OHS±OSA) (29.5%); (2) neuromuscular disease (NMD) (22.7%); and (3) obstructive airway diseases (OAD) (19.1%). Overall cohort median survival following NIV initiation was 6.6 years. Median survival varied by underlying aetiology of respiratory failure: rapidly progressive NMD 1.1 years, OAD 2.7 years, OHS±OSA >7 years and slowly progressive NMD >7 years. Multivariate analysis demonstrated higher mortality in patients with rapidly progressive NMD (HR 4.78, 95% CI 3.38 to 6.75), COPD (HR 2.25, 95% CI 1.64 to 3.10), age >60 years at initiation of home NIV (HR 2.41, 95% CI 1.92 to 3.02) and NIV initiation following an acute admission (HR 1.38, 95% CI 1.13 to 1.68). Factors associated with lower mortality were NIV adherence >4 hours per day (HR 0.64, 95% CI 0.51 to 0.79), OSA (HR 0.51, 95% CI 0.31 to 0.84) and female gender (HR 0.79, 95% CI 0.65 to 0.96). CONCLUSION: The mortality rate following initiation of home NIV is high but varies significantly according to underlying aetiology of respiratory failure. In patients with chronic respiratory failure, initiation of home NIV following an acute admission and low levels of NIV adherence are poor prognostic features and may be amenable to intervention.

People undertaking pulmonary rehabilitation are willing and able to provide accurate data via a remote pulse oximetry system: a multicentre observational study.

QUESTIONS: Can people referred to pulmonary rehabilitation easily learn to use a system for remote transmission of oximetry data? Do they consider remote transmission of oximetry data to be satisfactory? Are the transmitted data valid compared with locally stored data? DESIGN: Multicentre, prospective, observational study. PARTICIPANTS: One hundred and five adults with chronic respiratory disease who were referred to pulmonary rehabilitation. INTERVENTION: At an initial session, participants were taught to record and transmit their oximetry data to a remote server. At subsequent testing session(s), participants were requested to independently activate and use the oximetry monitoring system for a period of exercise on a cycle ergometer, until autonomy with the system was demonstrated. A subgroup of five participants undertook five 45-minute training sessions to generate a dataset to assess whether the transmitted data were valid compared with the locally stored data. OUTCOME MEASURES: Outcome measures included the number of sessions needed to become autonomous, participant satisfaction with the system, and measures of the validity of the transmitted data. RESULTS: Participants became autonomous quickly: 86% at the first testing session and 100% within three testing sessions. At least 98% of participants agreed that the system was easy to use and they would be willing to use it throughout pulmonary rehabilitation. The system transmitted usable data from 98% (95% CI 96 to 100) of sessions and introduced minimal artefact. Mean absolute differences were 0.365 beats/minute for heart rate and 0.133% for oxyhaemoglobin saturation. For heart rate, exact agreement was 72% (SD 9) and similar agreement (within 3 beats/minute) was 99% (SD 1). For oxyhaemoglobin saturation, exact agreement was 87% (SD 3) and similar agreement (within 3%) was 100% (SD 0). CONCLUSION: The telemonitoring system used in this study was sufficiently valid and acceptable for use in at-home pulmonary rehabilitation by people with chronic respiratory disease. STUDY REGISTRATION: ClinicalTrials.gov NCT03295474 and NCT03004716 (subgroup study).

Home-based Neuromuscular Electrical Stimulation as an Add-on to Pulmonary Rehabilitation Does Not Provide Further Benefits in Patients With Chronic Obstructive Pulmonary Disease: A Multicenter Randomized Trial.

OBJECTIVE: To assess the additional effect of a home-based neuromuscular electrical stimulation (NMES) program as an add-on to pulmonary rehabilitation (PR), on functional capacity in subjects with chronic obstructive pulmonary disease (COPD). DESIGN: Single-blind, multicenter randomized trial. SETTING: Three PR centers. PARTICIPANTS: Subjects with severe to very severe COPD (N=73; median forced expiratory volume in 1 second, 1L (25th-75th percentile, 0.8-1.4L) referred for PR. Twenty-two subjects discontinued the study, but only 1 dropout was related to the intervention (leg discomfort). INTERVENTION: Subjects were randomly assigned to either PR plus quadricipital home-based NMES (35Hz, 30min, 5 time per week) or PR without NMES for 8 weeks. MAIN OUTCOME MEASURE: The 6-minute walk test (6MWT) was used to assess functional capacity. RESULTS: Eighty-two percent of the scheduled NMES sessions were performed. In the whole sample, there were significant increases in the distance walked during the 6MWT (P<.01), peak oxygen consumption (P=.02), maximal workload (P<.01), modified Medical Research Council dyspnea scale (P<.01), and Saint George's Respiratory Questionnaire total score (P=.01). There was no significant difference in the magnitude of change for any outcome between groups. CONCLUSIONS: Home-based NMES as an add-on to PR did not result in further improvements in subjects with severe to very severe COPD; moreover, it may have been a burden for some patients.

Inspiratory muscle training is used in some intensive care units, but many training methods have uncertain efficacy: a survey of French physiotherapists.

QUESTIONS: How common is inspiratory muscle training by physiotherapists in the intensive care unit (ICU)? Which patients receive the training? What methods are used to administer the training? Is maximal inspiratory pressure used to evaluate the need for the training and the patient's outcome after training? DESIGN: Cross-sectional survey of all ICUs in France. PARTICIPANTS: Two hundred and sixty-five senior physiotherapists. RESULTS: The response rate was 99% among eligible units. Therapist experience in ICU was significantly associated with the use of inspiratory muscle training (p=0.02). Therapists mainly used inspiratory muscle training either systematically or specifically in patients who failed to wean from mechanical ventilation. The training was used significantly more in non-sedated patients (p<0.0001). The most commonly nominated technique that respondents claimed to use to apply the training was controlled diaphragmatic breathing (83% of respondents), whereas 13% used evidence-based methods. Among those who applied some form of inspiratory muscle training, 16% assessed maximal inspiratory pressure. Six respondents (2%, 95% CI 1 to 5) used both an evidence-based method to administer inspiratory muscle training and the recommended technique for assessment of inspiratory muscle strength. CONCLUSION: Most physiotherapists in French ICUs who apply inspiratory muscle training use methods of uncertain efficacy without assessment of maximal inspiratory pressure. Further efforts need to be made in France to disseminate information regarding evidence-based assessment and techniques for inspiratory muscle training in the ICU. The alignment of inspiratory muscle training practice with evidence could be investigated in other regions.