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Open AccessReview

COPD Exacerbation: Why It Is Important to Avoid ICU Admission

by

Irene Prediletto

,

Gilda Giancotti

and

Stefano Nava

J. Clin. Med. 2023, 12(10), 3369; https://doi.org/10.3390/jcm12103369 - 09 May 2023

Viewed by 859

Abstract

Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD [...] Read more.

Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD causing acute respiratory failure (ARF) often requires admission to an intensive care unit (ICU) with endotracheal intubation and invasive mechanical ventilation. AECOPD also acts as comorbidity in critically ill patients; this condition is associated with poorer prognoses. The prevalence reported in the literature on ICU admission rates ranges from 2 to 19% for AECOPD requiring hospitalization, with an in-hospital mortality rate of 20–40% and a re-hospitalization rate for a new severe event being 18% of the AECOPD cases admitted to ICUs. The prevalence of AECOPD in ICUs is not properly known due to an underestimation of COPD diagnoses and COPD misclassifications in administrative data. Non-invasive ventilation in acute and chronic respiratory failure may prevent AECOPD, reducing ICU admissions and disease mortality, especially when associated with a life-threating episode of hypercapnic ARF. In this review, we report on up to date evidence from the literature, showing how improving the knowledge and management of AECOPD is still a current research issue and clinical need. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

Open AccessReview

Getting It Right in Restrictive Lung Disease

by

Annalisa Carlucci

and

Barbara Fusar Poli

J. Clin. Med. 2023, 12(10), 3353; https://doi.org/10.3390/jcm12103353 - 09 May 2023

Viewed by 411

Abstract

Restrictive lung disease (predominantly in patients with neuromuscular disease (NMD) and ribcage deformity) may induce chronic hypercapnic respiratory failure, which represents an absolute indication to start home NIV (HNIV). However, in the early phases of NMD, patients may present only diurnal symptoms or [...] Read more.

Restrictive lung disease (predominantly in patients with neuromuscular disease (NMD) and ribcage deformity) may induce chronic hypercapnic respiratory failure, which represents an absolute indication to start home NIV (HNIV). However, in the early phases of NMD, patients may present only diurnal symptoms or orthopnoea and sleep disturbances with normal diurnal gas exchange. The evaluation of respiratory function decline may predict the presence of sleep disturbances (SD) and nocturnal hypoventilation that can be respectively diagnosed with polygraphy and PCO₂ transcutaneous monitoring. If nocturnal hypoventilation and/or apnoea/hypopnea syndrome are detected, HNIV should be introduced. Once HNIV has been started, adequate follow-up is mandatory. The ventilator’s built-in software provides important information about patient adherence and eventual leaks to correct. Detailed data about pressure and flow curves may suggest the presence of upper airway obstruction (UAO) during NIV that may occur with or without decrease in respiratory drive. Etiology and treatment of these two different forms of UAO are different. For this reason, in some circumstances, it might be useful to perform a polygraph. PtCO₂ monitoring, together with pulse-oximetry, seem to be very important tools to optimize HNIV. The role of HNIV in neuromuscular disease is to correct diurnal and nocturnal hypoventilation with the consequence of improving quality of life, symptoms, and survival. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

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Open AccessReview

Moving from Inpatient to Outpatient or Home Initiation of Non-Invasive Home Mechanical Ventilation

by

Mike J. Kampelmacher

J. Clin. Med. 2023, 12(8), 2981; https://doi.org/10.3390/jcm12082981 - 19 Apr 2023

Viewed by 424

Abstract

Home mechanical ventilation (HMV) is an effective treatment for patients with chronic hypercapnic respiratory failure caused by restrictive or obstructive pulmonary disorders. Traditionally, HMV is initiated in the hospital, nowadays usually on a pulmonary ward. The success of HMV, and especially non-invasive home [...] Read more.

Home mechanical ventilation (HMV) is an effective treatment for patients with chronic hypercapnic respiratory failure caused by restrictive or obstructive pulmonary disorders. Traditionally, HMV is initiated in the hospital, nowadays usually on a pulmonary ward. The success of HMV, and especially non-invasive home mechanical ventilation (NIV), has led to a steep and ongoing increase in the incidence and prevalence of HMV, in particular for patients with COPD or obesity hypoventilation syndrome. Consequently, the number of available hospital beds to accommodate these patients has become insufficient, and models of care that minimize the use of (acute) hospital beds need to be developed. At present, the practices for initiation of NIV vary widely, reflecting the limited research on which to base model-of-care decisions, local health system features, funding models, and historical practices. Hence, the opportunity to establish outpatient and home initiation may differ between countries, regions, and even HMV centres. In this narrative review, we will describe the evidence regarding the feasibility, effectiveness, safety, and cost savings of outpatient and home initiation of NIV. In addition, the benefits and challenges of both initiation strategies will be discussed. Finally, patient selection and execution of both approaches will be examined. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

Open AccessReview

Ventilators, Settings, Autotitration Algorithms

by

Manel Luján

and

Cristina Lalmolda

J. Clin. Med. 2023, 12(8), 2942; https://doi.org/10.3390/jcm12082942 - 18 Apr 2023

Viewed by 479

Abstract

The choice of a ventilator model for a single patient is usually based on parameters such as size (portability), presence or absence of battery and ventilatory modes. However, there are many details within each ventilator model about triggering, pressurisation or autotitration algorithms that [...] Read more.

The choice of a ventilator model for a single patient is usually based on parameters such as size (portability), presence or absence of battery and ventilatory modes. However, there are many details within each ventilator model about triggering, pressurisation or autotitration algorithms that may go unnoticed, but may be important or may justify some drawbacks that may occur during their use in individual patients. This review is intended to emphasize these differences. Guidance is also provided on the operation of autotitration algorithms, in which the ventilator is able to take decisions based on a measured or estimated parameter. It is important to know how they work and their potential sources of error. Current evidence on their use is also provided. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

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Open AccessReview

Optimizing Tracheal Oxygen Tension and Diffusion Ratio When Choosing High-Flow Oxygen Therapy or CPAP for the Treatment of Hypoxemic Respiratory Failure: Insights from Ex Vivo Physiologic Modelling

by

Bill Truschel

and

Michael I. Polkey

J. Clin. Med. 2023, 12(8), 2878; https://doi.org/10.3390/jcm12082878 - 14 Apr 2023

Viewed by 482

Abstract

This article is a review of the physiological and technological processes underpinning high-flow nasal therapy with oxygen (HFNT or HFOT) for the treatment of hypoxemic respiratory failure. A mathematical model was carefully built to represent the relationships between the settings on the HFNT [...] Read more.

This article is a review of the physiological and technological processes underpinning high-flow nasal therapy with oxygen (HFNT or HFOT) for the treatment of hypoxemic respiratory failure. A mathematical model was carefully built to represent the relationships between the settings on the HFNT device and the resultant diffusion of oxygen into hypoxemic, arterial blood. The analysis was used to recommend a strategy for setting the flow rate at or above the patient’s peak inspiratory flow when HFNT is used with a blender and equal to the patient’s peak inspiratory rate when bleed-in oxygen is used. The analysis also teaches how to titrate the settings to achieve a desired fraction of inhaled oxygen, (

F_{i} O_{2})

, in the trachea using a simple ratio when bleed-in oxygen is used. The model was used to compare HFNT as a method to improve oxygen diffusion efficacy with other forms of oxygen therapy. The analysis in this article relates the efficacy of HFOT/HFNT to that of CPAP with supplemental oxygen by computing the diffusion ratio of oxygen therapy versus breathing room air. We predicted that in non-atelectatic lungs, when considering oxygenation, HFNT can be equally effective as CPAP with supplemental oxygen therapy for treating hypoxemic respiratory failure. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

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Open AccessReview

What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation

by

Manel Luján

,

Pablo Flórez

and

Xavier Pomares

J. Clin. Med. 2023, 12(7), 2692; https://doi.org/10.3390/jcm12072692 - 04 Apr 2023

Viewed by 555

Abstract

Most of the published reviews about non-invasive home ventilation mainly reflect the technical aspects of ventilators. There is much less information about the consumables most used at home. However, the choice of a good interface or tubing system can lead to physiological changes [...] Read more.

Most of the published reviews about non-invasive home ventilation mainly reflect the technical aspects of ventilators. There is much less information about the consumables most used at home. However, the choice of a good interface or tubing system can lead to physiological changes in the patient–ventilator interaction that the clinician should be aware of. These physiological changes may affect the performance of the ventilator itself, the reliability of monitoring and, of course, the comfort of the patient. The use of different circuits, masks or filters is therefore related to the concepts of rebreathing, compressible volume, instrumental dead space or leak estimation and tidal volume. Through certain bench experiments, it is possible to determine the implications that each of these elements may have in clinical practice. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

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Open AccessReview

Home High-Flow Therapy in Patients with Chronic Respiratory Diseases: Physiological Rationale and Clinical Results

by

Maria Laura Vega Pittao

,

Gioacchino Schifino

,

Lara Pisani

and

Stefano Nava

J. Clin. Med. 2023, 12(7), 2663; https://doi.org/10.3390/jcm12072663 - 03 Apr 2023

Viewed by 825

Abstract

High-flow therapy (HFT) is the administration of gas flows above 15 L/min. It is a non-invasive respiratory support that delivers heated (up to 38 °C), humidified (100% Relative Humidity, RH; 44 mg H₂O/L Absolute Humidity, AH), oxygen-enriched air when necessary, through [...] Read more.

High-flow therapy (HFT) is the administration of gas flows above 15 L/min. It is a non-invasive respiratory support that delivers heated (up to 38 °C), humidified (100% Relative Humidity, RH; 44 mg H₂O/L Absolute Humidity, AH), oxygen-enriched air when necessary, through a nasal cannula or a tracheostomy interface. Over the last few years, the use of HFT in critically ill hypoxemic adults has increased. Although the clinical benefit of home high-flow therapy (HHFT) remains unclear, some research findings would support the use of HHFT in chronic respiratory diseases. The aim of this review is to describe the HFT physiological principles and summarize the published clinical findings. Finally, we will discuss the differences between hospital and home implementation, as well as the various devices available for HHFT application. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

Open AccessReview

Mechanical Insufflation-Exsufflation: Considerations for Improving Clinical Practice

by

Michelle Chatwin

and

Ruth Helen Wakeman

J. Clin. Med. 2023, 12(7), 2626; https://doi.org/10.3390/jcm12072626 - 31 Mar 2023

Viewed by 1433

Abstract

The provision of mechanical insufflation-exsufflation (MI-E) devices to enhance cough efficacy is increasing. Typically, MI-E devices are used to augment cough in patients with neuromuscular disorders but also in patients who are weak in an acute care setting. Despite a growing evidence base [...] Read more.

The provision of mechanical insufflation-exsufflation (MI-E) devices to enhance cough efficacy is increasing. Typically, MI-E devices are used to augment cough in patients with neuromuscular disorders but also in patients who are weak in an acute care setting. Despite a growing evidence base for the use of these devices, there are barriers to the provision of MI-E, including clinician lack of knowledge and confidence. Enhancing clinician education and confidence is key. Individualized or protocolized approaches can be used to initiate MI-E. Evaluation of MI-E efficacy is critical. One method to evaluate effectiveness of MI-E is the MI-E-assisted cough peak flow (CPF). However, this should always be considered alongside other factors discussed in this review. The purpose of this review is to increase the theoretical understanding of the provision and evaluation of MI-E and provide insight into how this knowledge can be applied into clinical practice. Approaches to initiation and titration can be selected based on the clinical situation, patient diagnosis (including and beyond neuromuscular disorders), and clinician’s confidence. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

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Open AccessReview

Monitoring Systems in Home Ventilation

by

Jean-Michel Arnal

,

Mathilde Oranger

and

Jésus Gonzalez-Bermejo

J. Clin. Med. 2023, 12(6), 2163; https://doi.org/10.3390/jcm12062163 - 10 Mar 2023

Viewed by 922

Abstract

Non-invasive ventilation (NIV) is commonly used at home for patient with nocturnal hypoventilation caused by a chronic respiratory failure. Monitoring NIV is required to optimize the ventilator settings when the lung condition changes over time, and to detect common problems such as unintentional [...] Read more.

Non-invasive ventilation (NIV) is commonly used at home for patient with nocturnal hypoventilation caused by a chronic respiratory failure. Monitoring NIV is required to optimize the ventilator settings when the lung condition changes over time, and to detect common problems such as unintentional leaks, upper airway obstructions, and patient–ventilator asynchronies. This review describes the accuracy and limitations of the data recorded by the ventilator. To efficiently interpret this huge amount of data, clinician assess the daily use and regularity of NIV utilization, the unintentional leaks and their repartition along the NIV session, the apnea–hypopnea index and the flow waveform, and the patient–ventilator synchrony. Nocturnal recordings of gas exchanges are also required to detect nocturnal alveolar hypoventilation. This review describes the indication, validity criteria, and interpretation of nocturnal oximetry and transcutaneous capnography. Polygraphy and polysomnography are indicated in specific cases to characterize upper airway obstruction. Telemonitoring of the ventilator is a useful tool that should be integrated in the monitoring strategy. The technical solution, information, and limitations are discussed. In conclusion, a basic monitoring package is recommended for all patients complemented by advanced monitoring for specific cases. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

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Open AccessBrief Report

Getting It Right in Obstructive Lung Disease

by

Annalisa Carlucci

and

Barbara Fusar Poli

J. Clin. Med. 2023, 12(8), 3032; https://doi.org/10.3390/jcm12083032 - 21 Apr 2023

Viewed by 476

Abstract

Chronic hypercapnic respiratory failure in obstructive lung diseases may benefit from nocturnal Home non-invasive ventilation (HNIV). It has been shown that in patients with persistence of hypercapnia after an acute episode of chronic obstructive pulmonary disease (COPD) exacerbation requiring mechanical ventilation, HNIV may [...] Read more.

Chronic hypercapnic respiratory failure in obstructive lung diseases may benefit from nocturnal Home non-invasive ventilation (HNIV). It has been shown that in patients with persistence of hypercapnia after an acute episode of chronic obstructive pulmonary disease (COPD) exacerbation requiring mechanical ventilation, HNIV may improve the risk for new admission and survival. The ability to reach these aims depends on the correct timing of enrolling patients, as well as a correct definition of ventilatory needing and setting of the ventilator. This review tries to define a possible home treatment path of hypercapnic respiratory failure in COPD by analyzing the main studies published in recent years. Full article

(This article belongs to the Special Issue Non-invasive Respiratory Support: How to Get It Right in Clinical Medicine)

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