Outpatient Noninvasive Ventilation
2020; Elsevier BV; Volume: 158; Issue: 6 Linguagem: Inglês
10.1016/j.chest.2020.08.004
ISSN1931-3543
AutoresSarah Bettina Schwarz, Wolfram Windisch,
Tópico(s)Neuroscience of respiration and sleep
ResumoFOR RELATED ARTICLE, SEE PAGE 2493Long-term noninvasive ventilation (NIV) is an established form of treatment for patients who experience chronic respiratory failure, which can be caused by diseases such as thoracic restrictive disorders (RTD), neuromuscular disorders (NMD), COPD, and obesity hypoventilation syndrome.1Ergan B. Oczkowski S. Rochwerg B. et al.European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD.Eur Respir J. 2019; 54: 1901003Crossref PubMed Scopus (62) Google Scholar, 2Windisch W. Geiseler J. Simon K. Walterspacher S. Dreher M. on behalf of the Guideline Commission. German National Guideline for treating chronic respiratory failure with invasive and non-invasive ventilation, revised edition 2017, part 1.Respiration. 2018; 96: 66-97Crossref PubMed Scopus (29) Google Scholar, 3Windisch W. Geiseler J. Simon K. Walterspacher S. Dreher M. on behalf of the Guideline Commission. German National Guideline for treating chronic respiratory failure with invasive and non-invasive ventilation, revised edition 2017, part 2.Respiration. 2018; 96: 171-203Crossref PubMed Scopus (37) Google Scholar Patients with chronic respiratory failure usually require treatment in hospital, given that they are severely ill with significant comorbidities that negatively impact their health-related quality of life and long-term survival. In particular, nocturnal measurements are essential for optimizing treatment, because NIV is performed typically overnight. According to the German guidelines for long-term home mechanical ventilation, it is recommended explicitly that both the initiation and control of NIV therapy should not be performed in an outpatient setting,2Windisch W. Geiseler J. Simon K. Walterspacher S. Dreher M. on behalf of the Guideline Commission. German National Guideline for treating chronic respiratory failure with invasive and non-invasive ventilation, revised edition 2017, part 1.Respiration. 2018; 96: 66-97Crossref PubMed Scopus (29) Google Scholar primarily due to the overall lack of scientific evidence available on this topic. FOR RELATED ARTICLE, SEE PAGE 2493 Nevertheless, there are, in theory, several advantages associated with outpatient initiation and management of NIV: (1) the lack of available beds could be overcome, (2) treatment delay could be avoided, (3) the risks associated with hospitalization, including nosocomial infections, would essentially be prevented, (4) outpatient care could allow the patient’s wishes to be accommodated, and (5) outpatient care is likely to be more economical. In this issue of CHEST, van den Biggelaar et al4van den Biggelaar R.J.M. Hazenberg A. Cobben N.A.M. Gaytant M.A. Vermeulen K.M. Wijkstra P.J. A randomized trial of initiation of chronic non-invasive mechanical ventilation at home vs in-hospital in patients with neuromuscular disease and thoracic cage disorder: The Dutch Homerun Trial.Chest. 2020; 158: 2493-2501Abstract Full Text Full Text PDF Scopus (5) Google Scholar have addressed the question of whether the initiation of long-term NIV in the home environment is not inferior to in-hospital initiation in patients with NMD and RTD. A total of 96 patients were assigned randomly for the purpose of the study. The main finding was the observation of significant improvements in gas exchange and health-related quality of life, which were comparable in the home vs in-hospital-treated groups. In addition, a cost reduction of >3,200 € per patient over a 6-mo period was calculated for the home group. Based on these results, the authors concluded that, in this patient cohort, the initiation of NIV at home is not inferior to in-hospital initiation and might even be a more attractive option for patients. The current publication is in line with previous studies on outpatient NIV care, the majority of which was conducted in the Netherlands (Table 1). It is the largest and most comprehensive randomized controlled trial (RCT) for the restrictive diseases cohort, including difficult-to-treat patients such as those with amyotrophic lateral sclerosis. Notably, the results of the largest and most comprehensive RCT with patients with COPD was published recently by the same group from the Netherlands and yielded a comparable outcome.9Duiverman M.L. Vonk J.M. Bladder G. et al.Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial.Thorax. 2020; 75: 244-252Crossref PubMed Scopus (48) Google ScholarTable 1Outpatient Noninvasive Ventilation Care: Available Studies on the Initiation and Management of Noninvasive VentilationStudyCountryCases, No.DesignSettingDisease CategoryMain Outcome of Outpatient Noninvasive VentilationHazenberg et al,5Hazenberg A. Kerstjens H.A. Prins S.C. Vermeulen K.M. Wijkstra P.J. Initiation of home mechanical ventilation at home: a randomised controlled trial of efficacy, feasibility and costs.Respir Med. 2014; 108: 1387-1395Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar 2014Netherlands77RCTInitiationNMD/RTDEarlier treatment scheduling and cost-effective with equivalent treatmentSheers et al,6Sheers N. Berlowitz D.J. Rautela L. Batchelder I. Hopkinson K. Howard M.E. Improved survival with an ambulatory model of non-invasive ventilation implementation in motor neuron disease.Amyotroph Lateral Scler Frontotemporal Degener. 2014; 15: 180-184Crossref PubMed Scopus (26) Google Scholar 2014Australia29Prospective, uncontrolledInitiationNMDEarlier treatment scheduling and survival benefitBertella et al,7Bertella E. Banfi P. Paneroni M. et al.Early initiation of night-time NIV in an outpatient setting: a randomized non-inferiority study in ALS patients.Eur J Physical Rehabilitation Med. 2017; 53: 892-899PubMed Google Scholar 2017Italy55RCTInitiationALSNo differences in acceptance or adherenceSchwarz et al,8Schwarz S.B. Callegari J. Hamm C. Windisch W. Magnet F.S. Is outpatient control of long-term non-invasive ventilation feasible in chronic obstructive pulmonary disease patients?.Respiration. 2018; 95: 154-160Crossref PubMed Scopus (14) Google Scholar 2018Germany130RetrospectiveControlCOPDAvoidance of in-patient control visits in 2 of 3 casesDuiverman et al,9Duiverman M.L. Vonk J.M. Bladder G. et al.Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial.Thorax. 2020; 75: 244-252Crossref PubMed Scopus (48) Google Scholar 2020Netherlands67RCTInitiationCOPDCost-effective with equivalent treatmentvan den Biggelaar et al,4van den Biggelaar R.J.M. Hazenberg A. Cobben N.A.M. Gaytant M.A. Vermeulen K.M. Wijkstra P.J. A randomized trial of initiation of chronic non-invasive mechanical ventilation at home vs in-hospital in patients with neuromuscular disease and thoracic cage disorder: The Dutch Homerun Trial.Chest. 2020; 158: 2493-2501Abstract Full Text Full Text PDF Scopus (5) Google Scholar 2020Netherlands96RCTInitiationNMD/RTDCost-effective with equivalent treatmentALS = amyotrophic lateral sclerosis; NMD = neuromuscular disorder; RCT = randomized controlled trial; RTD = restrictive thoracic disorder Open table in a new tab ALS = amyotrophic lateral sclerosis; NMD = neuromuscular disorder; RCT = randomized controlled trial; RTD = restrictive thoracic disorder Several specific and important issues are key to the success of the outpatient NIV care strategy in the Netherlands: First, a centralized, specialized system exists in which both in- and outpatient NIV treatment is restricted to four university hospitals that are well distributed across the country.10Vereniging Samenwerkingsverband Chronische AdemhalingsondersteuningCentra voor Thuisbeademing.https://www.vsca.nl/thuisbeademing/centra-voor-thuisbeademing/Date accessed: July 31, 2020Google Scholar This ensures that all NIV patients are treated in highly specialized centers. Second, all centers command a clinically established outpatient care structure for NIV patients, who are treated by highly trained nurses.4van den Biggelaar R.J.M. Hazenberg A. Cobben N.A.M. Gaytant M.A. Vermeulen K.M. Wijkstra P.J. A randomized trial of initiation of chronic non-invasive mechanical ventilation at home vs in-hospital in patients with neuromuscular disease and thoracic cage disorder: The Dutch Homerun Trial.Chest. 2020; 158: 2493-2501Abstract Full Text Full Text PDF Scopus (5) Google Scholar,5Hazenberg A. Kerstjens H.A. Prins S.C. Vermeulen K.M. Wijkstra P.J. Initiation of home mechanical ventilation at home: a randomised controlled trial of efficacy, feasibility and costs.Respir Med. 2014; 108: 1387-1395Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,9Duiverman M.L. Vonk J.M. Bladder G. et al.Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial.Thorax. 2020; 75: 244-252Crossref PubMed Scopus (48) Google Scholar,11Vereniging Samenwerkingsverband Chronische AdemhalingsondersteuningVeldnorm Chronische Beademing. 2020.https://www.vsca.nl/veldnormen/Date accessed: July 31, 2020Google Scholar Most importantly, this level of care is available for all outpatients around the clock. Third, well-defined standard operating procedures were developed for the purpose of the current study and were mandatory for all centers. Finally, detailed telemonitoring systems have been established for nocturnal measurements, including transcutaneous Pco2 monitoring, which has been shown to be useful particularly for the continuous observation of nocturnal NIV.1Ergan B. Oczkowski S. Rochwerg B. et al.European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD.Eur Respir J. 2019; 54: 1901003Crossref PubMed Scopus (62) Google Scholar,2Windisch W. Geiseler J. Simon K. Walterspacher S. Dreher M. on behalf of the Guideline Commission. German National Guideline for treating chronic respiratory failure with invasive and non-invasive ventilation, revised edition 2017, part 1.Respiration. 2018; 96: 66-97Crossref PubMed Scopus (29) Google Scholar,11Vereniging Samenwerkingsverband Chronische AdemhalingsondersteuningVeldnorm Chronische Beademing. 2020.https://www.vsca.nl/veldnormen/Date accessed: July 31, 2020Google Scholar,12Huttmann S.E. Windisch W. Storre J.H. Techniques for the measurement and monitoring of carbon dioxide in the blood.Ann Am Thorac Soc. 2014; 11: 645-652Crossref PubMed Scopus (61) Google Scholar With the use of this approach, the outpatient setting actually reflected the inpatient setting, both in terms of technical equipment and the well-trained staff. Could the Dutch setting for outpatient NIV therefore serve as a blueprint for other countries or different healthcare systems? Given that it is undoubtedly the leading system in the world, this would certainly be desirable. However, there are some concerns that may hinder other countries from developing an ambulatory NIV approach similar to that of the Dutch, and these issues would need to be addressed before the initiation of outpatient treatment. First, relatively short distances between patients and specialized NIV centers are preferable, which means that geographic conditions similar to those in the Netherlands, where NIV centers are well-distributed across a small area, would be required. Second, a strong interconnection between in- and outpatient care is essential, something which, for example, is lacking in Germany compared with the Netherlands. Third, long-term NIV would need to be restricted to highly specialized centers to guarantee that all patients are treated by experts, as well as to achieve cost-effectiveness. Finally, telemonitoring that includes nocturnal measurements is the key to successful outpatient treatment and would need to be implemented by all centers that plan to initiate outpatient NIV. In conclusion, the current RCT by van den Biggelaar et al4van den Biggelaar R.J.M. Hazenberg A. Cobben N.A.M. Gaytant M.A. Vermeulen K.M. Wijkstra P.J. A randomized trial of initiation of chronic non-invasive mechanical ventilation at home vs in-hospital in patients with neuromuscular disease and thoracic cage disorder: The Dutch Homerun Trial.Chest. 2020; 158: 2493-2501Abstract Full Text Full Text PDF Scopus (5) Google Scholar clearly shows that outpatient initiation of long-term NIV in patients with NMD and RTD is a feasible, cost-effective approach that is not inferior to in-patient NIV initiation. This approach, however, is dependent on a highly sophisticated set-up that allows the provision of outpatient nocturnal monitoring by well-trained specialized staff. The Dutch group has now described such a setting that could eventually serve as a blueprint for other countries. A Randomized Trial of Initiation of Chronic Noninvasive Mechanical Ventilation at Home vs In-Hospital in Patients With Neuromuscular Disease and Thoracic Cage Disorder: The Dutch Homerun TrialCHESTVol. 158Issue 6PreviewThis nationwide, multicenter study shows that HMV initiation at home is noninferior to hospital initiation, as it shows the same improvement in gas exchange and health-related quality of life. In fact, from a patient’s perspective, it might even be a more attractive approach. In addition, starting at home saves over €3,200 ($3,793) per patient over a 6-month period. Full-Text PDF
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