Vol. 11 •Issue 1 • Page 25
Home Care Teams Key to NPPV Success
In the past, treatment of chronic obstructive pulmonary disease frequently resulted in drug therapy, oxygen therapy and, in some cases, long-term invasive ventilation using a tracheostomy to connect with the ventilator to support a patient’s breathing. The advancement of noninvasive ventilators and the mask interface during the 1990s has reduced the need for patients to have a tracheostomy in place and made ventilatory support more acceptable to individuals suffering from chronic respiratory failure.
Tracheostomy has inherent disadvantages: It’s expensive (trachea interface charges average $2,000 to $3,000 more than mask interface charges); it requires trained surgical personnel, anesthesia and operating room support; and it results in greater morbidity and mortality. Other risks include upper airway stenosis, a permanent scar and a potential to exacerbate injury to the larynx caused by translarynegeal intubations.
In comparison, current and forthcoming medical literature strongly suggests noninvasive positive pressure ventilation (NPPV) improves the COPD patient’s quality of life, decreases health care costs and improves arterial blood gases despite progression of the disease.
Although this form of mechanical ventilation is noninvasive and has less risk than invasive ventilation, it isn’t risk free. Reduction of complications and ensuring optimal therapy requires frequent monitoring of the patient and system. A comprehensive home care management team supports such assurances by frequently visiting the NPPV patient in the home.
HOME CARE TEAMS
The home care team normally consists of the patient, the family, the durable medical equipment supplier, the respiratory care therapist and, potentially, home nursing agencies, community service groups and privately funded caregivers.
Generally, the supplier of the durable medical equipment is responsible for the operation and care of the NPPV patient. Home respiratory care personnel visits are included in the service. RTs provide home care visits on a routine basis to evaluate the function of the equipment and patient status.
Successful use of NPPV requires a commitment from the patient and the RT. Patients must be willing to tolerate a nasal mask (versus a trachea tube) strapped to their face for periods of six to eight hours or more daily. RTs must have the time and patience to ensure the proper adjustment of the ventilator and to verify achievement of the goals of NPPV.
Most applications of NPPV are designed to allow ventilatory muscles to rest and recover to ensure maximum muscle capability when NPPV is not in use.1-4 Proper setting of the NPPV ensures controlled ventilation. Pressure-supported breaths using a backup rate must be set to reduce the patient’s work of breathing. Optimal setting enhances the likelihood of patient/ventilator synchrony.
Efficacy and compliance during NPPV need constant monitoring, especially considering the progressive nature of COPD. In a study done at Temple University School of Medicine, researchers found that many NPPV patients require ongoing adjustments of their interface and ventilator to be successful. NPPV adjustments made after initial setup for associated problems included the following:
• masks (36 percent)
• ventilator source (31 percent)
• leaks (43 percent)
• skin irritation (22 percent)
• rhinitis (13 percent)
• aerophagia (13 percent)
• discomfort from headgear (9 percent).
Of the study population (n=36), three patients required tracheostomy as their COPD progressed. The Temple group concluded that a comprehensive follow-up program is required to correct problems with NPPV and to ensure optimal patient compliance.5
Other common problems that need intervention are mouth and nasal dryness, gastric distention, eye irritation, gum pain, soreness on the bridge of the nose and nosebleed.6 More serious medical problems include life-threatening inspissated secretions that cause airway blockage7 and acute respiratory failure associated with oral constant aspiration pneumonitis.8
A variety of interventions may be utilized to improve comfort and reduce some of the problems associated with NPPV. Ob-viously, not all faces are exactly the same, hence patients have a large selection of masks to choose from. RTs can help patients find one that fits best. Nasal pillows may help some people when mask changes don’t completely satisfy the patient.
Other inventions include the addition of humidification, either cool passover or heated, which can decrease nasal dryness and congestion. Pharmacologic agents such as nasal decongestions, nasal steroids and antihistamines may help reduce nasal symptoms during NPPV.
NPPV BENEFITS
Comprehensive programs to support NPPV are beneficial to patients and create a health care cost savings. In a study by Janssen, et al., they found that NPPV in the home decreased hospitalization rates and that age (a segmented group with an age above 75 years) was no barrier to implementation with home support. They also indicated the cost/benefit ratio for NPPV to be favorable.9
It has been further established that patients receiving NPPV in the home have a significantly higher quality of life despite their being able to recognize the advancement of their disease.10 In addition, the long-term use of NPPV at night improves awake gas exchange in patients with chronic respiratory failure.11
Results from the United Kingdom, published in Thorax, have examined the long-term follow-up of NPPV and its effect on survival.12 These researchers stated that hospitalizations and physician consultations were halved after one year compared with the year before NPPV, and that there was a sustained improvement in arterial blood gases at 12 months and 24 months while patients were breathing room air, despite progressive deterioration in ventilatory function. NPPV was well tolerated, and survival appeared to be prolonged when compared to long-term oxygen therapy trials.
Other research further suggests that NPPV significantly im-proves quality of life9,10 and home patient management can reduce use of health care re-sources.13 In a study by Waugh, et al., investigators found, using a modified SF-36 written quality of life survey, subjects showed marked improvement in quality of life following NPPV. This finding is profound when considering that COPD is a progressive disease.10 n
REFERENCES
1. Segall D. Noninvasive nasal mask-assisted ventilation in respiratory failure of Duchenne muscular dystrophy. Chest. 1988; 93:1298-1300.
2. Goldstein RS, Peirson DJ. Long-term mechanical ventilation as elective therapy. Respir Care. 1991; 36:288-89.
3. Ellis ER, McCavley VB, Mellins C, et al. Treatment of alveolar hypoventilation in a 6-year-old girl with intermittent positive pressure ventilation through a nose mask. Am Rev Respir Dis. 1987; 136:188-91.
4. Bach JR, Alba AS. Management of chronic alveolar hypoventilation by nasal ventilation. Chest. 1990; 97:52-7.
5. Criner GJ, Brennen K, Travaline JM, Kreimer D. Efficacy and compliance with noninvasive positive pressure ventilation in patients with chronic respiratory failure. Chest. 1999; 119 (3):667-75.
6. Leger P, Bedicam JM, Cornette A, et al. Nasal intermittent positive pressure ventilation: long-term follow-up in patients with severe chronic respiratory insufficiency. Chest. 1994; 105:100-105.
7. Wood KE, Flaten AL, Backes W. Inspissated secretions: a life-threatening complication of prolonged noninvasive ventilation. Respir Care. 2000; 45(5): 491-93.
8. Keddissi JI, Metcalf JP. The use of noninvasive ventilation in acute respiratory failure associated with oral contrast aspiration pneumonitis. Respir care. 2000; 45(5):494-96.
9. Janssens JP, Cicotti E, Fitting JW, Rochat T. Noninvasive home ventilation in patients over 75 years of age: tolerance, compliance and impact on quality of life. Respir Med. 1998;92(12):1311-20
10. Waugh JB, Spratt G, Causey DE, Lain DC. Effect of noninvasive positive pressure ventilation on quality of life in subjects with chronic hypercapnia in the homesetting. Chest. 2000; 118(4)91S. (Abstract) Manu-script: RT, The J for Respir Care Practit. Dec/Jan.2001;43-5.
11. Moloney F, Kiely JL, McDonnell T, McNicholas WT. Nocturnal nasal intermittent positive pressure ventilation (NIPPV) therapy for chronic respiratory failure: long-term effects. Ir Med J. 1999; 92(6):401-02.
12. Jones SE, Packham S, Hebden M, Smith AP. Domicilisry nocturnal intermittent positive pressure ventilation in patients with respiratory failure due to severe COPD: long-term follow-up and effect on survival. Thorax. 1998 (58):495-98.
13. McNelly T, Lauver R, Blanchard AR, Speir WA, Lain DC. The impact of home patient management on health care utilization. Chest. 2001;120(4):201S.
Lain is a sleep specialist for Sleep Safe, Kennett, Mo., and a medical adviser for Rotech Inc., Orlando, Fla. He also is adjunct assistant professor at the Medical College of Georgia and associate director, Westshore, Southwest Cleveland Sleep Center Inc., Westlake, Ohio. Holmes is program director at Sleep Safe.
