to organization or towards the Tower of Babel? J. C. WINCK, M. R. GONÃALVES. Service of Pneumology, Faculty of Medicine, University of Porto, Porto, ...
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EDITORIAL
Noninvasive ventilation: on the road to organization or towards the Tower of Babel? J. C. WINCK, M. R. GONÇALVES Service of Pneumology, Faculty of Medicine, University of Porto, Porto, Portugal
I
n 1997, a 3 week epidemiologic survey 1 concluded that in European ICU’s, Non Invasive Mechanical Ventilation (NIV) was used as a first line treatment in 16% of patients, while the same survey in 2002 2 reported a significant increase to 24% of patients, with the same success rate (60% versus 56%). In a 2003 survey, 62.8% of respondents from 4 specialties in Ontario reported using bi-level NIV in acute respiratory failure (ARF) 3 while in a regional survey of acute care hospitals in Massachusetts and Rhode Island the overall utilization rate for NIV was 20% of ventilator starts.4 In both surveys,3, 4 chronic obstructive pulmonary disease (COPD) and congestive heart failure constituted the majority of the diagnosis of patients receiving NIV and the main reasons for lower utilisation rates were a lack of physician knowledge and inadequate equipment. In another survey of teaching hospitals across Canada, the use of NIV for the treatment of acute exacerbations of COPD varied enormously, from sites that rarely used NIV to others where it was routine practice.5 In a National audit in England and Wales mortality in acute COPD was higher in small district general hospital than in teaching hospitals where NIV was more frequently used.6 At least in COPD exacerbations there has been a change in practice in recent years with expert centers treating with NIV patients with increasing levels of acidosis while maintaining the same rate of success.7
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Success of NIV relies on several factors: type and severity of ARF, underlying disease, timing, location of the treatment and experience of the team.8-11 Although the majority of evidence comes from studies in the ICU, due to the increasing numbers of patients with ARF and ICU shortage, NIV «in the real world» is performed outside that ideal setting! In fact, as professionals gain more confidence with the technique, they treat more severe patients outside more protected environments.7 Several single centre observational studies performed in hospitals in North America show that NIV is typically began in the emergency department but the greatest proportion of time spent delivering NIV is in the ICU.11-13 In Europe the scenario is different: in a UK physician survey including 264 hospitals, Doherty et at.14 showed that NIV for COPD exacerbations is mainly started in the ward. An Italian observational study 15 (including 8 hospitals) showed however that for COPD with ARF, NIV was most commonly performed in respiratory intermediate care Units (RICU), a location not commonly encountered in other countries. These units could be a successful and less costly solution at least for patients with pure respiratory failure.16, 17 A more recent web-based survey of 25 European countries demonstrated that NIV use was rather high and homogeneously distributed, with a greater utilisation rate among pulmonologists.18
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This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary tion of the Publisher.
WINCK
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Noninvasive ventilation: on the road to organization or towards the Tower of Babel?
Due to the shortage of ICU and RICU beds, new models of NIV delivery have been developed. In Italy, Cabrini et al.19demonstrated that is was possible to safely apply NIV by a medical emergency team (MET) in a wide variety of settings outside ICU, with a high success rate and few complications. This was achieved thanks to the large experience of the team, strict local guidelines and good coordination with the wards’ staff. Others have tried to set-up a nurseprovided ward-based 24-hours NIV service, or a respiratory therapist driven ward-based NIV, showing that with highly trained staff it is possible to have successful outcomes.20-21 In fact, the «human factor» is a key issue in NIV, with some studies showing that treating patients outside a specialized respiratory ward is a risk of failure.22 In various studies it has been shown that respiratory therapists (RT) receive more training on NIV than other professionals 23 and that hospitals with higher presence of RT have a higher rate of NIV use.24 In Australian emergency departments, NIV management is shared between physicians and nursing staff.25 Concerning the cause of ARF, from the published evidence in COPD, it is suggested that patients with pH levels between 7.30-7.35 can be managed in different settings (including on the ward) while the more acidotic (pH
