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Patrick B Murphy - One of the best experts on this subject based on the ideXlab platform.

  • copd Home oxygen therapy and Home Mechanical Ventilation improving admission free survival in persistent hypercapnic copd
    Chest, 2018
    Co-Authors: Gerard J Criner, Michael Dreher, Nicholas Hart, Patrick B Murphy
    Abstract:

    As seen in this CME online activity (available at http://journal.cme.chestnet.org/copd-hot-hmv), acute exacerbations of COPD are associated with significant levels of morbidity and mortality. Acute noninvasive Ventilation has been demonstrated its clinical efficacy and cost-effectiveness in reducing intubation rate and mortality and in patients with acute decompensated hypercapnic exacerbations of COPD. However, those patients with evidence of chronic hypercapnic respiratory failure have worse long-term outcomes compared with patients who have only transient hypercapnia during the acute phase returning to eucapnia in the recovery stage. Indeed, there are limited options available to improve the clinical outcome in these COPD patients with persistent hypercapnia. The Home Oxygen Therapy-Home Mechanical Ventilation (HOT-HMV) trial investigated admission-free survival in patients with persistent hypercapnia following a life-threatening exacerbation requiring acute noninvasive Ventilation. Phenotyping patients to ensure chronic hypercapnia enriched the trial population to identify those patients at highest risk of readmission or death following an exacerbation. The addition of Home noninvasive Ventilation to Home oxygen therapy in patients with persistent hypercapnia led to improved admission-free survival. The noninvasive Ventilation was titrated to overnight measures of transcutaneous CO2 to achieve control of nocturnal hypoVentilation, which improved daytime chronic respiratory failure. Home noninvasive Ventilation is a complex intervention requiring a multidisciplinary team and long-term patient follow-up to maximize the clinical benefit to the patient.

  • s37 Home Mechanical Ventilation hmv and Home oxygen therapy hot following an acute exacerbation of copd in patients with persistent hypercapnia results of the per protocol analysis from the hot hmv uk trial
    Thorax, 2017
    Co-Authors: Patrick B Murphy, Gill Arbane, R Phillips, Nicholas Hart
    Abstract:

    Introduction Intention-to-treat analysis from the HOT-HMV UK trial showed an improvement in admission-free survival with the addition of Home Mechanical Ventilation (HMV) to Home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of COPD [JAMA;317:2177]. Delivery of HMV is essential and a per-protocol analysis was conducted to assess if patients who were adherent had better outcome. Method Patients were randomised to HOT or HOT-HMV if they had persistent hypercapnia (PaCO2 >7 kPa) 2 weeks following resolution of respiratory acidosis (pH >7.30) secondary to an acute exacerbation of COPD. NIV was titrated to nocturnal hypoVentilation and patients were followed up for 1 year. Patients allocated to the HOT arm that breached safety criteria had HMV added to HOT. Patients were included in the analysis in the HOT-HMV group if they had mean adherence of >4 hours/night. Patients allocated to HOT were included up until trial withdrawal or treatment switching. Results 57 patients were randomised to HOT-HMV of whom 15 were non-adherent and 11 had missing usage data and were treated as non-adherent. 59 patients were allocated to HOT of whom 5 patients were excluded due to treatment switching. Median time to readmission or death was 1.1 months in the HOT group and 3.7 months in the HOT-HMV group (adjusted hazard ratio (HR) 0.41, 95% CI 0.23, 0.74, p= Conclusion Patients with persistent hypercapnia following an acute exacerbation of COPD who were adherent to HOT-HMV had a reduced risk of readmission or death and in addition, unlike the intention to treat analysis, had an improvement in gas exchange and a reduction in all-cause mortality at 12 months. Addition of HMV to HOT should be considered for patients with persistent hypercapnia following a life-threatening exacerbation of COPD.

  • s38 Home Mechanical Ventilation hmv and Home oxygen therapy hot following an acute exacerbation of copd in patients with persistent hypercapnia predicting 1 year admission free survival in the hot hmv uk trial
    Thorax, 2017
    Co-Authors: Patrick B Murphy, Gill Arbane, Alessandra Bisquera, Nicholas Hart
    Abstract:

    Introduction Data from the HOT-HMV UK trial showed an improvement in admission-free survival with the addition of Home Mechanical non-invasive Ventilation (HMV) to Home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of COPD [JAMA;317:2177]. A post-hoc analysis was conducted to investigate (1) which baseline patient characteristics predict 12 month outcome and (2) the difference of these characteristics between treatment groups. Method Patients were randomised to HOT or HOT-HMV if they had persistent hypercapnia (PaCO2 >7 kPa) 2 weeks following resolution of respiratory acidosis (pH >7.30) secondary to an acute exacerbation of COPD. Non-invasive Ventilation was titrated to treat nocturnal hypoVentilation and patients were followed up for 1 years after discharge. Between group comparison of readmission and death were assessed in terms of baseline demographics, anthropometrics, lung function, gas exchange, quality of life and dyspnoea level. Results 116 patients were enrolled and randomised to HOT (n=59) or HOT-HMV (n=57) with (mean ±sd or median [IQR]) age 67±10 years, BMI 22 [18–26] kg/m2, FEV10.6±0.2 L, PaCO259±7 mmHg, SRI-SS 46±15, SGRQ-SS 74 [63–80], MRC dyspnoea score 5 [4–5]. Patients allocated HOT were less likely to be admitted with increasing BMI (25±5 vs 22±6 kg/m2; p=0.044). Patients allocated to HOT-HMV are were less likely to be admitted if they had higher FEV1 (0.66±0.24 vs 0.54±0.20 L; p=0.042), lower levels of dyspnoea (MRC dyspnoea score 4±1.0 vs 5±0.5; p=0.002) or higher levels of specific measures of quality of life (SGRQ-AC 85±13 vs 92±7; p=0.015) (Table 1). Baseline severity of respiratory failure did not predict 12 month outcome in either group. Conclusion Factors influencing outcome in patients with COPD and persistent hypercapnia receiving HOT-HMV treatment were airways obstruction and level of dyspnoea. However, in the patients receiving HOT alone, BMI was the only factor. There was no between group difference in with the exception of a sub-scale of the SGRQ. Interestingly, the severity of respiratory failure at baseline does not influence risk of readmission or death within 12 months as the patients all demonstrated severe chronic respiratory failure

  • hot hmv uk trial secondary outcome analysis early readmission is reduced by the addition of Home Mechanical Ventilation to Home oxygen therapy in copd patients with chronic respiratory failure following a life threatening exacerbation
    Thorax, 2016
    Co-Authors: Patrick B Murphy, Gill Arbane, Stephen Bourke, P M A Calverley, A Crooks, Lee Dowson, Nicholas Duffy, G J Gibson, Philippa Hughes, John R Hurst
    Abstract:

    Introduction Hospital readmission following treatment for a life-threatening exacerbation of COPD with acute NIV is frequent and associated with an adverse impact in terms of lung function and health related quality of life. They have been identified as a priority area in the NHS with financial penalties for any patient readmitted within 28 days following discharge. Method A multicentre open labelled randomised controlled trial recruited patients with persistent hypercapnia (PaCO 2 > 7 kPa) 2–4 weeks following resolution of acute acidosis. Patients were randomised to either Home oxygen therapy (HOT) or HOT and Home Mechanical Ventilation (HOT-HMV). HMV was titrated overnight to control nocturnal hypercapnia. Follow up was for 12 months. The primary outcome, 12-month admission free survival, has been reported previously demonstrating a significant treatment effect (ERS 2016). Secondary outcome analysis included 28-day all-cause hospital readmission and 12 month exacerbation rate. Results 116 patients were randomised (HOT = 59, HOT-HMV = 57), age 67 ± 10 years, FEV1 0.6 ± 0.2 L, PaCO 2 7.9 ± 0.9 kPa. 28-day readmission was 22 (37%) in the HOT and 7 (12%) in the HOT-HMV arm (unadjusted HR 0.27, 0.12 to 0.63, p = 0.003; adjusted HR 0.26, 0.11 to 0.61, p = 0.002) (Figure 1). 12 month exacerbation rate was reduced from median 5 (1 to 9) per year in the HOT arm to 4 (2to 6) in the HOT-HMV arm (unadjusted HR 0.64 (0.44 to 0.94); p = 0.022; adjusted HR 0.66, 0.46 to 0.95, p = 0.026). Conclusion The addition of HMV to HOT in patients with persistent hypercapnia following an acute life-threatening exacerbation of COPD reduces both 28-day readmission and 12 month exacerbation frequency. These data strongly support a change in clinical practice in the management of patients with severe COPD and persistent hypercapnia.

  • late breaking abstract improving admission free survival with Home Mechanical Ventilation hmv and Home oxygen therapy hot following life threatening copd exacerbations hot hmv uk trial nct00990132
    European Respiratory Journal, 2016
    Co-Authors: Patrick B Murphy, Gill Arbane, P M A Calverley, Lee Dowson, S C Bourke, Nick Duffy, John G Gibson, Phil Hughes, John R Hurst
    Abstract:

    Introduction: Hospital readmission and mortality following severe exacerbations of COPD requiring acute non-invasive Ventilation (NIV) remain high. We hypothesised that HMV and HOT, following cessation of acute NIV, would be superior to HOT alone. Method: An open labelled parallel randomised controlled trial comparing HMV and HOT with HOT alone was performed. The primary outcome was 1-year admission free survival. Patients with persistent hypercapnia (PaCO 2 >7kPa) 2-4 weeks after resolution of respiratory acidosis were recruited. Minimisation was based on BMI, previous use of LTOT, exacerbation frequency and recruiting centre. Patients with BMI >35 kg/m 2 or OSA syndrome were excluded. Results: 116 patients were recruited (67.0±9.6 years, 53% female, BMI 21.6 (18.2-26.1)kg/m 2 , FEV 1 0.6±0.2L and PaCO 2 (7.9±0.9kPa). 59 patients were allocated to HOT (1.0 (0.5-2)Lpm) and 57 to HOT-HMV (O 2 1.0 (0.5-1.5)Lpm) with an IPAP 24 (22-26)cmH 2 O, EPAP 4 (4-5)cmH 2 O and back up rate 14 (14-16)bpm. Median admission free survival was 4.3 months in the HOT-HMV group and 1.4 months in the HOT group; unadjusted HR 0.54 (0.34-0.84); p=0.007, adjusted HR 0.49 (0.31-0.77); p=0.002. Conclusion: Although prognosis is poor in patients with persistent hypercapnia post exacerbation of COPD, the addition of HMV to HOT improved admission free survival.

Nicholas Hart - One of the best experts on this subject based on the ideXlab platform.

  • copd Home oxygen therapy and Home Mechanical Ventilation improving admission free survival in persistent hypercapnic copd
    Chest, 2018
    Co-Authors: Gerard J Criner, Michael Dreher, Nicholas Hart, Patrick B Murphy
    Abstract:

    As seen in this CME online activity (available at http://journal.cme.chestnet.org/copd-hot-hmv), acute exacerbations of COPD are associated with significant levels of morbidity and mortality. Acute noninvasive Ventilation has been demonstrated its clinical efficacy and cost-effectiveness in reducing intubation rate and mortality and in patients with acute decompensated hypercapnic exacerbations of COPD. However, those patients with evidence of chronic hypercapnic respiratory failure have worse long-term outcomes compared with patients who have only transient hypercapnia during the acute phase returning to eucapnia in the recovery stage. Indeed, there are limited options available to improve the clinical outcome in these COPD patients with persistent hypercapnia. The Home Oxygen Therapy-Home Mechanical Ventilation (HOT-HMV) trial investigated admission-free survival in patients with persistent hypercapnia following a life-threatening exacerbation requiring acute noninvasive Ventilation. Phenotyping patients to ensure chronic hypercapnia enriched the trial population to identify those patients at highest risk of readmission or death following an exacerbation. The addition of Home noninvasive Ventilation to Home oxygen therapy in patients with persistent hypercapnia led to improved admission-free survival. The noninvasive Ventilation was titrated to overnight measures of transcutaneous CO2 to achieve control of nocturnal hypoVentilation, which improved daytime chronic respiratory failure. Home noninvasive Ventilation is a complex intervention requiring a multidisciplinary team and long-term patient follow-up to maximize the clinical benefit to the patient.

  • s37 Home Mechanical Ventilation hmv and Home oxygen therapy hot following an acute exacerbation of copd in patients with persistent hypercapnia results of the per protocol analysis from the hot hmv uk trial
    Thorax, 2017
    Co-Authors: Patrick B Murphy, Gill Arbane, R Phillips, Nicholas Hart
    Abstract:

    Introduction Intention-to-treat analysis from the HOT-HMV UK trial showed an improvement in admission-free survival with the addition of Home Mechanical Ventilation (HMV) to Home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of COPD [JAMA;317:2177]. Delivery of HMV is essential and a per-protocol analysis was conducted to assess if patients who were adherent had better outcome. Method Patients were randomised to HOT or HOT-HMV if they had persistent hypercapnia (PaCO2 >7 kPa) 2 weeks following resolution of respiratory acidosis (pH >7.30) secondary to an acute exacerbation of COPD. NIV was titrated to nocturnal hypoVentilation and patients were followed up for 1 year. Patients allocated to the HOT arm that breached safety criteria had HMV added to HOT. Patients were included in the analysis in the HOT-HMV group if they had mean adherence of >4 hours/night. Patients allocated to HOT were included up until trial withdrawal or treatment switching. Results 57 patients were randomised to HOT-HMV of whom 15 were non-adherent and 11 had missing usage data and were treated as non-adherent. 59 patients were allocated to HOT of whom 5 patients were excluded due to treatment switching. Median time to readmission or death was 1.1 months in the HOT group and 3.7 months in the HOT-HMV group (adjusted hazard ratio (HR) 0.41, 95% CI 0.23, 0.74, p= Conclusion Patients with persistent hypercapnia following an acute exacerbation of COPD who were adherent to HOT-HMV had a reduced risk of readmission or death and in addition, unlike the intention to treat analysis, had an improvement in gas exchange and a reduction in all-cause mortality at 12 months. Addition of HMV to HOT should be considered for patients with persistent hypercapnia following a life-threatening exacerbation of COPD.

  • s38 Home Mechanical Ventilation hmv and Home oxygen therapy hot following an acute exacerbation of copd in patients with persistent hypercapnia predicting 1 year admission free survival in the hot hmv uk trial
    Thorax, 2017
    Co-Authors: Patrick B Murphy, Gill Arbane, Alessandra Bisquera, Nicholas Hart
    Abstract:

    Introduction Data from the HOT-HMV UK trial showed an improvement in admission-free survival with the addition of Home Mechanical non-invasive Ventilation (HMV) to Home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of COPD [JAMA;317:2177]. A post-hoc analysis was conducted to investigate (1) which baseline patient characteristics predict 12 month outcome and (2) the difference of these characteristics between treatment groups. Method Patients were randomised to HOT or HOT-HMV if they had persistent hypercapnia (PaCO2 >7 kPa) 2 weeks following resolution of respiratory acidosis (pH >7.30) secondary to an acute exacerbation of COPD. Non-invasive Ventilation was titrated to treat nocturnal hypoVentilation and patients were followed up for 1 years after discharge. Between group comparison of readmission and death were assessed in terms of baseline demographics, anthropometrics, lung function, gas exchange, quality of life and dyspnoea level. Results 116 patients were enrolled and randomised to HOT (n=59) or HOT-HMV (n=57) with (mean ±sd or median [IQR]) age 67±10 years, BMI 22 [18–26] kg/m2, FEV10.6±0.2 L, PaCO259±7 mmHg, SRI-SS 46±15, SGRQ-SS 74 [63–80], MRC dyspnoea score 5 [4–5]. Patients allocated HOT were less likely to be admitted with increasing BMI (25±5 vs 22±6 kg/m2; p=0.044). Patients allocated to HOT-HMV are were less likely to be admitted if they had higher FEV1 (0.66±0.24 vs 0.54±0.20 L; p=0.042), lower levels of dyspnoea (MRC dyspnoea score 4±1.0 vs 5±0.5; p=0.002) or higher levels of specific measures of quality of life (SGRQ-AC 85±13 vs 92±7; p=0.015) (Table 1). Baseline severity of respiratory failure did not predict 12 month outcome in either group. Conclusion Factors influencing outcome in patients with COPD and persistent hypercapnia receiving HOT-HMV treatment were airways obstruction and level of dyspnoea. However, in the patients receiving HOT alone, BMI was the only factor. There was no between group difference in with the exception of a sub-scale of the SGRQ. Interestingly, the severity of respiratory failure at baseline does not influence risk of readmission or death within 12 months as the patients all demonstrated severe chronic respiratory failure

  • parasternal electromyography to determine the relationship between patient ventilator asynchrony and nocturnal gas exchange during Home Mechanical Ventilation set up
    Thorax, 2015
    Co-Authors: Michelle Ramsay, Patrick B Murphy, Anita K Simonds, Michael I Polkey, Swapna Mandal, Euisik Suh, Joerg Steier, Abdel Douiri, Nicholas Hart
    Abstract:

    Introduction Patient-ventilator asynchrony (PVA) can adversely affect the successful initiation of non-invasive Home Mechanical Ventilation (HMV). The aim of this observational study was to quantify the prevalence of PVA during initiation of HMV and to determine the relationship between PVA and nocturnal gas exchange. Method Type and frequency of PVA were measured by surface parasternal intercostal muscle electromyography, thoracoabdominal plethysmography and mask pressure during initiation of HMV. Severe PVA was defined, as previously, as asynchrony affecting ≥10% of breaths. Results 28 patients (18 male) were enrolled aged 61±15 years and with a body mass index of 35±9 kg/m 2 . Underlying diagnoses were neuromuscular disease with or without chest wall disease (n=6), obesity related chronic respiratory failure (n=12) and COPD (n=10). PVA was observed in all patients with 79% of patients demonstrating severe PVA. Triggering asynchrony was most frequent, observed in 24% (IQR: 11–36%) of breaths, with ineffective efforts accounting for 16% (IQR: 4–24%). PVA types were similar between disease groups, with the exception of auto-triggering, which was higher in patients with COPD (12% (IQR: 6–26%)). There was no correlation observed between PVA and time spent with oxygen saturations ≤90%, mean oxygen saturations or transcutaneous carbon dioxide levels during overnight Ventilation. Conclusions Severe PVA was identified in the majority of patients, irrespective of pathophysiological disease state. This was not associated with ineffective Ventilation as evidenced by gas exchange.

  • impact of patient ventilator asynchrony pva on the sleep quality of patients using Home Mechanical Ventilation hmv
    European Respiratory Journal, 2014
    Co-Authors: Michelle Ramsay, Anita K Simonds, Swapna Mandal, Euisik Suh, Joerg Steier, Nicholas Hart
    Abstract:

    Introduction: During HMV, PVA is reported to adversely affect gas exchange, respiratory muscle unloading and patient comfort. The impact of PVAs on sleep disruption is less clear. Methods: Patients attending a tertiary referral centre for initiation of HMV were enrolled in the study. HMV was titrated using transcutaneous capnography and oximetry. PVAs were scored from a 2 minute epoch every 10 minutes overnight using standard definitions and expressed as percentage of breaths or events per hour in sleep and wake. Polysomnography recordings were scored by an expert technician blinded to PVA assessment. We investigated the relationship between PVA at initiation of HMV (HMV i ), 3 months post therapy (HMV 3 ) and arousals. Results: 10 patients (3 female) were enrolled, 4 chronic obstructive disease, 2 obesity hypoVentilation syndrome and 4 neuromuscular/ chest wall disease. PVA was most commonly observed during wake periods. During sleep, PVA was most frequent in light sleep (stage1&2) and preceded almost half of all arousals at both HMV i and HMV 3 . Conclusion: These data suggest that PVA is a common phenomenon and a majority do not lead to sleep disruption. However, half of arousals were preceded by PVA. Focusing on predicting those PVA that lead to sleep disruption and mechanisms to improve on patient ventilator synchronisation may lead to further enhancement of sleep quality in patients using HMV.

Wolfram Windisch - One of the best experts on this subject based on the ideXlab platform.

  • the spontaneous breathing trial is of low predictive value regarding spontaneous breathing ability in subjects with prolonged unsuccessful weaning
    Medizinische Klinik, 2020
    Co-Authors: Friederike Sophie Magnet, E Heilf, S E Huttmann, Jens Callegari, Sarah Bettina Schwarz, J H Storre, Wolfram Windisch
    Abstract:

    Background The spontaneous breathing trial (SBT) is a well-established diagnostic test for predicting extubation failure in intubated intensive care unit (ICU) patients. However, the SBT has not been evaluated in a specific cohort of tracheostomized patients in whom weaning is prolonged and ultimately unsuccessful. Objective The aim of the trial was to investigate the relevance of SBT failure criteria in chronic respiratory failure subjects undergoing long-term invasive Home Mechanical Ventilation following tracheostomy and weaning failure. Methods Measurement of all established failure criteria including pneumotachygraphical assessment of the rapid shallow breathing index (RSBI) took place during an SBT. The decision to continue spontaneous breathing was based on failure criteria as well as the subjective willingness of the patient. Results Fifteen subjects with a median age of 58 years (interquartile range [IQR] 44-74) were studied; 10 with COPD, 4 with neuromuscular diseases and 1 with both. Twelve subjects met the SBT failure criteria within 30 min, but one third of these subjects were still able to continue with spontaneous breathing. In contrast, 3 subjects could not be weaned despite the SBT being successful. An increased RSBI was the most frequently observed SBT failure criterion (57% of all SBT). However, the SBT varied substantially in individual subjects who were able to sustain spontaneous breathing, despite having reached the cut-off for SBT failure. Conclusion The SBT was of low predictive value regarding spontaneous breathing ability in chronic respiratory failure subjects with prolonged, unsuccessful weaning.

  • quality of life and life satisfaction are severely impaired in patients with long term invasive Ventilation following icu treatment and unsuccessful weaning
    Annals of Intensive Care, 2018
    Co-Authors: S E Huttmann, Friederike Sophie Magnet, J H Storre, Christian Karagiannidis, Wolfram Windisch
    Abstract:

    Background Health-related quality of life (HRQL), life satisfaction, living conditions, patients’ attitudes towards life and death, expectations, beliefs and unmet needs are all poorly understood aspects associated with patients receiving invasive Home Mechanical Ventilation (HMV) following ICU treatment and unsuccessful weaning. Therefore, the present study aimed to assess (1) HRQL, (2) life satisfaction and (3) patients’ perspectives on life and death associated with invasive HMV as the consequence of unsuccessful weaning.

  • quality of life and life satisfaction are severely impaired in patients with long term invasive Ventilation following icu treatment and unsuccessful weaning
    Annals of Intensive Care, 2018
    Co-Authors: S E Huttmann, Friederike Sophie Magnet, J H Storre, Christian Karagiannidis, Wolfram Windisch
    Abstract:

    Health-related quality of life (HRQL), life satisfaction, living conditions, patients’ attitudes towards life and death, expectations, beliefs and unmet needs are all poorly understood aspects associated with patients receiving invasive Home Mechanical Ventilation (HMV) following ICU treatment and unsuccessful weaning. Therefore, the present study aimed to assess (1) HRQL, (2) life satisfaction and (3) patients’ perspectives on life and death associated with invasive HMV as the consequence of unsuccessful weaning. Patients undergoing invasive HMV with full technical supply and maximal patient care were screened over a 1-year period and assessed in their Home environment. The study comprised the following: (1) detailed information on specific aspects of daily life, (2) self-evaluation of 23 specific daily life aspects, (3) HRQL assessment using the Severe Respiratory Insufficiency Questionnaire, (4) open interviews about the patient’s living situation, HRQL, unsolved problems, treatment options, dying and the concept of an afterlife. Out of 112 patients admitted to a specialized weaning centre, 50 were discharged with invasive HMV and 25 out of these (14 COPD and 11 neuromuscular patients) were ultimately enrolled. HRQL and life satisfaction were severely impaired, despite maximal patient care and full supply of technical aids. The most important areas of dissatisfaction identified were mobility, communication, social contact and care dependency. Importantly, 32% of patients would have elected to die in hindsight rather than receive invasive HMV. Despite maximal patient care and a full supply of technical aids, both HRQL and life satisfaction are severely impaired in many invasive HMV patients who have failed prolonged weaning. These findings raise ethical concerns about the use of long-term invasive HMV following unsuccessful weaning.

  • german national guideline for treating chronic respiratory failure with invasive and non invasive Ventilation revised edition 2017 part 2
    Respiration, 2018
    Co-Authors: Wolfram Windisch, J Geiseler, Karsten Simon, Stephan Walterspacher, Michael Dreher
    Abstract:

    Today, invasive and non-invasive Home Mechanical Ventilation have become a well-established treatment option. Consequently, in 2010, the German Respiratory Society (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure." However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines. For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease-specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of Home Mechanical Ventilation in paraplegic patients and in those with failure of prolonged weaning. In the current guidelines, different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving Home Mechanical Ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.

  • german national guideline for treating chronic respiratory failure with invasive and non invasive Ventilation revised edition 2017 part 1
    Respiration, 2018
    Co-Authors: Wolfram Windisch, J Geiseler, Karsten Simon, Stephan Walterspacher, Michael Dreher
    Abstract:

    Today, invasive and non-invasive Home Mechanical Ventilation have become a well-established treatment option. Consequently, in 2010, the German Respiratory Society (Deutsche Gesellschaft fur Pneumologie und Beatmungsmedizin, DGP) has leadingly published the Guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure." However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the Guidelines. For this reason, the updated Guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease-specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the Guidelines include the topics of Home Mechanical Ventilation in paraplegic patients and in those with failure of prolonged weaning. In the current Guidelines, different societies as well as professional and expert associations have been involved when compared to the 2010 Guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving Home Mechanical Ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.

Michael Dreher - One of the best experts on this subject based on the ideXlab platform.

  • copd Home oxygen therapy and Home Mechanical Ventilation improving admission free survival in persistent hypercapnic copd
    Chest, 2018
    Co-Authors: Gerard J Criner, Michael Dreher, Nicholas Hart, Patrick B Murphy
    Abstract:

    As seen in this CME online activity (available at http://journal.cme.chestnet.org/copd-hot-hmv), acute exacerbations of COPD are associated with significant levels of morbidity and mortality. Acute noninvasive Ventilation has been demonstrated its clinical efficacy and cost-effectiveness in reducing intubation rate and mortality and in patients with acute decompensated hypercapnic exacerbations of COPD. However, those patients with evidence of chronic hypercapnic respiratory failure have worse long-term outcomes compared with patients who have only transient hypercapnia during the acute phase returning to eucapnia in the recovery stage. Indeed, there are limited options available to improve the clinical outcome in these COPD patients with persistent hypercapnia. The Home Oxygen Therapy-Home Mechanical Ventilation (HOT-HMV) trial investigated admission-free survival in patients with persistent hypercapnia following a life-threatening exacerbation requiring acute noninvasive Ventilation. Phenotyping patients to ensure chronic hypercapnia enriched the trial population to identify those patients at highest risk of readmission or death following an exacerbation. The addition of Home noninvasive Ventilation to Home oxygen therapy in patients with persistent hypercapnia led to improved admission-free survival. The noninvasive Ventilation was titrated to overnight measures of transcutaneous CO2 to achieve control of nocturnal hypoVentilation, which improved daytime chronic respiratory failure. Home noninvasive Ventilation is a complex intervention requiring a multidisciplinary team and long-term patient follow-up to maximize the clinical benefit to the patient.

  • german national guideline for treating chronic respiratory failure with invasive and non invasive Ventilation revised edition 2017 part 2
    Respiration, 2018
    Co-Authors: Wolfram Windisch, J Geiseler, Karsten Simon, Stephan Walterspacher, Michael Dreher
    Abstract:

    Today, invasive and non-invasive Home Mechanical Ventilation have become a well-established treatment option. Consequently, in 2010, the German Respiratory Society (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure." However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines. For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease-specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of Home Mechanical Ventilation in paraplegic patients and in those with failure of prolonged weaning. In the current guidelines, different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving Home Mechanical Ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.

  • german national guideline for treating chronic respiratory failure with invasive and non invasive Ventilation revised edition 2017 part 1
    Respiration, 2018
    Co-Authors: Wolfram Windisch, J Geiseler, Karsten Simon, Stephan Walterspacher, Michael Dreher
    Abstract:

    Today, invasive and non-invasive Home Mechanical Ventilation have become a well-established treatment option. Consequently, in 2010, the German Respiratory Society (Deutsche Gesellschaft fur Pneumologie und Beatmungsmedizin, DGP) has leadingly published the Guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure." However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the Guidelines. For this reason, the updated Guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease-specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the Guidelines include the topics of Home Mechanical Ventilation in paraplegic patients and in those with failure of prolonged weaning. In the current Guidelines, different societies as well as professional and expert associations have been involved when compared to the 2010 Guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving Home Mechanical Ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.

  • guidelines for non invasive and invasive Home Mechanical Ventilation for treatment of chronic respiratory failure update 2017
    Pneumologie, 2017
    Co-Authors: W Windisch, Michael Dreher, J Brambring, D Dellweg, J Geiseler, T Kohnlein, K Siemon, B Grolle, S Hirschfeld, Uwe Mellies
    Abstract:

    Today, invasive and non-invasive Home Mechanical Ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of Home Mechanical Ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving Home Mechanical Ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the Home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

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  • s37 Home Mechanical Ventilation hmv and Home oxygen therapy hot following an acute exacerbation of copd in patients with persistent hypercapnia results of the per protocol analysis from the hot hmv uk trial
    Thorax, 2017
    Co-Authors: Patrick B Murphy, Gill Arbane, R Phillips, Nicholas Hart
    Abstract:

    Introduction Intention-to-treat analysis from the HOT-HMV UK trial showed an improvement in admission-free survival with the addition of Home Mechanical Ventilation (HMV) to Home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of COPD [JAMA;317:2177]. Delivery of HMV is essential and a per-protocol analysis was conducted to assess if patients who were adherent had better outcome. Method Patients were randomised to HOT or HOT-HMV if they had persistent hypercapnia (PaCO2 >7 kPa) 2 weeks following resolution of respiratory acidosis (pH >7.30) secondary to an acute exacerbation of COPD. NIV was titrated to nocturnal hypoVentilation and patients were followed up for 1 year. Patients allocated to the HOT arm that breached safety criteria had HMV added to HOT. Patients were included in the analysis in the HOT-HMV group if they had mean adherence of >4 hours/night. Patients allocated to HOT were included up until trial withdrawal or treatment switching. Results 57 patients were randomised to HOT-HMV of whom 15 were non-adherent and 11 had missing usage data and were treated as non-adherent. 59 patients were allocated to HOT of whom 5 patients were excluded due to treatment switching. Median time to readmission or death was 1.1 months in the HOT group and 3.7 months in the HOT-HMV group (adjusted hazard ratio (HR) 0.41, 95% CI 0.23, 0.74, p= Conclusion Patients with persistent hypercapnia following an acute exacerbation of COPD who were adherent to HOT-HMV had a reduced risk of readmission or death and in addition, unlike the intention to treat analysis, had an improvement in gas exchange and a reduction in all-cause mortality at 12 months. Addition of HMV to HOT should be considered for patients with persistent hypercapnia following a life-threatening exacerbation of COPD.

  • s38 Home Mechanical Ventilation hmv and Home oxygen therapy hot following an acute exacerbation of copd in patients with persistent hypercapnia predicting 1 year admission free survival in the hot hmv uk trial
    Thorax, 2017
    Co-Authors: Patrick B Murphy, Gill Arbane, Alessandra Bisquera, Nicholas Hart
    Abstract:

    Introduction Data from the HOT-HMV UK trial showed an improvement in admission-free survival with the addition of Home Mechanical non-invasive Ventilation (HMV) to Home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of COPD [JAMA;317:2177]. A post-hoc analysis was conducted to investigate (1) which baseline patient characteristics predict 12 month outcome and (2) the difference of these characteristics between treatment groups. Method Patients were randomised to HOT or HOT-HMV if they had persistent hypercapnia (PaCO2 >7 kPa) 2 weeks following resolution of respiratory acidosis (pH >7.30) secondary to an acute exacerbation of COPD. Non-invasive Ventilation was titrated to treat nocturnal hypoVentilation and patients were followed up for 1 years after discharge. Between group comparison of readmission and death were assessed in terms of baseline demographics, anthropometrics, lung function, gas exchange, quality of life and dyspnoea level. Results 116 patients were enrolled and randomised to HOT (n=59) or HOT-HMV (n=57) with (mean ±sd or median [IQR]) age 67±10 years, BMI 22 [18–26] kg/m2, FEV10.6±0.2 L, PaCO259±7 mmHg, SRI-SS 46±15, SGRQ-SS 74 [63–80], MRC dyspnoea score 5 [4–5]. Patients allocated HOT were less likely to be admitted with increasing BMI (25±5 vs 22±6 kg/m2; p=0.044). Patients allocated to HOT-HMV are were less likely to be admitted if they had higher FEV1 (0.66±0.24 vs 0.54±0.20 L; p=0.042), lower levels of dyspnoea (MRC dyspnoea score 4±1.0 vs 5±0.5; p=0.002) or higher levels of specific measures of quality of life (SGRQ-AC 85±13 vs 92±7; p=0.015) (Table 1). Baseline severity of respiratory failure did not predict 12 month outcome in either group. Conclusion Factors influencing outcome in patients with COPD and persistent hypercapnia receiving HOT-HMV treatment were airways obstruction and level of dyspnoea. However, in the patients receiving HOT alone, BMI was the only factor. There was no between group difference in with the exception of a sub-scale of the SGRQ. Interestingly, the severity of respiratory failure at baseline does not influence risk of readmission or death within 12 months as the patients all demonstrated severe chronic respiratory failure

  • hot hmv uk trial secondary outcome analysis early readmission is reduced by the addition of Home Mechanical Ventilation to Home oxygen therapy in copd patients with chronic respiratory failure following a life threatening exacerbation
    Thorax, 2016
    Co-Authors: Patrick B Murphy, Gill Arbane, Stephen Bourke, P M A Calverley, A Crooks, Lee Dowson, Nicholas Duffy, G J Gibson, Philippa Hughes, John R Hurst
    Abstract:

    Introduction Hospital readmission following treatment for a life-threatening exacerbation of COPD with acute NIV is frequent and associated with an adverse impact in terms of lung function and health related quality of life. They have been identified as a priority area in the NHS with financial penalties for any patient readmitted within 28 days following discharge. Method A multicentre open labelled randomised controlled trial recruited patients with persistent hypercapnia (PaCO 2 > 7 kPa) 2–4 weeks following resolution of acute acidosis. Patients were randomised to either Home oxygen therapy (HOT) or HOT and Home Mechanical Ventilation (HOT-HMV). HMV was titrated overnight to control nocturnal hypercapnia. Follow up was for 12 months. The primary outcome, 12-month admission free survival, has been reported previously demonstrating a significant treatment effect (ERS 2016). Secondary outcome analysis included 28-day all-cause hospital readmission and 12 month exacerbation rate. Results 116 patients were randomised (HOT = 59, HOT-HMV = 57), age 67 ± 10 years, FEV1 0.6 ± 0.2 L, PaCO 2 7.9 ± 0.9 kPa. 28-day readmission was 22 (37%) in the HOT and 7 (12%) in the HOT-HMV arm (unadjusted HR 0.27, 0.12 to 0.63, p = 0.003; adjusted HR 0.26, 0.11 to 0.61, p = 0.002) (Figure 1). 12 month exacerbation rate was reduced from median 5 (1 to 9) per year in the HOT arm to 4 (2to 6) in the HOT-HMV arm (unadjusted HR 0.64 (0.44 to 0.94); p = 0.022; adjusted HR 0.66, 0.46 to 0.95, p = 0.026). Conclusion The addition of HMV to HOT in patients with persistent hypercapnia following an acute life-threatening exacerbation of COPD reduces both 28-day readmission and 12 month exacerbation frequency. These data strongly support a change in clinical practice in the management of patients with severe COPD and persistent hypercapnia.

  • late breaking abstract improving admission free survival with Home Mechanical Ventilation hmv and Home oxygen therapy hot following life threatening copd exacerbations hot hmv uk trial nct00990132
    European Respiratory Journal, 2016
    Co-Authors: Patrick B Murphy, Gill Arbane, P M A Calverley, Lee Dowson, S C Bourke, Nick Duffy, John G Gibson, Phil Hughes, John R Hurst
    Abstract:

    Introduction: Hospital readmission and mortality following severe exacerbations of COPD requiring acute non-invasive Ventilation (NIV) remain high. We hypothesised that HMV and HOT, following cessation of acute NIV, would be superior to HOT alone. Method: An open labelled parallel randomised controlled trial comparing HMV and HOT with HOT alone was performed. The primary outcome was 1-year admission free survival. Patients with persistent hypercapnia (PaCO 2 >7kPa) 2-4 weeks after resolution of respiratory acidosis were recruited. Minimisation was based on BMI, previous use of LTOT, exacerbation frequency and recruiting centre. Patients with BMI >35 kg/m 2 or OSA syndrome were excluded. Results: 116 patients were recruited (67.0±9.6 years, 53% female, BMI 21.6 (18.2-26.1)kg/m 2 , FEV 1 0.6±0.2L and PaCO 2 (7.9±0.9kPa). 59 patients were allocated to HOT (1.0 (0.5-2)Lpm) and 57 to HOT-HMV (O 2 1.0 (0.5-1.5)Lpm) with an IPAP 24 (22-26)cmH 2 O, EPAP 4 (4-5)cmH 2 O and back up rate 14 (14-16)bpm. Median admission free survival was 4.3 months in the HOT-HMV group and 1.4 months in the HOT group; unadjusted HR 0.54 (0.34-0.84); p=0.007, adjusted HR 0.49 (0.31-0.77); p=0.002. Conclusion: Although prognosis is poor in patients with persistent hypercapnia post exacerbation of COPD, the addition of HMV to HOT improved admission free survival.