Advanced COPD patients under home mechanical ventilation and/or long term oxygen therapy: italian health care costs.

Introduction. Little information is available on health care costs for patients with very severe chronic obstructive pulmonary disease The aim of the current work was to evaluate Italian health care costs in these patients. Patients and Methods. Prospective 1-year analysis were assessed in three subgroups of patients; non-invasively ventilated (n=30); invasively-ventilated (n=12) and on long-term oxygen therapy (n= 41). Acute costs for care were a sum of fees for doctor\u2019s consultations, admissions to hospital (ward and intensive care unit) and emergency drugs. Chronic costs were the sum of costs for pharmacotherapy and home ventilation and/or oxygen care. Results. Mean cost/day/patient was 96\ub1112 \u20ac (range 9-526 \u20ac), with acute costs accounting for 72% and chronic costs for 28% of the total cost burden, with no significant differences in costs associated with the three subgroups. Acute costs had a non-normally distribution (range 0 to 510 \u20ac) with cost for hospitalization being the highest cost burden with greater than 30 % of acute care costs were attributed to only a small segment of patients. Chronic care costs were also unevenly distributed among the various groups (ANOVA p=0.006), with home oxygen supply being the highest cost burden. Conclusions. The current Health Care System is in urgent need for a reassessment of the high cost burden associated with hospitalizations and home oxygen supply

Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis

Background. Treatment of bronchiectasis includes drugs, oxygen therapy and bronchial clearance maneuvers. The aim of the current study was to assess safety and efficacy of IntrapulmonaryPercussive Ventilation when compared with usual Chest Physical Therapy in patients with bronchiectasis Methods. In two consecutive days, 22 patients underwent both Intrapulmonary Percussive Ventilation and Chest Physical Therapy following a randomized cross-over design. At inclusion (T0), at the end of 30-min session (T1), and after 30 min (T2) and 4 hrs (T3), side effects, heart rate, oxygen saturation rate, respiratory rate, sensation of phlegm encumbrance and dyspneameasured by visual analogue scales, were recorded. At T1, discomfort measured by visual analogue scales was also recorded. At T3, we evaluated efficacy in terms of volume (ml), and wet and dry weight (g) of sputum. Results. Side effects were not so severe as to determine study discontinuation and were similar (27%) between the two treatments. Heart rate (p<.001) and respiratory rate (p=0.047) decreased over time while sensation of phlegm encumbrance improved (p=0.026) withboth treatments. Only Intrapulmonary Percussive Ventilation improved (p=0.004) sensation of dyspnea and resulted more comfortable than Chest Physical Therapy (p=0.032). The two treatments caused important phlegm production without differences in total volume, and both wet and dry weight. Conclusions. In patients with bronchiectasis and productive cough, short-term application of Intrapulmonary Percussive Ventilation is similarly safe and effective than traditional chestPhysical Therapy with less discomfort. Further studies on cost-effectiveness of using IPV is recommended

Episodic medical home interventions in severe bedridden Chronic Respiratory Failure patients: a 4 year retrospective study

Background and Aim. Home care for respiratory patients includes a complex array of services delivered in an uncontrolled setting. The role of a respiratory specialist inside the home healthcare team has been scarcely studied up to now. Our aims were to analyse the number and quality of episodic home visits performed by respiratory physicians to severe bedridden Chronic Respiratory Failure (CRF) patients, and also to evaluate the safety of tracheotomy tube substitutions at home. Methods. 231 home interventions (59.8/year) in 123 CRF patients (59 males; age 63±17y, 24 on oxygen therapy, 35 under non invasive mechanical ventilation, 46 under invasive ventilation, 74 with tracheostomy) located 35±16 km far from referred hospital, were revised in a period of 4 years (2005-2008). Results. Chronic Obstructive Pulmonary Disease (COPD) (31%) and amyotrophic lateral sclerosis (ALS) (28%) were the more frequent diagnoses. Interventions were: tracheotomy tube substitution (64%) presenting 22% of minor adverse events and 1.4% of major adverse events; change or new oxygen prescription (37%); nocturnal pulsed saturimetric trend prescription (24%); change in mechanical ventilation (MV) setting (4%); new MV adaptation (7%). After medical intervention, new home medical equipment devices (oxygen and MV) were prescribed in 36% of the cases while rehabilitative hospital admission and home respiratory physiotherapy prescription was proposed in 9% and 6% of the cases respectively. Patient/caregiver’s satisfaction was reported on average 8.48±0.79 (1 = the worst; 10 = the higher). The local health care system (HCS) reimbursed 70€ for each home intervention. Families saved 42±20€ per visit for ambulance transportation. Conclusions. Home visits performed by a respiratory physician to bedridden patients with chronic respiratory failure: 1. include predominantly patients affected by COPD and ALS; 2. determine a very good satisfaction to patients/caregivers; 3. allow money saving to caregivers; 4. are predominantly made up to change tracheotomy tube without severe adverse events

Lung and respiratory muscle function at discharge from a respiratory intensive care unit

Background. The purpose of this prospective observational study was to describe lung and respiratory muscle function at Respiratory Intensive Care Unit (RICU) discharge after a severe exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Methods. The study was conducted in 42 consecutive COPD patients in whom arterial blood gases, dynamic and static lung volumes, maximal inspiratory pressure (MIP) were assessed at discharge from the RICU and compared with values measured 6 months previously when they were in a stable state. The same measurements were performed at 6-month interval in 42 comparable stable COPD patients not requiring any hospitalisation for at least 6 months used as controls. Results. 24% of patients in the study group were discharged with hypercapnia whereas they were normocapnic before the acute episode. Compared to prior to exacerbation, patients of study group showed a significant worsening in mean values of PaCO2 (p=0.005), MIP (p=0.005) and FEV1 (p=0.041). Predefined criteria of worsening in PaCO2, MIP and FEV1 were observed in 47%, 33% and 28% of patients in study respectively. Neither lung nor respiratory muscle function in last stable state did predict post RICU functional worsening. In a period of 6 months controls showed no change in the studied parameters. Conclusions. After a severe acute exacerbation requiring admission to a RICU and immediately before discharge 1) a large proportion of COPD patients still show preserved lung and respiratory muscle function 2) more than one third of them would require further care and rehabilitative attempts to restore functional derangements

Inspiratory muscle workload due to dynamic intrinsic PEEP in stable COPD patients: effects of two different settings of non-invasive pressure-support ventilation.

BACKGROUND: In severe stable hypercapnic COPD patients the amount of pressure time product (PTP) spent to counterbalance their dynamic intrinsic positive end expiratory pressure (PEEPi,dyn) is high: no data are available on the best setting of non invasive pressure support ventilation (NPSV) to reduce the inspiratory muscle workload due to PEEPi,dyn. METHODS: The objectives of this randomised controlled physiological study were: 1. To measure the inspiratory muscle workload due to PEEPi,dyn 2. To measure the effects on this parameter of two settings of NPSV in stable COPD patients with chronic hypercapnia admitted in a Pulmonary Division of two Rehabilitation Centers. Twenty-three stable COPD patients with chronic hypercapnia on domiciliary nocturnal NPSV for 30 +/- 20 months were submitted to an evaluation of breathing pattern, PEEPi,dyn, inspiratory muscle workload and its partitioning during both assisted and unassisted ventilation. Two settings of NPSV were randomly applied for 30 minutes each: i- "at patient's comfort" (C): Inspiratory pressure support (IPS) was the maximal tolerated pressure able to reduce awake PaCO2 with the addition of a pre-set level of external PEEP (PEEPe); ii- "physiological setting" (PH): the level of IPS able to achieve a &gt; 40% and &lt; 90% decrease in transdiaphragmatic pressure in comparison to spontaneous breathing (SB). A PEEPe level able to reduce PEEPi,dyn by at least 50% was added. RESULTS: During SB the tidal diaphragmatic pressure-time product (PTPdi/b) was 17.62 +/- 7.22 cmH2O*sec, the component due to PEEPi,dyn (PTPdiPEEPi,dyn) being 38 +/- 17% (range: 16-65%). Compared to SB,PTPdiPEEPi,dyn was reduced significantly with both settings, the reduction being greater with PH compared to C. CONCLUSIONS: In conclusion in severe COPD patients with chronic hypercapnia the inspiratory muscle workload due to PEEPidyn is high and is reduced by NPSV at a greater extent when ventilator setting is tailored to patient's mechanics

Advanced COPD patients under Home Mechanical Ventilation and/or Long Term Oxygen Therapy: Italian Healthcare Costs

Background and Aim. Little information is available on healthcare costs for patients with very severe chronic obstructive pulmonary disease. The aim of the current work was to evaluate Italian healthcare costs in these patients. Methods. Prospective 1-year analysis was assessed in three subgroups of patients; non-invasively ventilated (n=30); invasively-ventilated (n=12) and on longterm oxygen therapy (n=41). Acute costs for care were a sum of fees for doctor’s consultations, admissions to hospital (ward and intensive care units) and emergency drugs. Chronic costs were the sum of costs for pharmacotherapy and home ventilation and/or oxygen care. Results. Mean cost/day/patient was 96±112€ (range 9-526€), with acute costs accounting for 72% and chronic costs for 28% of the total cost burden, with no significant differences in costs associated with the three subgroups. Acute costs had a non-normal distribution (range 0 to 510€) being cost for hospitalisation the highest cost burden with more than 30% of acute care costs attributed to only a small segment of patients. Chronic care costs were also unevenly distributed among the various groups (ANOVA p=0.006), being home oxygen supply the highest cost burden. Conclusions. The current Health Care System is in urgent need for a reassessment of the high cost burden associated with hospitalisations and home oxygen supply

A pilot study of nurse-led, home monitoring for patients with chronic respiratory failure and with mechanical ventilation assistance.

We assessed the feasibility of telemedicine for home monitoring of 45 patients with chronic respiratory failure (CRF) discharged from hospital. The patients transmitted pulsed arterial saturation (pSat) data via a telephone modem to a receiving station where a nurse was available for a teleconsultation. A respiratory physician was also available. Scheduled and ad hoc appointments were conducted. Thirty-five patients were on home mechanical ventilation, 13 with invasive and 22 with non-invasive devices. The main diagnosis was chronic obstructive pulmonary disease (COPD). The follow-up period was 176 days (SD 69). In all, 376 calls for scheduled consultations were received and 83 ad hoc consultations were requested by the patients. The actions taken were: 55 therapy modifications, 19 hospitalizations in a respiratory department for decompensated CRF, three hospitalizations in an intensive care unit (ICU), 22 requests for further investigations, 25 contacts with the general practitioner (GP), 66 demands for respiratory consultations and 10 calls for the emergency department. The mean time recorded for the 459 calls was 16 min/patient/week. In 82% of calls, a pSat recording was received successfully. The nurse time required to train the users in the operation of the pSat instrument was high (mean time 30 min). However, the results showed that home monitoring was feasible, and useful for titration of oxygen, mechanical ventilation setting and stabilization of relapse

Inhaler technique knowledge and skills before and after an educational program in obstructive respiratory disease patients: A real-life pilot study

Patients present poor knowledge and skills about their respiratory disease and inhaler device. We aimed to: (1) evaluate COPD and asthmatic patients' ability to manage inhaled drugs (2) identify differences among devices and (3) correlate clinical data with patient ability.Patients (n=134) admitted for pulmonary rehabilitation (PR) were given an ad-hoc questionnaire covering 0% as the worst and 100% the best value of global ability (indicating the sum of knowledge and skills in managing inhaled drugs) at baseline (T0) and discharge (T1). Educational program was provided during PR. Setting of rehabilitation, age, sex, diagnosis, spirometry, CIRS score, level of autonomy to use medications, if naïve about PR, educational level, and number/type of prescribed inhaled drugs were recorded.Most patients used 1 drug while 37% used 2 drugs. DPIs were the main device prescribed. At baseline, patients' mean level of knowledge and skills were 73% and 58%, respectively. There was a significant difference in level of skills (p=0.046) among device families, DPIs resulting worst and pMDIs best. Global ability, skills and knowledge improved after educational support (p0.001) but did not reach the optimal level, 88%, 87% and 89%, respectively. Baseline global ability was positively correlated to female gender, younger age, previous PR access, outpatient status, higher education level and GOLD D class.At hospital admission, global ability was not optimal. Education may improve this, irrespective of the type of device used, in particular in male, elderly, naïve to PR, low educational level patients