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Background: The indications for Long Term Ventilation (LTV) are expanding. Pneumonia is common in these patients and transmission of bacterial infections, and more recently COVID-19 infection, between users of ventilators is a concern. UK national standards recommend bacterial/viral filters for use with acute Non-Invasive Ventilation (NIV) to protect the ventilator from contamination. However, there are no recommendations made for LTV. UK National guidance also explicitly states that there is no airflow from the patient to the ventilator.1 Aims and objectives: To investigate whether exhaled gas reaches the ventilator outlet. Method(s): We conducted experiments on three ventilators with different circuits during NIV delivered to a member of the study team using standard clinical settings. We used a side-stream end tidal CO2 (EtCO2) analyser attached to the tubing adjacent to the ventilator outlet as shown in the figure. Result(s): Regardless of ventilator and circuit used we demonstrated that exhaled gas reaches the ventilator outlet during NIV. EtCO2 values were 1.6-3.7kPa. Conclusion(s): Exhaled gas reaches the ventilator outlet during NIV. This raises an urgent requirement within the LTV community to test ventilators for bacterial and viral colonisation, consider the use of bacterial/viral filters, and discuss routine decontamination of these devices between individual patient uses. (Figure Presented).
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Introduction: Currently patients with COVID-19 related acute respiratory failure (ARF) may receive respiratory support with conventional oxygen therapy, high-flow nasal oxygen (HFNO) or continuous positive airway pressure (CPAP). A proportion of patients will subsequently require invasive ventilation. However, there is insufficient evidence on the relative effectiveness of different modes of noninvasive respiratory support (NIRS). In the absence of robust evidence to guide clinical decisions, there is likely significant variation in their use in UK practice. The RECOVERY-RS trial sought to address this knowledge gap, aiming to identify the most effective method of non-invasive respiratory support in COVID-19. This survey, conducted whilst RECOVERY-RS was in progress, sought to characterise the current use of NIRS in COVID-19 patients across the UK. Methods: An anonymous, online survey (10 questions) was distributed via national networks and professional societies. Healthcare professionals involved in managing COVID-19 patients were invited to participate with responses collected over two months from September to October 2020. Results: Of 145 respondents, the majority were critical care (60%) or respiratory (27%) clinicians. Prior to the COVID-19 pandemic, most reported having commonly used HFNO (89%) or CPAP (70%) for infection-related ARF. A small minority (3% HFNO vs 9% CPAP) reported no previous experience of their use. In COVID-19 patients suitable for intubation and ventilation, 92% of respondents had used CPAP and 61% HFNO to bridge to or prevent intubation. Conversely, 5% reported they would never use CPAP and 8% would never use HFNO as a bridge to intubation. 68% of clinicians chose CPAP as their personal preferred method of NIRS vs 26% HFNO when treating COVID-19 patients. In patients not suitable for invasive ventilation, CPAP was also more frequently used than HFNO (92% vs 61%). 37% worked in trusts enrolled in the RECOVERY-RS trial and the majority (59%) felt that RECOVERY-RS was an important study, addressing a key unanswered research question. Conclusion: This survey identified that a variety of methods of NIRS are being used for COVID-19 patients in the UK. CPAP predominates as both a ceiling of care treatment and as a bridge to intubation. This appears to represent a change in practice compared to the management of infection-related ARF prior to the COVID-19 pandemic, despite a lack of evidence at that time to suggest superior efficacy of CPAP. The heterogeneous survey results support the need for evidence of the most effective NIRS in COVID-19 in order to deliver optimal and standardised treatment.
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Background: Our regional assisted ventilation service has a cohort of almost 1000 patients receiving Long Term Ventilation (LTV) in the community. The clinical review of these patients has historically been delivered in the outpatient setting, either at the base hospital or at outreach clinics elsewhere in the region. During the early part of the COVID-19 pandemic, it was recognised that face-to-face contact with this shielded group of patients was impractical, therefore the routine outpatient review was replaced with a telephone consultation. Patients who required urgent assessment or review were prioritised, and were seen face-to-face either in the outpatient department or in the community, observing strict infection prevention and control measures in either setting. Objective To gain an understanding of the perspective of LTV patients about their clinical review being provided by telephone. Method: We sent a survey to 930 patients asking: • Whether they had received a telephone consultation during the last few months • If so, to score how helpful the telephone consultation was • Whether they would consider changing some of their future consultations to telephone/video • To score what their preferred method of consultation would be in the future Results: We received feedback from 355 respondents who had participated in a telephone consultation. Most patients (98%) rated their telephone consultation as helpful. 66% would consider changing their future consultation to telephone review. When asked about future management, one third would prefer face-to-face consultation, one third would prefer telephone review and one third would prefer a mixture of both. Discussion Throughout the COVID-19 pandemic, due to reduced face-to-face clinical contact, LTV patients have demonstrated a significant level of independence in self-managing their health care. This is an opportunity to embrace the flexibility in the way health care delivery has evolved during this time. Conclusion: The patient perspective on how their health care is delivered is critically important. LTV services will continue to need to apply clinical judgement when organising their patient review process, but this feedback demonstrates that most patients would be happy for telephone consultations to replace some, if not all, of the face-to-face review they have previously had.
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Background: Shielding for clinically vulnerable members of the population during the COVID-19 pandemic has had significant impacts on healthcare delivery. This study investigates whether shielding reduces hospital admissions amongst patients requiring long term ventilation (LTV) and whether there may be a role for shielding and adopting other hygiene methods every winter to reduce hospital admissions. Methods: 603 LTV patients in two large centres completed a questionnaire about shielding and COVID-19 symptoms during the lockdown. A comparative retrospective study of hospital admissions for acute hypercapnic respiratory failure requiring non-invasive ventilation (NIV) between the periods March-June 2019 and March - June 2020 during the peak of the COVID-19 pandemic, was also carried out. Results: 522(88.57%) of the 603 patients reported observing strict adherence to shielding whilst the remaining 81(13.43%) observed isolation precautions to various degrees. 30 (4.98%) reported having developed COVID-19 symptoms with just 2 (0.33%) testing positive but none required invasive ventilation and there were no deaths. Admissions requiring acute NIV in 2019 was 39(6.47%) compared to 9(1.49%) during the 2020 COVID19 peak. Conclusion: Compared to 2019, there was a drop in the number of admissions in patients requiring acute NIV during lock-down. COVID 19 incidence was also low in this shielded cohort. These suggest a case can be made for advocating shielding every winter for LTV patients and potentially for all patients with chronic respiratory disease. Widespread use of masks and improved hand hygiene could also help reduce spread of other viral illnesses like influenza which account for a significant number of admissions in (Figure presented) patients with chronic respiratory conditions over the winter months. Adopting a blanket strategy to shield all patients with chronic respiratory illness during winter is probably impractical. A stratify-and-shield policy requiring an adaptive social distancing strategy to keep the load on critical care services within manageable limits1 has been advocated. We anticipate our findings will generate exciting debate for and against shielding our most clinically vulnerable respiratory patients during winter.