The prevalence of non-invasive ventilation and long-term oxygen treatment in Helsinki University Hospital area, Finland.

BACKGROUND: Chronic respiratory failure (CRF) can be treated at home with non-invasive ventilation (NIV) and/or long-term oxygen (LTOT). The prevalence of these treatments is largely unknown. We aimed to clarify the prevalence and indications of the treatments, and the three-year mortality of the treated patients in the Helsinki University Hospital (HUH) area in Finland. METHODS: In this retrospective study we analyzed the prevalence of adult CRF patients treated with NIV and/or LTOT on 1.1.2018 and followed these patients until 1.1.2021. Data collected included the underlying diagnosis, patient characteristics, information on treatment initiation and from the last follow-up visit, and mortality during the three-year follow-up. Patients with home invasive mechanical ventilation or sleep apnea were excluded. RESULTS: On 1.1.2018, we had a total of 815 patients treated with NIV and/or LTOT in the Helsinki University Hospital (HUH) area, with a population of 1.4 million. The prevalence of NIV was 35.4 per 100,000, of LTOT 24.6 per 100,000 and of the treatments combined 60.0 per 100,000. Almost half, 44.5%, were treated with NIV, 41.0% with LTOT, and 14.4% underwent both. The most common diagnostic groups were chronic obstructive pulmonary disease (COPD) (33.3%) and obesity-hypoventilation syndrome (OHS) (26.6%). The three-year mortality in all patients was 45.2%. In the COPD and OHS groups the mortality was 61.3% and 21.2%. In NIV treated patients, the treatment durations varied from COPD patients 5.3 years to restrictive chest wall disease patients 11.4 years. The age-adjusted Charlson co-morbidity index (ACCI) median for all patients was 3.0. CONCLUSIONS: NIV and LTOT are common treatments in CRF. The prevalence in HUH area was comparable to other western countries. As the ACCI index shows, the treated patients were fragile, with multiple co-morbidities, and their mortality was high. Treatment duration and survival vary greatly depending on the underlying diagnosis.

Home invasive mechanical ventilation in Finland in 2015-2019.

INTRODUCTION: The prevalence of long-term invasive mechanical ventilation via tracheostomy in chronic respiratory insufficiency is largely unknown. We aimed to clarify prevalence and aetiology of the use of home invasive mechanical ventilation (HIMV) in Finland in 2015-2019. METHODS: Information on HIMV patients was collected yearly from all Finnish Hospital District patient registries between 1 January 2015 and 1 January 2019. Data included underlying diagnosis, time from diagnosis to HIMV initiation, treatment length, mortality and basic sociodemographic data. RESULTS: In 2015, we had 107 HIMV patients. During the follow-up we received 34 new patients (24.1%) and 46 patients (32.6%) died. In 2019, we had 95 HIMV patients and the prevalence in Finland was 2.0 in 100 000. The most common diagnoses were motor neurone disease (29.1%) and spinal cord injuries (19.9%). Mean duration of HIMV among all patients on 1 January 2019 was 12.3 years and among deceased patients, 11.2 years. Treatment durations ranged from 7.7 years for motor neurone disease patients to 47.3 years for post-polio syndrome patients. Most patients (81.6%) used HIMV 24 h·day-1. CONCLUSIONS: HIMV is a rare, long-lasting treatment, most often used in chronic hypoventilation caused by chronic neurological disease. Based on our 4 year follow-up the prevalence of HIMV seems to be diminishing in Finland. Treatment duration and survival vary greatly depending on the underlying diagnosis. Most of the patients were totally dependent on HIMV, requiring 24-h care.

Validation of the Finnish severe respiratory insufficiency questionnaire.

INTRODUCTION: Chronic respiratory insufficiency impacts patients' lives and reduces quality of life. The Severe Respiratory Insufficiency (SRI) questionnaire examines health-related quality of life and is designed specifically for patients receiving home mechanical ventilation (HMV) for chronic respiratory failure (CRF). OBJECTIVES: The aim of this study was to validate the Finnish version of the SRI and study its reproducibility in patients with CRF. METHODS: Our 74 patients receiving HMV or long-term oxygen treatment for CRF or both completed the SRI and St George's Respiratory questionnaires (SGRQ) three times (at baseline, and then one week and one month later). Reliability and validity of the questionnaires was analysed with Cronbach's alpha and intraclass correlation coefficient. Patients were prospectively followed up for 5 years, with data collected on their use of hospital services and mortality. RESULTS: Cronbach's alpha in the SRI ranged from 0.67 to 0.88 and was >0.7 on all subscales except the "attendant symptoms and sleep". On four subscales, Cronbach's alpha was >0.8, and on the summary scale, 0.95. The SRI showed high correlation with SGRQ. Both tests showed good reproducibility. During the 5-year follow-up, 27 (36%) patients died. CONCLUSIONS: The Finnish SRI proved valid, reliable and reproducible. Its psychometric properties were good and similar to those of the original questionnaire and of other validation studies.

Symptoms During CPAP Therapy Are the Major Reason for Contacting the Sleep Unit Between Two Routine Contacts.

STUDY OBJECTIVES: The demand for continuous positive airway pressure (CPAP) therapy outpaces available resources in most health care settings. We sought to evaluate predictors of nonroutine CPAP follow-up visits to improve resource utilization. METHODS: We randomly analyzed 1,141 of the 2,446 patients who had received at least 1 year of CPAP therapy. Reasons for contacts, type (routine = R, nonroutine = NR), and mode (face-to-face or not, physician, nurse) were collected. RESULTS: A total of 771 patients were classified R, and 370 NR. Age, profession, and sex did not affect the NR frequency. Symptoms increased the odds ratio for NR 12.1-fold, somnolence 34.8-fold, and suffocation at night 10.4-fold. Patients with nonroutine reasons abandoned CPAP therapy significantly (7.6-fold) more frequently than patients with routine reasons. CONCLUSIONS: Symptoms during CPAP therapy predicted the nonroutine contacts well. In line with this, patients with symptoms have become a priority follow-up group, and could constitute the only follow-up policy when dealing with insufficient medical resources.

Upper airway symptoms in primary snoring and in sleep apnea.

CONCLUSIONS: Upper airway symptoms were common in subjects referred for sleep study. In particular, nasal stuffiness and airway dryness already seemed to bother snorers before development of obstructive sleep apnea syndrome (OSAS). Mouth dryness increased with severity of obstructive sleep apnea (OSA). OBJECTIVES: Upper airway symptoms are common in patients with OSAS. However, prevalence of these symptoms is unknown in primary snoring and mild OSA. We evaluated frequency of upper airway symptoms in a large group of patients referred for diagnostic sleep studies. METHODS: We examined 524 consecutive subjects (69% men, mean ± SD age 51 ± 12 years, apnea-hypopnea index (AHI) 15 ± 21, body mass index 31 ± 6) by a questionnaire-based survey. The subjects filled in a questionnaire enquiring about current upper airway symptoms and history of nasal and pharyngeal disorders before the sleep study. RESULTS: Frequent upper airway symptoms among study subjects were common: 56% of the patients reported throat dryness, 55% mouth dryness, 54% nasal stuffiness, 52% nose dryness, 33% sneezing, 33% postnasal drip, and 24% rhinorrhea. The patients with moderate or severe OSAS (AHI ≥15 and Epworth sleepiness score ≥10) suffered from mouth dryness more often (71% vs 40%, p < 0.01) than those with mild or no OSAS.

[Noninvasive ventilation and acute respiratory failure]. / Noninvasiivinen ventilaatio ja äkillinen hengitysvajaus.

Noninvasive ventilation is effective in acute respiratory failure, in which drug therapy and administration of supplemental oxygen do not suffice and attempts are made to prevent the patient from ending up in invasive respirator therapy. The treatment is suited for acute respiratory failure for instance in cases of exacerbation of chronic obstructive pulmonary disease, in which a disturbance of pulmonary ventilation leads to the accumulation of carbon dioxide and to respiratory acidosis. Disadvantages associated with artificial airways are avoided, number of complications are reduced, hospitalization periods become shorter, mortality decreases and costs are saved.

Frequency of upper airway symptoms before and during continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome.

BACKGROUND: Upper airway side effects are common during nasal continuous positive airway pressure (nCPAP) treatment and may affect the use of nCPAP. OBJECTIVES: It was our aim to evaluate the prevalence of upper airway symptoms in obstructive sleep apnea syndrome (OSAS) patients before and during nCPAP treatment and to assess the possible association between the symptoms and long-term adherence to the treatment. METHODS: We examined 385 consecutive OSAS patients (79% men, mean age ± SD 52 ± 10 years and apnea-hypopnea index 33 ± 23) by means of a prospective questionnaire-based survey. The patients filled in questionnaires about upper airway symptoms before starting nCPAP and after 2 months of treatment. RESULTS: Upper airway symptoms were common before starting nCPAP: 61% of the patients reported dryness of mouth, 54% dryness of throat, 52% nasal stuffiness, 51% dryness of nose, 30% sneezing, 24% mucus in throat, 17% rhinorrhea, and 6% nose bleeds daily or almost daily. In CPAP users there was a significant decline in the number of patients with frequent mouth (37%), throat (34%), nose (28%) dryness and nasal stuffiness (24%). There was no difference in upper airway symptoms before nCPAP treatment between those who continued the treatment after 1 year and those who terminated the treatment. CONCLUSIONS: The most common upper airway symptoms in patients with untreated OSAS seem to be associated with mucosal dryness. These symptoms improved during nCPAP treatment probably due to the change in breathing pattern. The occurrence of upper airway symptoms before nCPAP start did not predict long-term adherence to the treatment.

Asthma Programme in Finland: the quality of primary care spirometry is good.

AIMS: To assess the quality of primary care spirometry by visual inspection of the flow-volume expiratory curve and to study the quantity of clinical information provided on the spirometry report sheets. METHODS: Retrospective audit of 868 expiratory flow-volume curves referred to three pulmonary clinics assessed against five predefined quality criteria. Clinical information included on the spirometry report sheets was also collected. RESULTS: Quality was good in 78% of pre-bronchodilation curves and in 80% of post-bronchodilation curves. Obtaining a sharp PEF value and full vital capacity exhalation seemed to be the critical points of measurement. Inter-rater reliability of the curve assessment was mainly good. Data on where the spirometry took place, and comments on the use of respiratory medication and patient co-operation were often lacking. CONCLUSIONS: The quality of primary care spirometry was good. Adequate clinical information on the report sheets would further improve the quality of this diagnostic process.

The Finnish national asthma programme: communication in asthma care--quality assessment of asthma referral letters.

AIMS AND OBJECTIVES: The Finnish National Asthma Programme, which was launched in year 1994, considered the management of asthma as a community problem. The role of the primary health care in the management of asthma was emphasized. Optimal asthma management includes good communication between health care professionals. Referral letters are an accepted tool for evaluation of the communication process. The aim of this study was to assess the quality of asthma-related referral letters. METHODS: All non-acute referral letters (n=3176) to three pulmonary departments were screened in 2001 and all those related to asthma were included (n=1289). The 14 previously derived asthma-specific criteria were applied: occupation, smoking, known allergies, current medication, other diseases, onset of symptoms, wheezing, dyspnoea, specified dyspnoea, cough, specified cough, use of asthma medication, peak-flow follow-up or spirometry with bronchodilatation test as an attachment. The study group was prepared to accept the maximum of 30% of the referral letters to be of poor quality. RESULTS: Twenty-one per cent of the referral letters were graded good, 34% satisfactory and 45% poor. Information on wheezing, smoking habits and current medication was mentioned in 44%, 42% and 41% of asthma letters respectively. CONCLUSIONS: The Finnish National Asthma Programme calls for optimizing communication between doctors. The proportion of poor letters was 50% higher than the preset standard and clearly indicates a need for improvement. We found several issues, which need to be better communicated (smoking, lung function tests, wheezing, medication) when referring a patient with suspected asthma.

A cognitive-behavioral weight reduction program in the treatment of obstructive sleep apnea syndrome with or without initial nasal CPAP: a randomized study.

BACKGROUND AND PURPOSE: To evaluate (a) whether an active weight reduction strategy based on the cognitive-behavioral approach and an initial very-low-calorie diet might lead to short- and long-term weight loss and alleviation of OSAS; and (b) whether the results of this intervention could be enhanced by combining it with nasal continuous positive airway pressure (CPAP) treatment during the first 6 months. PATIENTS AND METHODS: Thirty-one obese male symptomatic sleep apnea patients underwent a 2-year weight reduction program with total follow-up of 36 months from baseline. The mean age (+/-SD) was 49.1+/-7.9 years, body mass index 43.8+/-5.4, and oxygen desaturation index (ODI4) 51.3+/-31.1. The patients were randomized to CPAP (17 patients) and non-CPAP groups (14 patients). RESULTS: The mean weight loss was 19.1+/-10.2 kg (14% of the original weight) for the whole group at 6 months, 18.3+/-13.2 (13%) at 12 months and 12.6+/-14.7 kg (9%) at 24 months. Excellent or good treatment results, as defined in terms of an ODI4 (average number of oxygen desaturation events p/h>4% from baseline) reduction of at least 50% from the baseline, were seen in 61% of patients at 6 months and were still observable in 42% of patients at 24 months. The correlations between changes in weight and in ODI4 were 0.59 (P<0.01) at 6 months, 0.68 (P<0.01) and 0.75 (P<0.01) at 24 months. Adding CPAP treatment to the weight reduction therapy for the first 6 months did not result in greater weight loss or diminution of desaturation indices (without CPAP) at any time point. One year after the termination of the program the mean weight loss was 6.6+/-12.9 kg, and 42% of patients still showed at least 5% weight loss as compared with their original weight. CONCLUSION: Satisfactory weight loss associated with improvement of OSAS could be achieved by means of a cognitive-behavioral weight loss program. Adding CPAP in the initial phase of the weight reduction program did not result in significantly greater weight loss.

Asthma Programme in Finland: high consensus between general practitioners and pulmonologists on the contents of an asthma referral letter.

AIMS: The purpose of the present study was to define quality criteria for an asthma referral letter using a national co-operative effort between general practitioners and pulmonologists. METHODS: A consensus-seeking expert panel representing primary and secondary health care merged evidence from the literature and existing national and local asthma programmes to produce 19 provisional criteria to be included in an asthma referral letter. These criteria were contained within a national questionnaire review which was sent out to groups of Finnish physicians. The target groups for the review were all chief pulmonologists in specialist care (n = 32), and representatives of all Finnish health centres (n = 283) - either the chief physician (n = 143) or the local asthma co-ordinating physician (n = 140). RESULTS: The overall response rate to the national questionnaire study was 75%. The three groups of responding physicians had very similar gradings on the necessity of the 19 provisional criteria, most of which were considered very necessary. 14 final disease-specific criteria for an asthma referral letter were derived as a result of this study. CONCLUSION: The main result of this study is an agreed data set of essential information that needs to be included in an asthma referral letter. Importantly these criteria were developed by general practitioners and pulmonologists together.