Extending the use of non-invasive ventilation in ward-based settings: clinical effectiveness outside COPD
Introduction: Non-invasive ventilation (NIV) has been regarded as an effective method for avoiding the use of endotracheal intubation (ETI) and decreasing mortality in patients with acute hypercapnic respiratory failure (AHRF). It has been considered as an effective care strategy for many years to treat AHRF patients due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in critical care and ward settings. However, the clinical effectiveness of NIV in AHRF patients due to aetiologies other than COPD is still questioned and the use of ward-based NIV is not widely established which limits a hospital’s ability to design care pathways. Currently, managing patients who require NIV in a critical care setting is resource intensive and in the current economic climate, where healthcare budgets are increasingly limited, maximizing cost-effectiveness by enhancing ward-based care is important. Aim: To evaluate the clinical effectiveness of NIV in non-COPD patients with AHRF and the clinical effectiveness of using NIV outside COPD in ward-based settings. Methods: Firstly, a systematic review was conducted to assess the existing literature regarding the clinical effectiveness of bilevel positive airway pressure (BIPAP) in non-COPD patients with AHRF. Next, a retrospective cohort study to evaluate the success and failure rates and predictors associated with NIV application in the ward-based setting for patients with AHRF unrelated to COPD. Finally, a multi-methods study to understand the healthcare professional perspectives on the use of NIV for respiratory failure outside of critical care units, how the attitudes have changed after the COVID-19 pandemic, and the future of ward-based NIV. Results: Existing controlled trials that evaluate the clinical effectiveness of NIV for non-COPD patients with AHRF were small (mainly for acute cardiogenic pulmonary oedema (ACPO)) and lack of robust data. Our cohort demonstrated that obesity-related AHRF was the commonest condition, of all non-COPD conditions, used for-ward-based NIV management with the highest rate of survival to hospital discharge. Age, pneumonia on admission, and pre-NIV pH were identified as important predictors of surviving ward-based NIV treatment. Healthcare providers felt positive regarding ward-based NIV especially for AHRF due to COPD and OHS with limited/uncertain use for other conditions. The pandemic emphasizes the role of ward units in the care of different patient conditions (Covid and non-Covid patients) to relieve the pressure from other units. Healthcare providers support the expansion of designated wards, multidisciplinary staff deployment with proper training and competencies to improve the ward-based NIV practice in the future. Conclusion: Ward-based NIV for AHRF patients unrelated to COPD may be considered a useful and safe management strategy especially for conditions with promising and positive outcomes like OHS but further future robust studies are required to confirm this. A particular challenge is a process of initiating and expanding the ward-based NIV service by expanding the designated wards capacities with more well-trained multidisciplinary staff deployment.