Evidence is weak for the ability of long-term non-invasive positive pressure ventilation (NPPV) to improve survival in patients with stable hypercapnic chronic obstructive pulmonary disease (COPD). ...Previous prospective studies did not target a reduction in hypercapnia when adjusting ventilator settings. This study investigated the effect of long-term NPPV, targeted to markedly reduce hypercapnia, on survival in patients with advanced, stable hypercapnic COPD.
This investigator-initiated, prospective, multicentre, randomised, controlled clinical trial enrolled patients with stable GOLD stage IV COPD and a partial carbon dioxide pressure (PaCO2) of 7 kPa (51.9 mm Hg) or higher and pH higher than 7.35. NPPV was targeted to reduce baseline PaCO2 by at least 20% or to achieve PaCO2 values lower than 6.5 kPa (48.1 mm Hg). Patients were randomly assigned (in a 1:1 ratio) via a computer-generated randomisation sequence with a block size of four, to continue optimised standard treatment (control group) or to receive additional NPPV for at least 12 months (intervention group). The primary outcome was 1-year all-cause mortality. Analysis was by intention to treat. The intervention was unblinded, but outcome assessment was blinded to treatment assignment. This study is registered with ClinicalTrials.gov, number NCT00710541.
Patients were recruited from 36 respiratory units in Germany and Austria, starting on Oct 29, 2004, and terminated with a record of the vital status on July 31, 2011. 195 patients were randomly assigned to the NPPV group (n=102) or to the control group (n=93). All patients from the control group and the NPPV group were included in the primary analysis. 1-year mortality was 12% (12 of 102 patients) in the intervention group and 33% (31 of 93 patients) in the control group; hazard ratio 0.24 (95% CI 0.11-0.49; p=0.0004). 14 (14%) patients reported facial skin rash, which could be managed by changing the type of the mask. No other intervention-related adverse events were reported.
The addition of long-term NPPV to standard treatment improves survival of patients with hypercapnic, stable COPD when NPPV is targeted to greatly reduce hypercapnia.
German Lung Foundation; ResMed, Germany; Tyco Healthcare, Germany; and Weinmann, Germany.
Outpatient intensive nursing care offers individuals who require specialized intensive nursing care on a permanent basis the opportunity to survive outside of an intensive care unit in an ambulatory ...environment. With advancements in surgical and intensive medical practices, coupled with demographic changes in the population resulting in a higher number of older, multimorbid patients, the available treatment options have been continuously extended. Many patients survived their intensive care stays but could not be weaned from ventilation or they had to retain a tracheal cannula, even without ventilation therapy. Presently, this group constitutes the majority of patients receiving outpatient intensive nursing care in Germany and represents a substantial cost factor in healthcare. The care of these patients is governed by the Guideline of the Joint Federal Committee on the Prescription of Outpatient Intensive Nursing Care (AKI-RL), which is based on the Intensive Care and Rehabilitation Strengthening Act (GKV-IPReG) 2021.
Abstract
Background
The timely integration of palliative care is important for patients suffering from various advanced diseases with limited prognosis. While a German S-3-guideline on palliative ...care exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for integration of palliative care into intensive care medicine is missing to date.
Method
Ten German medical societies worked on recommendations on palliative care aspects in intensive care in a consensus process from 2018 to 2023.
Results
Based on the german consensus paper, the palliative care aspects of the respective medical disciplines concerning intensive care are addressed. The recommendations partly refer to general situations, but also to specific aspects or diseases, such as geriatric issues, heart or lung diseases, encephalopathies and delirium, terminal renal diseases, oncological diseases and palliative emergencies in intensive care medicine. Measures such as non-invasive ventilation for symptom control and compassionate weaning are also included.
Conclusion
The timely integration of palliative care into intensive care medicine aims to improve quality of life and symptom control and also takes into acccount the often urgently needed support for patients’ highly stressed relatives.
Zusammenfassung
Die zeitgerechte Integration der Palliativmedizin ist ein wichtiger Bestandteil in der medizinischen Behandlung von verschiedenen Erkrankungen im fortgeschrittenen Stadium. Während ...eine erweiterte S3-Leitlinie zur Palliativmedizin für Patienten mit einer nicht heilbaren Krebserkrankung existiert, fehlt bis dato eine Leitlinie für nicht-onkologische Patienten bzw. eine konkrete Empfehlung für Patienten, die in der Notaufnahme oder auf Intensivstation behandelt werden. Basierend auf dem vorliegenden Konsensuspapier wird auf die palliativmedizinischen Aspekte der jeweiligen Fachdisziplinen eingegangen. Durch die zeitgerechte Integration der Palliativversorgung soll eine verbesserte Lebensqualität und Symptomlinderung in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin erreicht werden.
The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S‑3-guideline on palliative medicine exists for patients with ...incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
Zusammenfassung
Die Integration der Palliativmedizin ist ein wichtiger Bestandteil in der medizinischen Behandlung von verschiedenen Erkrankungen im fortgeschrittenen Stadium. Während eine erweiterte ...S3-Leitlinie zur Palliativmedizin für Patienten mit einer nichtheilbaren Krebserkrankung existiert, fehlt bis dato eine Leitlinie für nichtonkologische Patienten bzw. eine konkrete Empfehlung für Patienten, die in Notaufnahmen oder auf Intensivstationen behandelt werden. Basierend auf dem vorliegenden Konsensuspapier wird auf die palliativmedizinischen Aspekte der jeweiligen Fachdisziplinen eingegangen. Durch die zeitgerechte Integration der Palliativversorgung soll eine verbesserte Lebensqualität und Symptomlinderung in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin erzielt werden.
Background and Objective: The objective of this study was to develop a specific instrument for measuring health-related quality of life (HRQL) in patients receiving home mechanical ventilation (HMV).
...Methods: The Severe Respiratory Insufficiency (SRI) Questionnaire was developed and tested for its psychometric properties following a multicentric clinical trial including 226 patients receiving HMV (mean age 57.3±14.0 years).
Results: Forty-nine items passed the selection process and were allocated to seven subscales: Respiratory Complaints, Physical Functioning, Attendant Symptoms and Sleep, Social Relationships, Anxiety, Psychologic Well-Being, and Social Functioning. Cronbach's α was >0.7 in all subscales and >0.8 in four subscales indicating high internal consistency reliability. Construct validity was confirmed by factor analysis, indicating one summary scale that accounts for 59.8% of the variance. Concurrent validity was confirmed by correlating subscales of the SRI and the SF-36 (0.21<r<0.79). Item-scale correlations revealed a high item discriminant validity. In addition, different diagnostic groups could be discriminated by the SRI. Here, the overall best HRQL was measured in the following order: patients with kyphoscoliosis, miscellaneous disorders, neuromuscular diseases, post-tuberculosis, and chronic obstructive pulmonary disease (P<.05).
Conclusion: The SRI is a new multidimensional instrument with high psychometric properties designed to measure specific HRQL in patients with SRI receiving HMV.
The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable ...cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
To collect benchmark data on the MOS 36-Item Short-Form Health Status Survey (SF-36) in patients receiving noninvasive positive pressure ventilation and to examine whether health-related quality of ...life is influenced by the underlying disease or by physical parameters.
Multicentric clinical cross-sectional trial in four general wards specialized in noninvasive positive pressure ventilation.
226 patients (78 chronic obstructive pulmonary disease, 57 kyphoscoliosis, 20 posttuberculosis sequelae, 17 Duchenne muscular dystrophy, 13 polyneuropathy, 13 myopathy, 6 amyotrophic lateral sclerosis, 12 obesity-hypoventilation syndrome, 4 poliomyelitis sequelae, 3 phrenic nerve lesion, 3 central hypoventilation syndrome) who used noninvasive positive pressure ventilation for home mechanical ventilation.
Health-related quality of life as assessed by the SF-36 was lower than in the general population. Overall the Physical Component Summary (PCS) was significantly lower than the general population norm; the Mental Component Summary (MCS) was also reduced but less markedly. Patients with chronic obstructive pulmonary disease were more impaired in MCS than those with kyphoscoliosis. PCS was significantly associated with age. Gender, lung function, and arterial blood gas values were not significant predictors of health-related quality of life.
Benchmark SF-36 data in patients receiving noninvasive positive pressure ventilation are given. Although physical health is significantly impaired in these patients, this does not necessarily lead to mental limitation, and mental health is influenced by the underlying disease, but not by physical parameters.
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