Dear Editor, We thank M. Lujan and A. M. Esquinas for their considered letter regarding the use of ambulatory models for implementing non-invasive ventilation (NIV) in motor neuron disease (MND). A...
The worldwide burden of diabetes is projected to be 5.4% of the adult population by the year 2025. Diabetes is associated with multiple medical complications that both decrease health-related quality of life (HR-QOL) and contribute to earlier mortality. There is growing evidence for the effectiveness of multidisciplinary disease management programs that incorporate self-management principles in improving patients' long-term outcomes. The aim of this project was to evaluate the effectiveness of this approach in improving: (1) glycemic control measured by HbA1c, and (2) HR-QOL measured by the Assessment of Quality of Life (AQOL), at enrollment and at 12-months follow-up. Between 2004 and 2008, a total of 967 patients were enrolled in the program; 545 (56%) of these patients had HbA1c data available at baseline and at 12 months. Mean HbA1c at enrollment was 8.6% (SD 1.9) versus 7.3% (SD 1.2) at 12 months (P < 0.001). Overall, 68% of patients experienced improvements in HbA1c. At enrollment, patients reported "fair" HR-QOL, which was significantly lower than age-adjusted population norms who reported "good" HR-QOL. At 12 months, 251 (64%) patients had improved HR-QOL, 27 (7%) had no change, and 114 (29%) deteriorated. Mean utility scores improved by 0.11 (P < 0.001), which is almost twice the minimum clinically important difference for the AQOL. This study confirms that a multidisciplinary disease management program for patients with poorly controlled type 2 diabetes can improve both glycemic control and HR-QOL. (Population Health Management 2012;15:12–19)
Introduction: Non-adherence to long-term assisted ventilation may risk persistent symptoms, unplanned hospitalisations or premature mortality for those requiring this treatment. Previous studies have reported non-adherence rates of up to 50% but limited data are available from Australian populations. Aim: The primary aim was to determine the usage of long-term non-invasive ventilation (NIV) during the initial six months of therapy. Secondary aims were to examine adherence patterns across demographics, disease groups and locations of care. Methods: A prospective observational study was undertaken enrolling consecutive patients commencing NIV at a centralised home mechanical ventilation service. Participant usage (minutes per day) was collected over the first 6 months of therapy via manual device downloads. Adherence per month was categorised as an average usage of greater than 4 hours per night. Results: Data from 86 of 100 participants enrolled was available for analysis. Missing data was due to device malfunction or failure to attend follow-up. The majority (65%) of participants had a diagnosis of motor neuron disease (MND) and were implemented on NIV in an outpatient setting (72%). Twenty two percent, all with MND, died within the study period. During the first month after NIV initiation, people with MND were significantly less likely to be able to adhere with NIV, compared with those with other diagnoses (27/56 (48%), versus 22/30 (73%), p=0.028). At study conclusion (6 months or the month prior to death in those with MND), overall adherence was 61%. Conclusion: Non-adherence is common in those commencing NIV, especially in people with MND, despite enrolment within a centralised home mechanical ventilation service.
Background: Transitioning to non-invasive ventilation (NIV) can cause anxiety in people with Motor Neuron Disease (MND), which may reduce adherence rates. Music therapy has demonstrated positive effects with mechanical (invasive) ventilation.Method: This feasibility study examined the effects of music-assisted relaxation (MAR) on NIV adherence, anxiety, and quality of life for people with MND. Data were collected at baseline, 7-days post, and 3-months post NIV implementation.Results: Of 18 consenting participants, 15 chose the MAR condition. Results suggested that supporting NIV transition within the first 7 days may be advantageous for long-term adherence. No effects were found for anxiety or quality of life. Limitations included small sample size, lack of an adequate control, and possible ceiling effects on the instruments used. Qualitative data indicated most participants considered the relaxing and distracting effects of MAR were useful.Conclusions: In this small sample, we found some demand for and acceptability of a music-based intervention in this setting. Participants reported differing experiences of using MAR, and there were technical and logistical issues regarding timely and accessible provision of a MAR intervention within the treatment trajectory of NIV implementation. Conflicting quantitative and qualitative data support the need for mixed method research in this area.
Abstract Introduction Non-invasive ventilation (NIV) with home mechanical ventilators is an effective treatment for chronic respiratory failure. Optimal therapy requires titration of NIV settings to ensure adherence. Modern ventilators produce ventilator data for review via cloud-based platforms. The impact of relying on this data for NIV titration compared with polysomnography (PSG) is unknown. The aim of this study was to compare the agreement of ventilator settings based on summarised ventilator data and NIV PSG within participants. Methods A prospective cohort of 30 individuals with chronic respiratory failure were established on NIV. One month later, participants were administered questionnaires to assess NIV satisfaction, underwent in-lab PSG, and their data from the ventilator cloud-based platform was reviewed. Optimal NIV settings were separately determined by blinded review of the summarised ventilator data and PSG data by a respiratory and sleep physician. Results 20/30 users experienced discomfort whilst using NIV therapy. Ventilator prescription using NIV PSG and Airview data were different. Inspiratory positive airway pressure (IPAP) and pressure support (PS) were an average of 2.76cmH2O (95% confidence interval 2.0,3.5) and 1.8cmH2O (95%CI 1.1,2.5) lower based on ventilator data. Comparative analysis with Bland Altman plots demonstrated a mean difference (MD) in IPAP of 1.4cmH2O (limits of agreement (LOA) -4.47 to 7.29) and PS MD of 0.96cmH2O (LOA -3.43 to 5.36). Conclusion User reported discomfort with NIV therapy was common. Differences in IPAP and PS were observed with lower prescribed pressures when titration was performed using ventilator data compared with NIV PSG. This may influence the titration of NIV therapy; however, the clinical impact of this difference on users is currently unknown.
Clinical practice guidelines recommend further testing for people with tetraplegia and signs and symptoms of obstructive sleep apnoea (OSA), followed by treatment with positive airway pressure therapy. Little is known about how clinicians manage OSA in tetraplegia. The theoretical domains framework (TDF) is commonly used to identify determinants of clinical behaviours. This study aimed to describe OSA management practices in tetraplegia, and to explore factors influencing clinical practice.Semi-structured interviews were conducted with 20 specialist doctors managing people with tetraplegia from spinal units in Europe, UK, Canada, USA, Australia and New Zealand. Interviews were audiotaped for verbatim transcription. OSA management was divided into screening, diagnosis and treatment components for inpatient and outpatient services, allowing common practices to be categorised. Data were thematically coded to the 12 constructs of the TDF. Common beliefs were identified and comparisons were made between participants reporting different practices.Routine screening for OSA signs and symptoms was reported by 10 (50%) doctors in inpatient settings and eight (40%) in outpatient clinics. Doctors commonly referred to sleep specialists for OSA diagnosis (9/20 in inpatients; 16/20 in outpatients), and treatment (12/20, 17/20). Three doctors reported their three spinal units were managing non-complicated OSA internally, without referral to sleep specialists. Ten belief statements representing six domains of the TDF were generated about screening. Lack of time and support staff (Environmental context and resources) and no prompts to screen for OSA (Memory, attention and decision processes) were commonly identified barriers to routine screening. Ten belief statements representing six TDF domains were generated for diagnosis and treatment behaviours. Common barriers to independent management practices were lack of skills (Skills), low confidence (Beliefs about capabilities), and the belief that OSA management was outside their scope of practice (Social/Professional role and identity). The three units independently managing OSA were well resourced with multidisciplinary involvement (Environmental context and resources), had 'clinical champions' to lead the program (Social influences).Clinical management of OSA in tetraplegia is highly varied. Several influences on OSA management within spinal units have been identified, facilitating the development of future interventions aiming to improve clinical practice.
Measurement of inspiratory capacity (IC) as a marker of dynamic lung hyperinflation has been shown to correlate with dyspnea and exercise performance in stable COPD, and is therefore of potential utility in the management of this condition. We have examined whether similar relationships exist during acute exacerbations of COPD and asthma in order to determine whether there is a role for IC monitoring in acute management of these conditions. Eight patients with COPD and ten with asthma requiring hospital admission for acute exacerbations were studied with spirometry (including IC) at admission and at discharge and had concurrent self-perceived resting dyspnea ratings recorded. Over the admission there were significant improvements in resting dyspnea for the COPD group only, and improvements in spirometric indices in the asthma group only. No significant correlations were found between changes in dyspnea and changes in IC, in terms of acute responses to bronchodilator and in response to treatment over the hospital admission. These data suggest that dynamic hyperinflation during acute exacerbations of COPD and asthma is not as sensitive an indicator of resting dyspnea as in stable disease. A role for IC monitoring in the management of acute exacerbations of these diseases has not been identified.
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