Abstract
BACKGROUND: Use of noninvasive ventilation (NIV) for the treatment of patients with acute respiratory failure (ARF) has greatly increased in the last decades. In contrast, the increasing knowledge of its effectiveness and physician confidence in managing this technique have been accompanied by a declining number of available ICU beds. As a consequence, the application of NIV outside the ICU has been reported as a growing phenomenon. Previously published surveys highlighted a great heterogeneity in NIV use, clinical indications, settings, and efficacy. Moreover, they revealed a marked heterogeneity with regard to staff training and technical and organizational aspects. We performed the first worldwide web-based survey focused on NIV use in general wards for ARF.
METHODS: A questionnaire to obtain data regarding hospital and ICU characteristics, settings and modalities of NIV application and monitoring, estimated outcomes, technical and organizational aspects, and observed complications was developed. The multiple-choice anonymous questionnaire to be filled out online was distributed worldwide by mail, LinkedIn, and Facebook professional groups.
RESULTS: One-hundred fifty-seven questionnaires were filled out and analyzed. Respondents were from 51 countries from all 5 continents. NIV application in general wards was reported by 66% of respondents. Treatments were reported as increasing in 57% of cases. Limited training and human resources were the most common reasons for not using NIV in general wards. Overall, most respondents perceived that NIV avoids tracheal intubation in most cases; worsening of ARF, intolerance, and inability to manage secretions were the most commonly reported causes of NIV failure.
CONCLUSIONS: Use of NIV in general wards was reported as effective, common, and gradually increasing. Improvement in staff training and introduction of protocols could help to make this technique safer and more common when applied in general wards setting.
Introduction
The use of noninvasive ventilation (NIV) for the treatment of patients with acute respiratory failure (ARF) has greatly increased in the last decades.1 Early treatment with NIV is of crucial importance to improve a patient's outcome because it has been demonstrated to reduce the need for tracheal intubation, ICU stay, and re-intubation rates in different patient groups.2–4 However, the increasing awareness of the effectiveness of NIV has been accompanied, worldwide, by a declining number of available ICU beds over the years. This shortage, together with an increased confidence of physicians in managing this technique, has resulted in the increased use of NIV outside the ICU. Preliminary reports confirmed NIV efficacy even in a general ward setting.5 Previously published surveys performed on this topic highlighted a great heterogeneity in NIV use, clinical indications, settings, and efficacy in general wards.6–16 Moreover, they revealed a marked heterogeneity even with regard to staff training and technical and organizational aspects of NIV use. We therefore performed the first worldwide web-based international survey focused on NIV use in general wards for ARF.
QUICK LOOK
Current knowledge
The use of noninvasive ventilation (NIV) for the treatment of exacerbations of COPD has increased markedly over the last decade owing to growing evidence demonstrating improved outcomes. Growth of NIV outside of intensive care has been variable based on indication and geography.
What this paper contributes to our knowledge
A worldwide survey of NIV suggests that use outside the ICU is increasing. The survey identified lack of training and protocols as impediments to safe and effective use on the general floor.
Methods
We developed a questionnaire to obtain data regarding hospital, general ward (outside ICU, non-monitored ward) or respiratory intermediate unit (characterized by a nurse/patient ratio of 1:3–1:4, multivariable monitors, NIV or invasive ventilation allowed, immediate availability of a physician)17; ICU characteristics, settings, and modalities of NIV application and monitoring; perceived outcomes; technical and organizational aspects; and observed complications. The questionnaire was evaluated for clarity and relevance by an international panel of NIV experts (see the supplementary materials at http://www.rcjournal.com). In October 2013, the multiple-choice questionnaire was sent by mail (using all the pertinent mailing lists available to us), LinkedIn, and Facebook professional groups via a link to Maian Survey, a free online survey system. The questionnaire was anonymous, and the collected answers were automatically tabulated in a web Excel worksheet.
Results
One-hundred fifty-seven questionnaires were filled out online and analyzed. Respondents were from 51 countries (Table 1).
Location of Respondents' Hospitals
The characteristics of the respondents' hospitals are listed in Table 2. In 66% of the hospitals, NIV was applied in general wards. Limited training and limited human resources were the most common reported reasons from centers not using NIV in general wards; very few respondents reported doubts of its efficacy.
Characteristics of the Respondents' Hospitals and Settings of NIV Use
In 57% of cases, NIV treatment in general wards was reported as increasing. Training had been performed before NIV introduction in general wards in 49% of cases; periodic education was available in 58% of the centers. In 61% of the centers, once started on NIV, the patient was always or often left in the initial ward, whereas only 19% of respondents never left the patients on NIV in an general ward.
The ventilators commonly belonged to the ICU or the pulmonology ward, whereas in only 4% of cases, every ward had its own devices. A trend toward an increase in the number of CPAP/NIV devices was reported by 59% of respondents.
Treatments were often not protocolized (see Table 2). Pulmonologists and intensivists prescribed NIV in most hospitals; however, in 29% of cases, ward physicians could prescribe NIV autonomously. In 32% of hospitals, the physician authorized to prescribe NIV was not continuously present; accordingly, the nursing staff and ward physician had a relevant role in the management of NIV, as reported by two thirds of respondents.
Treated diseases and monitoring aspects are summarized in Tables 3 and 4. In Table 5, the most common complications are reported. Overall, most respondents perceived that NIV was successful in most cases (Table 6); worsening of ARF, intolerance to the interface, and inability to manage secretions were the most commonly reported causes of NIV failure (Table 7).
Causes of ARF Treated by NIV Outside the ICU
Reported Standard Monitoring for NIV Treatments Outside the ICU
Complications or Problems Reported in Patients Receiving NIV
Perceived NIV Success Rate in General Wards
Causes of NIV Failure in General Wards
Discussion
This study is the first international survey focusing on NIV for ARF in general non-monitored wards. The limited number of respondents compared with the huge number of hospitals in the world makes our data preliminary: our results should not be generalized or considered representative of all hospitals worldwide. This bias limits also the value of comparisons with other surveys. Nevertheless, our original results offer a basis for future larger studies.
The results from our study, including respondents from all 5 continents, suggests that NIV use in general wards is common and growing worldwide. In a recent survey among the members of the Noninvasive Ventilatory Support Group of the European Respiratory Society, NIV use in general (mainly pulmonary) wards was reported as common.16 The percentage of hospitals using NIV in general wards is increasing: from < 10% in 20059 to 66% in our survey. As reported in previous studies,6,7,9 in most hospitals, NIV is prescribed only in some hospital wards, and once the treatment is started, patients generally remain in their wards. The main reason for this phenomenon is likely the overall respondents' perception of NIV efficacy. In fact, > 50% of respondents believed that NIV was successful in more than half of cases. This percentage is doubled compared with the percentages reported in previous surveys.6,7 Nevertheless, the perceived success rate is still lower than the success rates reported in most published studies on NIV4: NIV efficacy in general wards should be further improved, and simple interventions to achieve this aim seem at hand. As an example, nearly 42% of respondents attributed NIV failure to poor patient compliance with the interface: a careful, better choice and management of the most comfortable interface could likely be obtained through better staff training.
In addition to well-established indications such as acute pulmonary edema and COPD exacerbation, NIV is also commonly used in conditions in which response to NIV is less clear, such as asthma. Moreover, use for indications with a known high failure rate, such as pneumonia, in non-immunocompromised patients has been reported. These results are comparable with those reported by Cabrini et al6 in 2011, with the exception of neuromuscular diseases, which was a much more prevalent cause for NIV use outside the ICU in our survey (77% vs 38%).
In general, NIV should not be used in general wards when its efficacy is uncertain, at a minimum, and better monitored settings are preferred. However, the reported data do not necessarily imply that there is a lack of awareness about NIV failure risk; on the contrary, they could merely demonstrate that better monitored beds are often unavailable, forcing physicians to manage ARF in suboptimal settings. Nevertheless, awareness of NIV limitations and risks should be promoted: mandatory preliminary training and the use of a protocol could be of help if NIV is to be administered in non-monitored wards.
Finally, lack of training and limited human and financial resources (not monitored wards) are the most common reported reasons for not using NIV in general. Despite the increasing data on NIV efficacy, in particular when applied early,2 a relevant percentage of hospitals have not yet decided to invest in this field. It is worth noting that the cost effectiveness of NIV outside the ICU has already been demonstrated.18,19
NIV use in general wards is an area of research that has been largely neglected compared with studies performed in ICUs. The fact that almost all published studies on NIV were performed in ICUs could be misleading, as the results might not accurately represent where NIV is currently used in the real world. Our study suggests that research on NIV use outside the ICU is urgently required.
Limitations
Our survey has some limitations. We (experienced in both NIV and surveys) developed the questionnaire, and it was reviewed by a larger number of international experts; however, the questionnaire did not undergo a full evaluation process. Information about the criteria used to define respiratory failure in every center and the severity of the respiratory failure was not collected: future surveys should consider these issues to better understand which patients are currently treated on general wards. Data on NIV performed in general wards on do-not-intubate patients or patients considered unfit for ICU admission (or who refused intubation or ICU admission) were not collected; these data would have been of help in better evaluating the use of NIV for controversial indications, such as asthma and pneumonia, in general wards. The hospitals that agreed to participate in the survey are not representative of all hospitals worldwide. Therefore, comparisons with previous studies should be made with caution. Moreover, the number of respondents was rather limited. Because the questionnaire was distributed by social media, we do not know how many people were contacted; for the same reason, we cannot report the responding rate among the different countries or different types of hospitals. However, the aim of the survey was to offer a first look at NIV use outside the ICU. We consider our effort successful, as hospitals from all 5 continents returned the questionnaire. We did not collect data on the profession or specialization of the respondents; respondents could report different complementary data or perceptions about NIV use. Finally, we explored a limited number of NIV aspects: future surveys should focus on specific aspect such as protocols, organization, association between NIV use on general wards and shortage of ICU beds, and physicians' preferences.
Conclusions
Based on this first international survey, NIV is often applied in general wards, and its use is increasing. Criticalities such as lack of training and protocols are reported and should be addressed to make NIV use safer and more effective. Further research in this area is required.
Footnotes
- Correspondence: Laura Pasin MD, Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy. E-mail: pasin.laura{at}hsr.it.
Supplementary material related to this paper is available at http://www.rcjournal.com.
The authors have disclosed no conflicts of interest.
- Copyright © 2015 by Daedalus Enterprises
