Outcome of Patients Treated With Noninvasive Ventilation by a Medical Emergency Team on the Wards: Scarce and Probably Secure and Resourceful Monitoring in Select Subjects—Reply

In Reply:

We reviewed the comments by Killen H Briones Claudett. Of 238 subjects, we excluded the ones who were immediately transferred to the ICU. These subjects were deemed to be ICU candidates during the initial medical emergency team (MET) evaluation and were not the focus of our study. Nonetheless, their characteristics are outlined in Table 1.

As mentioned in our study results, we used newer versions of CPAP or bi-level positive airway pressure machines in 44 subjects. The more advanced pressure controlled ventilation and average volume-assured pressure support modes were utilized in only 7 subjects. Newer generations of ventilators provide volume-controlled, pressure-controlled, and pressure support ventilation.¹ Most of these newer generation noninvasive ventilators are equipped with monitoring parameters such as exhaled tidal volume, minute volume, leak check, and breathing frequency.² This makes it easier for clinicians to monitor patient response, and in our opinion, ventilators are now much safer for use on the wards. In less resourceful areas where very old generation ventilators are still being used, our results may not apply.

Respiratory care units (RCUs) are a good option in hospitals that have this facility. However, to our knowledge, no one has looked at outcome differences between subjects managed on the ward in the context of an MET and managed in these RCUs. If a patient can be managed safely on the ward, it would be prudent to use these RCU beds for other patients requiring more aggressive care or observation.

The duration of the MET call in our study was 82–118 min (not hours), favoring the noninvasive ventilation group. This duration is much less than the time these subjects would spend in the ICU or specialized RCUs. In our opinion, this short duration of close monitoring by an MET of select subjects on the wards can help reduce already strained health care resources.

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