The Royal College of Physicians and Surgeons of Glasgow welcomes the National Confidential Enquiry into Patient Outcome and Death report, Inspiring Changes which has reviewed the provision and management of patients undergoing Non Invasive Ventilation (NIV) mainly for the management of Chronic Obstructive Pulmonary Disease (COPD). It is very supportive of the recommendations of the report in an important area of Medical Practice.
COPD is the second most common reason for hospital admissions throughout the UK. It is responsible for 25% of all deaths from lung disease. It is the fifth largest cause of death. Appropriate and timely treatment should available in our hospitals admitting acutely ill patients. NIV is not generally appropriate in patients with documented pneumonia.
The study which covered all areas of the UK, the Channel Islands and the Isle of Man highlighted the nature of pre-hospital care, indications for treatment, monitoring of patients and an escalation plan should treatment with NIV not be successful. It noted that because of coding issues the number of patients needing this treatment was underestimated. Of importance was that treatment with NIV was not always indicated and more appropriate care should be given. This follows the aims of Realistic Medicine. It identifies instances where treatment is inappropriate and where it needed escalated.
Significant gaps were identified in delivery of safe patient care in a growing number of patients given our aging population and the combination of COPD and obesity.
This report should alert Health Departments, Health Boards and Trusts to develop an action plan in line with the recommendations.
Each hospital requires a clinical lead responsible for safe implementation of a service, audit and governance. NIV needs to be coded separately. Monitoring with pulse oximetry, ECG and blood gases at appropriate intervals with an escalation plan for more intensive therapy if appropriate. Oxygen therapy needs to be appropriate in both the pre-hospital and hospital setting.
The recommendation that treatment should be started within one hour of blood gases is very challenging for some District General Hospitals as is the escalation plan to be put in place before the start of treatment.
The report also recommended an operational policy indicating areas where treatment should take place and staffing levels. Standards of documentation, prescription, monitoring of vital signs and clinical review were recommended.
Clinicians should consider referral of patients undergoing NIV to palliative care services, as this may be valuable for both active symptom control and end of life care. Following an episode of NIV, future treatment needs to be discussed with the patient to ensure good discharge planning and follow-up with involvement of the patient, the family and General Practitioner.
This is a timely report which has messages for all involved in the planning, provision of health care and treatment of patients with chronic lung disease such as COPD.
The report can be accessed below.
Non-invasive ventilation (NIV)
The provision of ventilatory support through the patient’s upper airway using a mask or similar device. This technique is distinguished from those which bypass the upper airway with a tracheal tube, laryngeal mask, or tracheostomy and are therefore considered invasive.
Chronic obstructive pulmonary disease (COPD)
This is a type of obstructive lung disease characterised by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum production. COPD is a progressive disease, meaning it typically worsens over time.
Pneumonia is swelling (inflammation) of the tissue in one or both lungs usually due to infection.