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Home Mechanical Ventilation in Sweden. Demography, Indications, Clinical Effects and Survival.

Laub, Michael LU (2006)
Abstract
Home mechanical ventilation in patients with chronic respiratory failure secondary to several different diseases has become widely acceptable as the provision of ventilatory support can provide symptomatic relief and increase life expectancy.



Aims: To study the selection criteria underlying the initiation of home mechanical ventilation and to quantify the effects of in relation to blood gases and lung function; to examine temporal changes in treatment prevalence in Sweden; to study survival and causes of death and demonstrate possible related impact factors.



Methods: Since January 1 1996 the nationwide Swedish Home Mechanical Ventilation Register prospectively has collected data on home ventilated... (More)
Home mechanical ventilation in patients with chronic respiratory failure secondary to several different diseases has become widely acceptable as the provision of ventilatory support can provide symptomatic relief and increase life expectancy.



Aims: To study the selection criteria underlying the initiation of home mechanical ventilation and to quantify the effects of in relation to blood gases and lung function; to examine temporal changes in treatment prevalence in Sweden; to study survival and causes of death and demonstrate possible related impact factors.



Methods: Since January 1 1996 the nationwide Swedish Home Mechanical Ventilation Register prospectively has collected data on home ventilated patients. The studies founding this thesis are based on data from this register. In the neuromuscular patients (N=352) we examined symptoms, clinical signs and physiological findings that were motivating the initiation of treatment. We studied the clinical effects of home ventilation over time in patients with sufficient follow up data (N=288) regardless of the underlying diagnosis. We looked at the temporal changes and geographic inequalities in the prescription of home ventilation in Sweden. We examined survival data for a period of ten years in 1526 patients and in 337 deceased patients we studied the causes of death.



Results: Daytime sleepiness was the most common clinical symptom motivating home mechanical ventilation in hypercapnic patients with neuromuscular diseases. The patients improved their daytime PO2 and PCO2 during spontaneous ventilation with approximately 1 kPa without a concomitant improvement in vital capacity after 6?24 months of treatment. We have found a medically justified continuing increase in the number of patients on HMV and an increasing proportion of Pickwickian patients. The evident dissimilarities in local prescription rates are not explained by different therapeutic criteria between the centres, but rather by differences in levels of ambition and/or problem recognition. The amyotrophic lateral sclerosis (ALS) group had by far the poorest survival rate. Survival was roughly in line with that in previous studies and predictors of increased risk for death in non-ALS patients were greater age, concomitant oxygen treatment, tracheostomy ventilation and launch of HMV in an emergent clinical setting. Acute start of ventilation and the use of concomitant oxygen were more frequent in small centres. In an eight-year period 1996 -2003 the cause of death was respiratory in 55% and cardiovascular in 31%. In the different patient categories there were apparent deviances from this pattern. We found more cardiovascular causes compared to previous reports and cardiac insufficiency may be underestimated as a terminal complication in home ventilation. This applies to the Pickwickian patients in particular.



Conclusions: In hypercapnic patients daytime sleepiness may be an important motive for starting HMV. Blood gases during spontaneous ventilation improve after start of treatment. The numbers of patients on home ventilation continue to increase (especially Pickwickian patients) and there are evident inequalities in local prescription rates in Sweden. ALS patients show by far the poorest survival, in the non-ALS patients a number of patient related factors affected survival. The hazard for cardiovascular death appears to be more significant than previously reported especially in the Pickwickian patients. (Less)
Abstract (Swedish)
Popular Abstract in Swedish

Respiratorbehandling i hemmet till patienter med kronisk underventilering (som kan bero på flera olika grundsjukdomar) har blivit allmänt accepterad, eftersom behandlingen kan ge symptomlindring och förbättrad överlevnad.



Syfte: Att undersöka vilka behandlingsmotiv som föranleder start av respiratorbehandling i hemmet och att kvantifiera effekterna av behandlingen på patienternas blodgaser och lungfunktion; att undersöka variationerna i behandlingsprevalensen i Sverige; att studera hur överlevnad och dödsorsaker beror på diagnos och vissa andra underliggande faktorer.



Metodik: Svenska hemrespiratorregistret har sedan 1 januari 1996 prospektivt samlat in data... (More)
Popular Abstract in Swedish

Respiratorbehandling i hemmet till patienter med kronisk underventilering (som kan bero på flera olika grundsjukdomar) har blivit allmänt accepterad, eftersom behandlingen kan ge symptomlindring och förbättrad överlevnad.



Syfte: Att undersöka vilka behandlingsmotiv som föranleder start av respiratorbehandling i hemmet och att kvantifiera effekterna av behandlingen på patienternas blodgaser och lungfunktion; att undersöka variationerna i behandlingsprevalensen i Sverige; att studera hur överlevnad och dödsorsaker beror på diagnos och vissa andra underliggande faktorer.



Metodik: Svenska hemrespiratorregistret har sedan 1 januari 1996 prospektivt samlat in data om patienter med respirator i hemmet. Studierna i denna avhandling baseras på data från detta register. Hos patienter med neuromuskulär sjukdom (n=352) undersökte vi vilka symptom, kliniska fynd och fysiologiska mätvärden som låg till grund för beslutet att starta behandling. Vi studerade de fysiologiska effekterna av längre tids behandling hos patienter med adekvata uppföljningsdata (n=288) oavsett grundsjukdom. Vi undersökte tidsmässiga förändringar och geografiska olikheter i förskrivning av respiratorbehandling i hemmet i Sverige. Vi undersökte överlevnadsdata under tio år hos 1526 patienter och hos 337 avlidna patienter studerade vi dödsorsakerna.



Resultat: Dagsömnighet var det vanligaste motivet för beslutet att starta behandling hos hyperkapniska patienter med neuromuskulär sjukdom. Patienterna föbättrade såväl PO2 som PCO2 med ca 1 kPa utan någon samtidig förbättring av vitalkapaciteten efter 6-24 månaders behandling. Vi finner en medicinskt välgrundad kontinuerlig ökning av antalet patienter och en ökning av andelen med Pickwicksyndrom. De uppenbara geografiska skillnaderna i antalet behandlade patienter kan inte förklaras utifrån olika behandlingskriterier, utan snarare i skillnader i ambitionsnivå eller problemigenkänning. Patienter med ALS har i särklass sämst överlevnad, på ungefär samma nivåer som i andra studier. Prediktorer för sämre överlevnad hos icke ALS-patienter var hög ålder, samtidig syrgasbehandling, respiratorbehandling via trakeostomi samt akut start av behandling. Kliniker med mindre patientunderlag hade en högre andel patienter som samtidigt fick syrgas och startade behandling akut. Under åttaårsperioden 1996-2003 var dödsorsaken respiratorisk hos 55% och kardiell hos 31%, med olika mönster i olika diagnosgrupper. Vi fann högre andel med kardiovaskulär död än i andra studier, och hjärtsvikt kan vara en underskattad komponent i det terminala förloppet hos patienter med respirator i hemmet. Detta gäller framför allt Pickwickpatienterna.



Slutsatser: Hos hyperkapniska patienter förefaller dagsömnighet att vara ett viktigt motiv för att starta respiratorbehandling i hemmet. Blodgaserna vid spontanandning förbättras efter en tids behandling. Antalet patienter ökar oavbrutet (framför allt Pickwickpatienter), och det föreligger inom Sverige stora skillnader i lokala förskrivningsvanor som inte förefaller medicinskt motiverade. ALS-patienterna har i särklass sämst överlevnad. Hos icke ALS-patienter påverkas överlevnaden av ett antal patientrelaterade faktorer. Risken för kardiell död är betydande, framför allt hos Pickwickpatienterna. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Gislason, Thorarinn, University Hospital, Reykjavik, Iceland
organization
publishing date
type
Thesis
publication status
published
subject
keywords
home mechanical ventilation, Andningsorganen, Respiratory system, causes of death, selection criteria, clinical effects, prevalence, temporal changes, survival, Chronic respiratory failure hypoventilation
pages
66 pages
publisher
Department of Respiratory Medicine and Allergology, Lund University
defense location
Segerfalksalen, Wallenbergs Neurocentrum, Sölvegatan 17, 221 85 Lund
defense date
2006-11-11 10:00:00
ISBN
91-85559-41-5
language
English
LU publication?
yes
additional info
id
64346665-3ea9-4589-8130-85eedf845f42 (old id 547404)
date added to LUP
2016-04-01 16:43:54
date last changed
2018-11-21 20:43:45
@phdthesis{64346665-3ea9-4589-8130-85eedf845f42,
  abstract     = {Home mechanical ventilation in patients with chronic respiratory failure secondary to several different diseases has become widely acceptable as the provision of ventilatory support can provide symptomatic relief and increase life expectancy.<br/><br>
<br/><br>
Aims: To study the selection criteria underlying the initiation of home mechanical ventilation and to quantify the effects of in relation to blood gases and lung function; to examine temporal changes in treatment prevalence in Sweden; to study survival and causes of death and demonstrate possible related impact factors.<br/><br>
<br/><br>
Methods: Since January 1 1996 the nationwide Swedish Home Mechanical Ventilation Register prospectively has collected data on home ventilated patients. The studies founding this thesis are based on data from this register. In the neuromuscular patients (N=352) we examined symptoms, clinical signs and physiological findings that were motivating the initiation of treatment. We studied the clinical effects of home ventilation over time in patients with sufficient follow up data (N=288) regardless of the underlying diagnosis. We looked at the temporal changes and geographic inequalities in the prescription of home ventilation in Sweden. We examined survival data for a period of ten years in 1526 patients and in 337 deceased patients we studied the causes of death.<br/><br>
<br/><br>
Results: Daytime sleepiness was the most common clinical symptom motivating home mechanical ventilation in hypercapnic patients with neuromuscular diseases. The patients improved their daytime PO2 and PCO2 during spontaneous ventilation with approximately 1 kPa without a concomitant improvement in vital capacity after 6?24 months of treatment. We have found a medically justified continuing increase in the number of patients on HMV and an increasing proportion of Pickwickian patients. The evident dissimilarities in local prescription rates are not explained by different therapeutic criteria between the centres, but rather by differences in levels of ambition and/or problem recognition. The amyotrophic lateral sclerosis (ALS) group had by far the poorest survival rate. Survival was roughly in line with that in previous studies and predictors of increased risk for death in non-ALS patients were greater age, concomitant oxygen treatment, tracheostomy ventilation and launch of HMV in an emergent clinical setting. Acute start of ventilation and the use of concomitant oxygen were more frequent in small centres. In an eight-year period 1996 -2003 the cause of death was respiratory in 55% and cardiovascular in 31%. In the different patient categories there were apparent deviances from this pattern. We found more cardiovascular causes compared to previous reports and cardiac insufficiency may be underestimated as a terminal complication in home ventilation. This applies to the Pickwickian patients in particular.<br/><br>
<br/><br>
Conclusions: In hypercapnic patients daytime sleepiness may be an important motive for starting HMV. Blood gases during spontaneous ventilation improve after start of treatment. The numbers of patients on home ventilation continue to increase (especially Pickwickian patients) and there are evident inequalities in local prescription rates in Sweden. ALS patients show by far the poorest survival, in the non-ALS patients a number of patient related factors affected survival. The hazard for cardiovascular death appears to be more significant than previously reported especially in the Pickwickian patients.},
  author       = {Laub, Michael},
  isbn         = {91-85559-41-5},
  language     = {eng},
  publisher    = {Department of Respiratory Medicine and Allergology, Lund University},
  school       = {Lund University},
  title        = {Home Mechanical Ventilation in Sweden. Demography, Indications, Clinical Effects and Survival.},
  year         = {2006},
}