1995 OPEN FORUM Abstracts
USE OF A REGISTRY & RESPIRATORY THERAPIST-DRIVEN PROTOCOL FOR NON-INVASIVE ASSISTED VENTILATION (NAV) IN THE HOSPITAL SETTING.
Allen G. Kendall RRT. Arlene Wenzel RN, Peter C. Gay MD. Mayo Foundation. Rochester. Mn. 55905.
The use of NAV has rapidly increased in the hospital setting but there are no definitive indications for its use nor uniformity of application of this equipment. In order to improve delivery and follow-up care of patients (pts) receiving NAV in the hospital setting. we developed a therapist-driven protocol and monitored patient use with a nasal ventilation registry. The registry was used to track indications, equipment utilized. documentation of need, and outcome in all pts who were introduced to NAV in the hospital setting from 1988 to 1994. The registry included 5 pediatric pts and 119 adult pts with the following diagnoses: COPD- 38 pts: ALS- 18 pts: other neuromuscular disease- 21 pts: primary hypoventilation- 14 pts: kyphoscoliosis- 14 pts: obesity hypoventilation- 14 pts: other- 5 pts. Patients were introduced to this therapy in the following locations: ICU- 88 pts: general ward- 22 pts: sleep lab- 7 pts: chronic vent unit- 5 pts: and 2 pts were introduced in other skilled areas. There were 83 pts who utilized a bilevel pressure device and 41 pts used a portable volume ventilator with 115 pts beginning via nasal mask and 9 initiating with a full face mask. Thirty seven patients had used some type of assisted ventilation prior to entering the registry and approximately 25% of the patients preferred a do not resuscitate status on admission to the hospital. The mean total hospital days for these pts was 10.9 ± 9.1 (Std Dev) with a mean total hours of assisted ventilation of 120.3 ± 94.6 hours. There were 80 pts who continued with this treatment after the introduction phase that were either stabilized (46 pts) or improved (34 pts). Forty-four pts discontinued NAV after the introductory phase either by refusal- 13 pts. rapid stabilization or improvement- 11 pts. opting for CPAP- 8 pts. expiring- 8 pts: or requiring intubation or tracheostomy- 4 pts. In the 80 pts. who continued NAV after hospital discharge, the documentation for continued use was provided by overnight oximetry- 29 pts, polysomnograhy- 27 pts. or arterial blood gases and clinical judgment- 24 pts. The outcome of these 80 continuing pts when seen at various times for first follow up is as noted: stable or improved- 44 pts: worse- 7 pts: later discontinued- 11 pts: and lost to follow up- 18 pts. We concluded that 35.5% of pts that are introduced to NAV in the hospital setting were not able to tolerate this. Of the patients available for follow-up who were discharged to home with assisted ventilation, the majority (51 of 62 pts or 82.3%) continued this treatment. More formal documentation of the need for this ongoing treatment was not provided by overnight oximetry or polysomnography in many (24) of 80 pts or 30%). We continue to use this registry to better establish indications. refine the introduction, urge documentation of continued use, and improve follow-up for patients using NAV.