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Non-invasive Home Ventilation for the treatment of chronic respiratory failure

By Daniel Schorre posted 01-30-2019 02:06

  
Over the past 2 1/2 years, I have had the privilege of providing care in the homes of patient's suffering from chronic respiratory failure secondary primarily to COPD. The care model we use is placing these patients on a Trilogy non-invasive home ventilator utilizing AVAPS-AE mode to help maintain CO2 levels, rest their respiratory muscles and provide a source of rescue for exertional shortness of breath. I was a hospital based RT for 10 years. I worked every area of the hospital. I saw patient "X" come into the ED with a COPD exacerbation, be placed on Bi-level NIPPV, pumped full of steroids and bronchodilators, brought back to as close to baseline as possible, and after 7 or so days, be released back home. I saw patient "X" return to our facility 6-8 weeks later - wash, rinse, repeat. Now, patient "X" is on a non-invasive home ventilator, staying out of the ED and living a better quality of life. 

Hospital based RTs have all seen patient "X" come into the acute care hospital, in fact, hospital based RTs see multiple patient "X"s an a day to day or at least week to week basis, but do we truly provide them with all the tools to thrive in the home setting? Most RTs can recite the home oxygen qualification criteria in their sleep. Some look at a COPD patient and think to themselves "you did it to yourself smoking", hand them their Q4 Duoneb, and walk away. But have you ever considered sending the patient home on a device to help control the CO2 levels, and not just worry about the O2 levels? We have all gotten the call "Patient "X" is short of breath and breathing hard but his sat is 96%." 

Let's think about it for a bit. If we can prevent a COPD exacerbation from happening, or at least reduce the occurrences of an exacerbation, then are we not providing better care for the patient? COPD is a very complex, progressive disease process. Patients exhibit air flow limitations, air trapping, and some have excessive mucus production. There are intrinsic and extrinsic factors that contribute to changes in lung compliance and airway resistance. 

When i speak to other RTs, and MDs about using non-invasive home ventilation for these patients, about 80% look at me like I am crazy. Then they say "the patient will never go for a sleep study" or "they already have a Bi-PAP at home." Both are semi-valid points, but they don't address the root of the problem - it's more than sleep apnea and 60% of the time it's not sleep apnea at all! 

Let's look at Bi-level NIPPV (Bi-PAP). In the world of sleep medicine, Bi-level NIPPV settings are titraited, typically in a facility based setting,  to maintain a patient airway for the treatment of Obstructive Sleep Apnea (OSA). The inspiratory pressure setting is high enough to keep the airway open on inhalation and the expiratory pressure setting is set low enough to maintain a patent airway on exhalation. While OSA can worsen over time with weight gain or other factors, it is a slow to very limited progression. When we think about using Bi-level NIPPV for ventilatory issues, is the simplest form of pressure limited, volume variable ventilation.  You set an inspiratory pressure, an expiratory pressure and the difference is essentially pressure support which determines your tidal volume. Tidal volume is directly impacted by lung compliance and airway resistance. Any intrensic or extrensic change in lung compliance or airway resistance will have a direct affect on tidal volume. Decreased lung compliance or increased airway resistance will decrease tidal volume which leads to hypoventilation. So say you were able to get patient "X" to go to a sleep study and they did not have OSA, they still have COPD and through the progression of the disease, they will still have intrensic and extrensic changes in lung compliance and airway resistance potentially leading to hypoventilation (COPD Exacerbation). the changes come in the form of increased mucus production, bronchoconstriction, airway edema, development of lung tissue scaring, development of brochiectasis, and other factors. Now, let's say the did have OSA or they already have a Bi-PAP because of OSA or they qualified for a Bi-PAP under the CMS RAD guidelines, but they are still coming back to you for COPD exacerbations. That's because Bi-PAP is not adequate enough to regulate tidal volume with changes in lung compliance and airway resistance as previously stated. They will come back to the hospital. Utilizing AVAPS-AE mode via a Trilogy non-invasive home ventilator allows for average tidal volume assurance  through auto-titraition of pressure support to ensure adequate ventilation regardless of changes in lung compliance or airway resistance based on prescribed settings. in addition, the auto-titraiting EPAP will help to overcome OSA overlap disease if it is present essentially treating both disease process at the same time.  

I was provided data from a recent study through KPMG titled "Mortality and Cost Study Analysis - A US based cost study analysis assessing the mortality, costs and hospitalization rates for NIV intervention." published July 27, 2018. This study looked at approximately 5% (roughly 18,000 patients) of all of medicare patients who were diagnosed with COPD and Chronic Respiratory Failure. It focused on determining if these patients were prescribed a RAD BiPAP (E0470/E0471 billing code) and Non-invasive Home Ventilator (E0466) or nothing at all. It then looked at 24 week mortality rate, inpatient spending, total cost of healthcare. The findings were pretty compelling.

Mortality Rate - Patient's left untreated or who were treated with a RAD alone showed a 38% mortality rate over the 24 week period. Those placed on non-invasive home ventilation had a relative reduction of 42% mortality rate compared to the other cohort. Conclusion - Non-invasive home ventilation saves lives.

Total Healthcare Cost - Patient's with no treatment, total 1 year cost of healthcare for these patient was averaged at $80, 600, those on a RAD device​ averaged $69, 500 and those on a non-invasive home vent was $55,300 when provided by by a specific DME company. Conclusion - Non-invasive home ventilation saves money.

Inpatient Spending - Patient's with no treatment saw an average inpatient cost of care of about $34,000. Patient's placed on a RAD device saw an increase in inpatient spending from $25,000 6 months prior to RAD initiation to $33,000 6 moths after RAD initiation. Those placed on non-invasive home ventilation saw a reduction in inpatient spending from $27,000 6 moths prior to initiation to $25,000 6 months after initiation. Conclusion - noninvasive home ventilation keeps patient's out of the hospital therefore decreasing inpatient spending  while patient's on RAD devices have a higher instance of hospitalization compared to Non-invasive home ventilation therefore increasing inpatient spending costs. 

If you would like a copy of the study, I will certainly provide it to you, but what I challenge you to do is think about "frequent flyer" patients and ask yourself "Am i doing all I can for that patient upon discharge to keep them from coming back?" If non-invasive home ventilation is not part of your home discharge plan specifically for COPD patients with chronic respiratory failure, then the answer to that questions is clearly "no."

I encourage you to have an open discussion on this topic.
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06-18-2019 12:25

Daniel - could you please send me a copy of the KPMG study.  This will be very helpful as we continue meetings on the Hill and with CMS on removing noninvasive vents from competitive bidding.

Thanks, Anne Marie (anneh@aarc.org)

05-09-2019 12:47

I am interested in a copy of this study.. Thank you for your time and effort.

mfrederickson@mcdh.net

04-25-2019 14:45

​Daniel,

Yes please email me a copy of the study. We are working very hard to reduce readmissions, this information is very helpful.

03-23-2019 09:40

Daniel;
Quite effective and reasonable approach to management of these complex patients.  Great work sir!