1. Successful wireless monitoring and therapy alteration in home NIV: proof of principle
Karen Ward, Verity Ford, Helen Ashcroft, Sara Wordingham-Baker,
Robert Angus, Biswajit Chakrabarti, Nick Duffy, Robert Parker
Aintree University Hospital NHS Foundation Trust
Background
Results
Table 1: Demographics and diagnosis
Figure 1: Start data, Patient A
Table 2: 90-day outcomes, Patient A
Patient A B C
Age
(years) 57 62 65
Gender
(M/F) M F
Diagnosis
Idiopathic
diaphragm weakness
Kypho-scoliosis
OSA/OHS
Patient A
90-day period
Compliance, hours/day (mean)
7.3
Usage, days (%) 99
Leak, LPM (median)
2.2
Tidal volume, mL (median)
1038
Minute ventilation, LPM (median)
14.7
Wireless monitoring and titration of therapy has previously been reported in CPAP (Dellaca et al, 2011); to date, one European centre has described this in non-invasive ventilation (NIV; Pinto et al, 2010).
This technology is now available in a standard UK NIV device (ResMed Lumis 150 VPAP ST-A), but has not yet been explored in clinical practice.
The Liverpool Sleep and Ventilation Service provides complex home ventilation, serving approx patients with NIV; referrals are accepted from other centres in the region. This entails significant travel for many patients, at NIV initiation and subsequent follow-up.
The ability to offer remote NIV titration and monitoring could allow clinical review without the need for the patient to attend clinic, or undertake elective admission.
Three patients were reviewed over 90 days (Table 1).
Ventilator interaction data has been visible since start of NIV, via the ResMed AirViewTM platform (Figs 1-4).
Patient A: Satisfactory compliance, tidal volume and minute ventilation seen (Figure 1) and no changes made. Outcomes sustained at 90 days (Table 2).
Patient B: History of 2 previous elective admissions for reasons of difficult ventilator titration, and high levels of mask leak. Seen to exceed leak recommendations for this device and circuit (24LPM) at 14 days (Figure 2). Setting changes made remotely, avoiding 110km travel; median leak improved at 24.9LPM (Figure 3, Table 2).
Patient C: Remote data revealed poor compliance with NIV but effective ventilation (Figure 4). Unable to effect improved usage; unchanged at 90 days (Table 4).
All patients achieved adequate ventilation as measured by tidal volume (Tables 2-4) and minute ventilation (Figure 5).
Legend: LPM = litres per minute.
Figure 2: Start data, Patient B
Figure 3: End data, Patient B
Table 3: Outcomes, Patient B
Patient B
First 14-
day period
Last 14-
Leak, LPM
53.9
24.9
Tidal volume, mL
1106
934
Respiratory rate, BPM 14
Minute ventilation, LPM
13.0
12.5
Aims
Pilot evaluation of:
Data transfer, from device to online platform
Remote modification of ventilator settings
Effectiveness of NIV therapy by this device
Discussion and Conclusions
Remote titration and monitoring of CPAP has been described (n=20) in patients with Obstructive Sleep Apnoea/Hypopnoea syndrome (Dellaca et al, 2011); similar exploratory work has been done amongst Amyotrophic Lateral Sclerosis patients using NIV altered via modem (n=20, Pinto et al, 2010).
This pilot demonstrates remote NIV titration and monitoring is effective, and now available in the UK.
For all three patients, remote monitoring yielded clinically relevant data which obviated travel and facilitated review.
Amongst select patients, remote titration has the potential to enable radical service redesign of NIV initiation and follow-up; future work will explore this capability.
Methods
Patients were considered for treatment with ResMed Lumis 150 VPAP ST-A ventilators from November 2015 onwards. Three machines were available for trial. Patients were considered eligible for trial if new to NIV, or already established on NIV. Issue of Lumis 150 VPAP ST-A was done in outpatient and inpatient settings. Patients with known or predicted ventilator dependency were not included.
Wireless monitoring was activated at time of ventilator issue, via the ResMed AirViewTM platform. Data review was undertaken at 28 and 90 days, and at times of clinical need.
Clinical outcomes reviewed included:
Ventilator usage and compliance
Leak
Pressure
Tidal volume
Respiratory rate
Minute ventilation
28 days data was available at time of abstract submission; 90 days data has since been received from all three users.
Legend: Data are median; LPM = litres per minute, BPM = breaths per minute.
Figure 4: Start data, Patient C
Table 4: 28- and 90-day outcomes, Patient C
Figure 5: Ventilator effectiveness
Patient C
First 28-
day period
90-day period
Compliance, hours/day used (mean)
2.1
2.0
Usage, days (%) 68 36
Leak, LPM (median)
20.5
20.4
Tidal volume, mL (median)
697
619
Minute ventilation, LPM (median)
11.4
10.1
References
Dellaca R, Monserrat JM, Govoni L, Pedotti A, Navajas D, Farre R. Telemetric CPAP titration at home in patients with sleep apnea-hypopnea syndrome. Sleep Medicine 2011; 12: p153-7.
Pinto A, Almeida JP, Pinto S, Pereira J, Oliveira AG, de Carvalho M. Home telemonitoring of non-invasive ventilation decreases healthcare utilisation in a prospective controlled trial of patients with amyotrophic lateral sclerosis. Journal of Neurology, Neurosurgery and Psychiatry 2010; 81: p
Legend: LPM = litres per minute.
Legend: LPM = litres per minute.