BACKGROUND: Noninvasive ventilation (NIV) is standard of care for chronic hypercapnic respiratory failure, but indications, devices, and ventilatory modes are in constant evolution.RESEARCH QUESTION: To describe changes in prevalence and indications for NIV over a 15-year period; to provide a comprehensive report of characteristics of the population treated (age, comorbidities, and anthropometric data), mode of implementation and follow-up, devices, modes and settings used, physiological data, compliance, and data from ventilator software. STUDY DESIGN AND METHODS:Cross-sectional observational study designed to include all subjects under NIV followed by all structures involved in NIV in the Cantons of Geneva and Vaud (1,288,378 inhabitants).RESULTS: A total of 489 patients under NIV were included. Prevalence increased 2.5-fold since 2000 reaching 38 per 100,000 inhabitants. Median age was 71 years, with 31% being > 75 years of age. Patients had been under NIV for a median of 39 months and had an average of 3 AE 1.8 comorbidities; 55% were obese. COPD (including overlap syndrome) was the most important patient group, followed by obesity hypoventilation syndrome (OHS) (26%). Daytime PaCO 2 was most often normalized. Adherence to treatment was satisfactory, with 8% only using their device < 3.5 h/d. Bilevel positive pressure ventilators in spontaneous/timed mode was the default mode (86%), with a low use of autotitrating modes. NIV was initiated electively in 50% of the population, in a hospital setting in 82%, and as outpatients in 15%.INTERPRETATION: Use of NIV is increasing rapidly in this area, and the population treated is aging, comorbid, and frequently obese. COPD is presently the leading indication followed by OHS.
Peritoneal tuberculosis (PT) is uncommon in industrialized countries. We report the case of a 35-y-old female with a 1-y history of abdominal discomfort, ascites, systemic symptoms, and highly elevated CA-125 suggesting malignancy, in whom the diagnosis of PT was considered. Both clinical symptoms and CA-125 levels regressed under tuberculostatic treatment.
<b><i>Background:</i></b> Long-term noninvasive ventilation (LTNIV) is widely used in patients with chronic hypercapnic respiratory failure (CHRF) related to COPD. Prognosis of these patients is however poor and heterogenous. <b><i>Research Question:</i></b> In COPD patients under LTNIV for CHRF, is it possible to identify specific phenotypes which are predictive of probability of pursuing NIV and survival? <b><i>Study Design and Methods:</i></b> A latent class analysis was performed in a COPD population under LTNIV included in a comprehensive database of patients in the Geneva Lake area, to determine clinically relevant phenotypes. The observation period of this subgroup of COPD was extended to allow assessment of survival and/or pursuit of NIV for at least 2 years after inclusion. A logistic regression was conducted to generate an equation accurately attributing an individual patient to a defined phenotype. The identified phenotypes were compared on a series of relevant variables, as well as for probability of pursuing NIV or survival. A competitive risk analysis allowed to distinguish death from other causes of cessation of NIV. <b><i>Results:</i></b> Two phenotypes were identified: a “respiratory COPD” profile with very severe airway obstruction, a low or normal body mass index, and a low prevalence of comorbidities and a “systemic COPD” profile of obese COPDs with moderate airway obstruction and a high rate of cardiovascular and metabolic comorbidities. The logistic regression correctly classified 95.7% of patients studied. Probability of pursuing NIV and survival were significantly related to these phenotypes, with a poorer prognosis for “respiratory COPD.” Probability of death 5 years after implementing NIV was 22.3% (95% CI: 15.4–32.2) for “systemic COPD” versus 47.2% (37.4–59.6) for “respiratory COPD” (<i>p</i> = 0.001). <b><i>Conclusion:</i></b> The two distinct phenotypes of COPD under LTNIV for CHRF identified appear to be strongly related to prognosis and require further validation in other cohort studies.
Background: Use of adaptive servo-ventilation (ASV) has been questioned in patients with central sleep apnea (CSA) and chronic heart failure (CHF). This study aims to detail the present use of ASV in clinical practice. Methods: Descriptive, cross-sectional, multicentric study of patients undergoing long term (≥3 months) ASV in the Cantons of Geneva or Vaud (1,288,378 inhabitants) followed by public or private hospitals, private practitioners and/or home care providers. Results: Patients included (458) were mostly male (392; 85.6%), overweight [BMI (median, IQR): 29 kg/m 2 (26; 33)], comorbid, with a median age of 71 years (59-77); 84% had been treated by CPAP before starting ASV. Indications for ASV were: emergent sleep apnea (ESA; 337; 73.6%), central sleep apnea (CSA; 108; 23.6%), obstructive sleep apnea (7; 1.5%), and overlap syndrome (6; 1.3%). Origin of CSA was cardiac (n = 30), neurological (n = 26), idiopathic (n = 28), or drug-related (n = 22). Among CSA cases, 60 (56%) patients had an echocardiography within the preceding 12 months; median left ventricular ejection fraction (LVEF) was 62.5% (54-65); 11 (18%) had a LVEF ≤45%. Average daily use of ASV was [mean (SD)] 368 (140) min; 13% used their device <3:30 h. Based on ventilator software, apnea-hypopnea index was normalized in 94% of subjects with data available (94% of 428). Conclusions: Use of ASV has evolved from its original indication (CSA in CHF) to a heterogeneous predominantly male, aged, comorbid, and overweight population with mainly ESA or CSA. CSA in CHF represented only 6.5% of this population. Compliance and correction of respiratory events were satisfactory.
Background: Noninvasive ventilation (NIV) is accepted as standard of care for chronic hypercapnic respiratory failure (CHRF) and is being increasingly implemented in older subjects. However, little is known regarding the use of NIV on a long-term basis in the very old. The outcomes of this study were: 1/to report the proportion of patients ≥ 75 years old (elderly) among a large group of long-term NIV users and its trend since 2000; 2/to compare this population to a younger population (<75 years old) under long-term NIV in terms of diagnoses, comorbidities, anthropometric data, technical aspects, adherence to and efficiency of NIV. Methods: In a cross-sectional analysis of a multicenter cohort study on patients with CHRF under NIV, diagnoses, comorbidities, technical aspects, adherence to and efficiency of NIV were compared between patients ≥ 75 and <75 years old (chi-square or Welch Student tests). Results: Of a total of 489 patients under NIV, 151 patients (31%) were ≥ 75 years of age. Comorbidities such as systemic hypertension (86 vs. 60%, p < 0.001), chronic heart failure (30 vs. 18%, p = 0.005), and pulmonary hypertension (25 vs. 14%, p = 0.005) were more frequent in older subjects. In the older group, there was a trend for a higher prevalence of chronic obstructive pulmonary disease (COPD) (46 vs. 36%, p = 0.151) and a lower prevalence of neuromuscular diseases (NMD) (19 vs. 11%, p = 0.151), although not significant. Adherence to and efficacy of NIV were similar in both groups (daily use of ventilator: 437 vs. 419 min, p = 0.76; PaCO 2 : 5.8 vs. 5.9 kPa, p = 0.968). Unintentional leaks were slightly higher in the older group (1.8 vs. 0.6 L/min, p = 0.018). Conclusions: In this cross-sectional study, one third of the population under NIV was ≥ 75 years old. Markers of efficacy of NIV, and adherence to treatment were similar when compared to younger subjects, confirming the feasibility of long-term NIV in the very old. Health-related quality of life was not assessed in this study and further research is needed to address this issue.
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