Pregabalin seems to be an effective and well-tolerated anti-epileptic drug when used as add-on treatment in patients with refractory partial epilepsy.
Background and objectives: Non-invasive ventilation (NIV) is increasingly used for patients presenting with acute hypercapnic respiratory failure (AHRF), however although studies have demonstrated clear benefit in patients with COPD there is little evidence to guide treatment for AHRF unrelated to COPD, particularly outside of the critical care unit. The current survey reports the use of NIV, predominantly delivered in a dedicated NIV unit, in patients with AHRF unrelated to COPD.Methods: Patients were included in this retrospective cohort survey if they had AHRF (pre-NIV pH<7.35 and PaCO 2 >6.0 kPa) unrelated to COPD and were managed with NIV. The primary outcome measure was survival to discharge with secondary outcomes of survival to 30, 90 and 365 days.Results: From 132 patient episodes requiring NIV, 79.55% survived to discharge, which is greater than previously reported outcomes for the use of NIV in COPD. Survival was independently associated with age but not pre-NIV pH, O 2 or diagnosis. Conclusions:NIV is a safe and effective treatment and can be considered for use in patients with AHRF unrelated to COPD in specialist NIV units. Further prospective studies are required to identify further important prognostic features in this group of patients.
IntroductionThere are over 4000 acute mask application episodes coded in the treatment of acute respiratory failure in the UK every month according to a 2017 survey (NCEPOD). Most guidelines on acute NIV use suggest good skin care strategies including regular mask pressure relief. However, data on the magnitude of the problem of nasal bridge pressure ulceration and the effect of proactive preventative steps (e.g., hydrocolloid dressings) remains scant. A previous smaller but similar survey in a district general hospital showed a trend in the reduction of Grade2 Pressure ulcer rates following change in practice but fell short of statistical significance (Stygall G, Morley K, Pickup L, et al. Thorax 2016. 71:3. A124–125.). We set out on a quality improvement project and systematically examined the effect of a proactive approach to prevent Grade2 Pressure ulcers in a dedicated ward-based Physiotherapy-led acute NIV service in a teaching hospital serving a population of about 4 00 000.MethodsIn addition to the routine acute NIV data for the unit, additional data was collected from 30/10/14 to 31/08/2015 on: NIV mask used (model and size), total number of admissions with days of NIV (NIV bed-days) and nasal bridge tissue viability grading. This included a 12 month period before (period1) and a 12 month period after (period2) the introduction of the proactive prevention approach. A pressure ulcer was defined as Grade2 or above. Pearson’s chi-squared test for comparison between groups and Fisher’s exact test were applied to assess significance.Results[See Table] In period1, there were 161 admissions and 9 Grade2 pressure ulcers from 666 NIV bed-days (ulceration rate=9/666); in period2 there were 134 admissions and 0 pressure ulcers from 718 NIV bed-days (ulceration rate=0/718). There was a statistically significant reduction in Grade2 Pressure ulceration rates (Pearson’s chi-square statistic=7.786; p-value=0.0013 in period2 compared to period1).ConclusionsApplication of an early prophylactic pressure-relieving hydrocolloid nasal dressing reduces the chance of developing Grade2 pressure ulcers in patients using NIV acutely. Further longitudinal studies including data on a preventative approach towards NIV-related nasal bridge pressure ulceration are needed to confirm the utility of this approach.Abstract P125 Table 130/10/14 – 29/10/1512mth period – BEFORE preventative strategy introduced(PERIOD1) Commencement date of application of proactive preventative hydrocolloid nasal dressings in acute NIV set ups: 30/10/1530/10/15-29/10/1612mth period – AFTER preventative strategy introduced(PERIOD2) NIV Admissions161134 Total NIV duration (NIV bed-days)666718 Grade2 Nasal bridge pressure ulcers90 The Pearson’s chi-square statistic is 7.786 with a p-value of 0.005. Therefore there were significantly fewer Grade2 Nasal bridge pressure ulcers for Period 2. Since the number of Grade2 Nasal bridge pressure ulcers is less than 5 in one of the cells, a Fisher’s exact test was performed, which yields a p-value of 0.0013 indicating hi...
Introduction NIV for acute hypercapnic respiratory failure (AHRF) in COPD, obesity related morbidity, chest wall and neuromuscular conditions has become widespread in the UK over the past decade. In terms of acute NIV set up, the BTS/Royal College of Physicians/Intensive Care Society 2008 guidance recommends starting with an inspiratory positive airway pressure (IPAP) of 10 cm H2O and expiratory positive airway pressure(EPAP) of 4–5 cmH2O, with small increments in IPAP aiming for apressure target of 20 cm H2O or until therapeutic response is achieved. We felt it necessary to analyse trends in maximum pressures achieved in the evolution of a respiratory ward-based NIV Unit (established2004). Methods Comparison of the in-house NIV registry data01/08/2004 –31/01/2006(Period 1) with 01/01/2011–30/06/2012 (Period 2) at an 11-bedded ward-based NIV unit within a1000-bedded hospital Trust in central England, looking at maximum IPAP and maximum EPAP achieved. There were 281 episodes of AHRF treated in Period 1 and 240 in Period 2 with similar distribution of gender. Results Maximum IPAP achieved for period 2 was significantly higher than period 1 (median IPAP max achieved=20 cmH2O vs. 14 cmH2O; Wilcox on rank sum test p=2.2 × 10–16) and the maximum EPAP achieved for period 2 was higher than period 1 (median EPAP max achieved=5 cmH2O vs. 14 cmH2O; Wilcoxonrank sum test p=8.068 × 10–6). Discussion We have previously shown that we achieved adequate therapeutic response with median IPAP max of 16.7 and median EPAP max of 5.2 cmH2O (Ali A et al. Pressure support in acute hypercapnic respiratory failure in an acute clinical setting. European Respiratory Journal 2011; 38:55. 683s.). However, as the ward-based, physiotherapy-intensive, multidisciplinary NIV service matures over an 8-year period, we are achieving significantly higher maximum IPAP and maximum EPAP. This is probably (a) in keeping with the increasing severity of AHRF that is being treated in the unit with similar in-hospital mortality (around 22%) and (b) demonstrates a learning curve. Further analysis of population characteristics and comparison with units of similar size may give further insights intoorganisational learning in relation to NIV. Abstract P220 Figure 1 Comparison of the distribution of the maximum IPAP achievedComparison of the distribution of the maximum EPAP achieved
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