Background: Patients with chronic obstructive pulmonary disease (COPD) pose a significant burden to healthcare providers with frequent exacerbations necessitating hospital admission. Randomised controlled data exist supporting the use of acute non-invasive ventilation (NIV) in patients with exacerbations of COPD with mild to moderate acidosis. The use of NIV is also described in chronic stable COPD, with evidence suggesting a reduction in hospital admissions and general practitioner care. We present economic data on the impact of domiciliary NIV on the need for admission to hospital and its attendant costs. Methods: A cost and consequences analysis of domiciliary NIV based on a before and after case note audit was performed in patients with recurrent acidotic exacerbations of COPD who tolerated and responded well to NIV. The primary outcome measure was the total cost incurred per patient per year from the perspective of the acute hospital. Effectiveness outcomes were total days in hospital and in intensive care. Results: Thirteen patients were identified. Provision of a home NIV service resulted in a mean (95% CI) saving of £8254 (£4013 to £12 495) (J11 720; J5698 to J17 743) per patient per year. Total days in hospital fell from a mean (SD) of 78 (51) to 25 (25) (p = 0.004), number of admissions from 5 (3) to 2 (2) (p = 0.007), and ICU days fell from a total of 25 to 4 (p = 0.24). Outpatient visits fell from a mean of 5 (3) to 4 (2) (p = 0.14).Conclusions: This study suggests that domiciliary NIV for a highly selected group of COPD patients with recurrent admissions requiring NIV is effective at reducing admissions and minimises costs from the perspective of the acute hospital. Such evidence is important in obtaining financial support for providing such a service.

Background: Non-invasive ventilation is an established treatment for chronic respiratory failure due to chest wall deformity. There are few data available to inform the choice between volume and pressure ventilators. The aim of this study was to compare pressure and volume targeted ventilation in terms of diurnal arterial blood gas tensions, lung volumes, hypercapnic ventilatory responses, sleep quality, and effect on daytime function and health status when ventilators were carefully set to provide the same minute ventilation. Methods: Thirteen patients with chest wall deformity underwent a 4 week single blind randomised crossover study using the Breas PV403 ventilator in either pressure or volume mode with assessments made at the end of each 4 week period. Results: Minute ventilation at night was less than that set during the day with greater leakage for both modes of ventilation. There was more leakage with pressure than volume ventilation (13.8 (1.9) v 5.9 (1.0) l/min, p = 0.01). There were no significant differences in sleep quality, daytime arterial blood gas tensions, lung mechanics, ventilatory drive, health status or daytime functioning. Conclusions: These data suggest that pressure and volume ventilation are equivalent in terms of the effect on nocturnal and daytime physiology, and resulting daytime function and health status.

In normal subjects, heated humidification during nasal NIV attenuates the adverse effects of mouth leak on effective tidal volume, nasal resistance and improves overall comfort. Heated humidification should be considered as part of an approach to patients who are troubled with nasal symptoms, once leak has been minimised.

Purpose -The purpose of this paper is to observe and analyse the effects of the use of telemedicine in care homes on the use of acute hospital resources. Design/methodology/approach -The study was an uncontrolled retrospective observational review of data on emergency hospital admissions and Emergency Department (ED) visits for care home residents in Airedale, Wharfedale and Craven. Acute hospital activity for residents was observed before and after the installation of telemedicine in 27 care homes. Data from a further 21 care homes that did not use telemedicine were used as a control group, using the median date of telemedicine installation for the "before and after" period. Patient outcomes were not considered. Findings -Care homes with telemedicine showed a 39 per cent reduction in the costs of emergency admissions and a 45 per cent reduction in ED attendances after telemedicine installation. In the control group reductions were 31 and 31 per cent, respectively. The incremental difference in costs between the two groups of care homes was almost £1.2 million. The cost of telemedicine to care commissioners was £177,000, giving a return on investment over a 20-month period of £6.74 per £1 spent.Research limitations/implications -The results should be interpreted carefully. There is inherent bias as telemedicine was deployed in care homes with the highest use of acute hospital resources and there were some methodological limitations due to poor data. Nevertheless, controlling the data as much as possible and adopting a cautious approach to interpretation, it can be concluded that the use of telemedicine in these care homes was cost-effective. Originality/value -There are very few telemedicine studies focused on care homes.

Churg-Strauss syndrome is a rare form of eosinophilic vasculitis associated with asthma. There have been several recent case reports of the condition in association with leukotriene antagonists and it has been speculated that the ChurgStrauss syndrome was unmasked when oral corticosteroids were withdrawn. We report a case of Churg-Strauss syndrome associated with montelukast therapy in an asthmatic patient in whom there had been no recent oral corticosteroid use. We believe that this is the first such reported case and would suggest that clinicians need to be vigilant in all patients who develop systemic symptoms when starting treatment with leukotriene antagonists. (Thorax 2000;55:805-806)