La Ventilazione non invasiva nel paziente cronico riacutizzato : dove ...

Il percorso assistenziale del paziente critico:
dalla Terapia Intensiva al Territorio
Corrado A, Augustynen A, Bertini S
SOD Terapia Intensiva Pneumologica
E Fisiopatologia Toracica
Az. Ospedaliera-Universitaria di Careggi, Firenze
24 maggio 2011
Salone dei Duecento
Palazzo Vecchio
Firenze
Il paziente con insufficienza respiratoria
A. O. U.
CAREGGI
FIRENZE

Function
High
Low
COPD
*CRF: Chronic Respiratory Failure
Long Term
Oxygen Therapy
CRF*
Time
Long Term
Ventilation
END-STAGE
Transplantation
?
Death

Organ system failure trajectory
High
Function
Low
Begins to use hospital
often; self-care
becomes difficult
Time
Mostly heart and lung failure
Death
Field MJ 1997
2-5 years, but death
usually seems sudden

Global Alliance against Chronic Respiratory Diseases

%
80
70
60
50
40
30
20
TIPOLOGIA di PAZIENTI ricoverati in UTIP
ANNI 2002-2009
53,6
46,3
46,7
2002-2005 2006-2009
BPCO NO-BPCO
53,3

NON BPCO
Fibrosi cistica
1%
Tumori
solidi/emopoietici
10%
Obesità/Overlap
9%
Altre
9%
Interstiziopatie
6%
SLA/DM/Mal
Neuromuscolari
18%
Asma
4%
Patologie
cardiovascolari
31%
Fibrotorace/cifoscol
iosi
12%

SCLEROSI
LATERALE
AMIOTROFICA

NUMERO PAZIENTI
REGISTRO
TOSCANO delle
MALATTIE RARE
148
235
Incidenza SLA
54
93
2000-04 2005-09 2000-04 2005-09
regione TOSCANA area CENTRO

High
Function
Low
SCLEROSI
LATERALE
AMIOTROFICA
INSUFFICIENZA
RESPIRATORIA
Time
Debolezza
muscoli respiratori
Ventilazione meccanica
Tosse inefficace
Aiuti alla clearance
disfagia
Nutrizione artificiale
Death

PERCORSO PER PAZIENTI AFFETTI DA SCLEROSI LATERALE AMIOTROFICA
1. PRENOTAZIONE 1^
VISITA NEUROLOGICA
CUP
PROCEDURA
2. VISITA
GESTIONE DEL PERCORSO NEUROLOGICA D.T.A.
Neurologo
DI SOGGETTI AFFETTI DA
3. COMUNICAZIONE
DIAGNOSI
Equipe multidisciplinare
SCLEROSI LATERALE
4. PRESCRIZIONE TERAPIA
AMIOTROFICAFARMACOLOGICA
e
VALUTAZIONE DIETETICA
Neurologo, Dietista
La presente procedura è applicata 5. CONTROLLI dal personale
PROGRAMMATI
AMB. NEUROLOGIA
sanitario operante nelle seguenti strutture:
Neurologo
AAD Servizio di fisioterapia e riabilitazione
neurologica
AAD Servizio di fisioterapia e riabilitazione
ACCESSO IN
URGENZA
NO
respiratoria
DA PS
Area di Attività Dietetica (Servizio Tecnico Sanitario)
8bis. RICOVERO
SOD Agenzia della nutrizione IN NEUROLOGIA
Neurologo
SOD Agenzia di continuità assistenziale
extraospedaliera
SOD Audiologia
10. CONFEZIONAMENTO
SOD Clinica delle organizzazioni
PEG
Chirurgo
SOD Endoscopia chirurgica
SOD Neurologia 1 e relative Aree di Attività
12. TRASFERIMENTO IN
Dipartimentali
NEUROLOGIA
Neurologo, Dietista
SOD Neurologia 2
SOD Otorinolaringoiatria
SOD Terapia Intensiva Pneumologica e Fisiopatologia
Toracica
6. VALUTAZIONE CLINICA
FUNZIONALE IN DH UTIP
Pneumologo, Dietista,
Fisioterapista, Foniatra
7. CONTROLLI
PROGRAMMATI IN DH UTIP
Pneumologo, Dietista,
Fisioterapista, Foniatra
PEG/
Tracheo
?
8. RICOVERO
PROGRMMATO/IN
URGENZA IN UTIP
Pneumologo
14. DIMISSIONE
DOMICILIO/
LUNGODEGENZA
SI
11. ESECUZIONE
TRACHEOSTOMIA
ORL
P/903/…
Ed. 1
Rev. 0
NIV/
Tosse A.
?
SI
13. TRASFERIMENTO
IN STRUTTURA
CONVENZIONATA
INTERMEDIA
NO
9. ADATTAMENTO A NIV/
Tosse Assistita in DH UTIP
Pneumologo, Fisioterapista

GIORNI

ALTRE CATEGORIE DI PAZIENTI CON IR RICOVERATI
IN UTIP dal 2002 al 2009 CON DIFFICOLTA’ DI
DIMISSIONE
Giorni Degenza (Mediana)
20
18
16
14
12
10
8
6
4
2
0
19
11
8
Totale paz: 313
•TIG: 215
•Chirurgia: 36
•TINCH: 15
•TICCH: 47
Precedente UTIP Stabiliz. Differenza
3

PAZIENTI RICOVERATI PER INSUFFICIENZA RESPIRATORIA
IN UTIP DAL 2002 AL 2009 E TRASFERITI PRESSO
STRUTTURE RIABILITATIVE/DI LUNGA DEGENZA
Giorni Degenza (Mediana)
25
20
15
10
5
0
6
13
23
17
18
12,5
5 4,5
Precedente UTIP Stabiliz. Differenza
Lungo Degenza Riabilitazione
Totale paz: 143
Longodegenza: 63
Riabilitazione: 80

Medical resources
(COSTS)
GREATEST
LEAST
ACUTE CARE
Critical Care Unit
Respiratory Care Unit
General Medical/Surgical Unit
INTERMEDIATE CARE
Subacute Care Unit
Long-term Care Hospital
Rehabilitation Hospital
LONG-TERM CARE
Skilled Nursing Facility
Congregate Living Center
Home care
Patient independence
(QoL)
LEAST
GREATEST

Nocturnal Home Monitoring of patients
with chronic respiratory failure in long
term mechanical ventilation: role of
teleassitence in the course of chronic
disease

AIM
To evaluate if, in patients with advanced chronic respiratory failure
in domiciliary treatment with chronic mechanical ventilation, a
nocturnal monitoring of cardiorespiratory and mechanical ventilatory
variables by a remote control supervised by a team highly skilled
may improve the outcomes of the disease in terms of a better
control, a reduction in the number of exacerbations and of
hospitalization, with improvement in quality of life.
END-POINTS
PRIMARY: optimization of the domiciliary treatment and reduction of
number of exacerbations and of hospital admission.
SECONDARY: evaluation of the impact of the tele-assistance on the
perception of the patients in terms of usefullness of the
service, safety, and facilitation in the management of the
disease.

STUDY DESIGN
Type and duration of the study. 2-years observational study
(from 1° October 2008 to 30 September 2010)
Patients. 20 patients with hypercapnic chronic respiratory
insufficiency due to neuromuscular diseases, Kiphoscoliosis, COPD
Inclusion Criteria: Patients in home mechanical ventilation for
at least 1 year and for or more than 8 hours/day
Esclusion criteria : OSA, Hypoventilation obesity syndrome
Planned monitoring: nocturnal home monitoring of ventilatory
and SaO2 parameters during mechanical ventilation (MV) by
means of a web-based integrated approach of technologies
developed by Telecare and Qubisoft

INTERVENTION
Once a week all patients underwent, during mechanical
ventilation, nocturnal home monitoring of the following
parameters: Tidal Volume, Respiratory Frequency, Minute
Ventilation, SaO2, Heart rate, and IPAP and EPAP using a
digital multiparametric recorder (SALLY PA) .
Sally PA ® allows acquisition and
storage of multiple non-invasive
clinical data. To facilitate data
accessibility, it is designed to collect
and transmit data via Internet. Sally
can monitor the parameters of any
ventilator.
Telephone counselling 24hours/24 with medical doctors
in charge in UTIP, when needed.

INTERVENTION
Acute medical problems and alarms generated by the
ventilator were immediately reported by phone to the
doctor in charge in UTIP, who in real time, looking at the
monitorized traces was able to suggest the solution for
the specific problem.
Intervention of emergency ambulance ( 118) in case of
failure of telephone counseling.
Patients were followed with regular visits every two
months by the outpatient clinic of UTIP.
Involvement of general practitioner for an integrated
management of the patient.

20 months
COMPLETE
(n=10)
regular
transmission of
data and regular
follow-up
Eligible Patients (n= 20)
Patients enrolled (n=15)
Died (n=5)
Died (n=5)
Actual Patients in follow-up (n=10)
COMPLIANCE TO STUDY PROTOCOL
PARTIAL
(n=2)
sporadic
transmission of
data and regular
follow-up
LOW
(n=2)
One transmission
of data and
regular follow-up
ABSENT
(n=1)
No transmission
of data no
regular follow-up

TYPE OF DISEASE and MECHANICAL VENTILATION, HOURS/DIE
OF TREATMENT
Disease Pats n IMV* hrs/die IMV NIV hrs/die NIV
ALS 3 2 24/24 1 16/24
MD 4 2 24/24 2 8/24
COPD 4 1 24/24 3 8/24
Kiphoscoliosis 1 1 8/24
Poliomielytis 1 1 8/24
Acrodisostosis 1 1 8/24
Ondine S. 1 1 8/24
Tot 15 5 11
*IMV= Invasive Mechanical Ventilation;
§ NIV=Non Invasive mechanical Ventilation

Overall hospital stay and number of hospital admission in 15 pats
2 previous years From the start of the study (%)
n hosp. adm 13 8 - 39
hosp. stay, days 157 133 -15
Hospital stay and number of hospital admission in Patients with good
adherence to the protocol (n 10)
2 previous years From the start of the study (%)
N Hosp. Adm 11 4 - 64
hosp stay, days 144 81 -44
Hospital stay and number of hospital admission in pats with scarce or
no adherence to the protocol (n 5)
2 previous years From the start of the study (%)
N hosp. adm 2 4 + 100
hosp stay, days 13 52 + 300

Satisfaction Score by telephone Questionnaire
a) Is the service of teleassistence useful?
0 = no/indifferent
1 = yes, a little
2 =yes, moderately
3 =yes, completely
b) Do you feel save with this service?
0 = no/indifferent
1 = yes, a little
2 =yes, moderately
3 =yes, completely
c) Has this service improved the management of your disease?
0 = no/indifferent
1 = yes, a little
2 =yes, moderately
3 =yes, completely
LEVEL OF SATISFACTION OF USERS
n pats score %,score
1 0/9 0
1 2/9 22
1 5/9 56
3 6/9 67
1 7/9 78
3 9/9 100
Tot 10 6/9 67
Level of satisfaction of users according to the aderence to the protocol
aderence to protocol no aderence to protocol
n ,pats score %,score n pats score %,score
2 6/9 67 1 0/9 0
1 7/9 78 1 5/9 56
3 9/9 100 1 6/9 77
1 2/9 22
Tot 6 8/9 89 4 3/9 33

controls
controls
Tele-assistance group
Tele-assistance group

CONCLUSIONI I
1. Negli ultimi anni abbiamo registrato pazienti
ricoverati in UTIP per IR con più elevate
complessità assistenziali rispetto alla BPCO. Fra
questi prevalgono pazienti affetti da patologia
cardiovascolare e neuromuscolare di varia
natura
2. La mancanza di strutture sul territorio di
supporto per la gestione della fase riabilitativa
ed educativa per il “management” della cronicità
allunga i tempi di degenza in terapia intensiva e
peggiora la qualità di vita del paziente
cronicamente critico

CONCLUSIONI II
3. La creazione di percorsi ospedale-territorio
specifici per patologie omogenee potrebbe
migliorare la qualità di vita dei pazienti e ridurre
i costi di gestione
4. I programmi di tele-assistenza potrebbero
costituire un valido supporto nella gestione
domiciliare in sicurezza di pazienti con
insufficienza respiratoria cronica in ventilazione
meccanica