key: cord-0940536-0ou9nrhe
authors: Watson, Alastair; Barnard, Hannah; Antoine‐Pitterson, Pearlene; Jones, Bethany; Turner, Alice M.; Mukherjee, Rahul
title: The impact of COVID‐19 on acute non‐invasive ventilation services: A case for change
date: 2021-10-03
journal: Respirology
DOI: 10.1111/resp.14156
sha: 0a41726b4efccfa788dae2fcee1e615bc0abc561
doc_id: 940536
cord_uid: 0ou9nrhe

nan

Acute non-invasive ventilation (NIV) is a life-saving treatment, particularly in hypercapnic chronic obstructive pulmonary disease (COPD) exacerbations. 1 COVID-19 has placed an unparalleled burden on delivery of healthcare services and led to excess deaths. However, the effect on acute NIV service delay is still to be full determined. It is essential we now evaluate the true impact of COVID-19 on NIV services and generate insights to deliver prospective, multicentre studies to improve care despite the continuing pandemic.

In the UK, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report showed that there was a delay in initiating NIV in 27% of patients and recommended that the emergency department (ED) is probably the best place to start acute NIV. 2 This enables the focus on starting standard medical therapy, including oxygen delivered to a target saturation of 88%-92%, as these measures alone result in 20% of patients presenting to ED with acidosis correcting their pH within the first hour. 3 Early NIV therapy improves physiological outcomes, reduces intubation rates and shortens hospital stay, this is reflected by NIV service quality metrics and national improvement objectives. 4 The 'door-to-mask' time (hospital arrival to NIV commencement) has been widely used to measure the quality of acute NIV services. However, this is a broad metric with various determinants impacting it, the new 2018 British Thoracic Society (BTS) quality standard within this has since been established which uses the 'decision to mask time' and indicates that patients should be started on NIV treatment within 60 min of their decisionmaking arterial blood gas. 4 We therefore audited data for all recipients of acute NIV at our local Heartlands Hospital ED before and after the pandemic start, 1 April-1 October 2019 and 2020, respectively. We used the new BTS quality standard and measured the decision to mask time (Table 1 ). Despite 45.8% fewer patients receiving NIV, in concordance with recent reports of fewer COPD exacerbation presentations, 5 we saw an increased median (interquartile range) decision to mask time, from 61 min (43-77) to 132 min (65-179), in 2020 (p < 0.0001) ( (Table 1) . This delay likely reflects stringent infection control measures around aerosol-generating procedures (AGPs) and recommendations for side rooms with 10-12 air-changes per hour for AGPs, resulting in patients no longer being set up on acute NIV until an appropriate side room became available. 6 Various hospitals have found new ways to overcome the limitation of suitable rooms for NIV set ups by converting small rooms or wards using dehumidifier exhausts to increase the number of air-changes per hour. 6 However, given the global impact of COVID-19 on hospitals, broad restructuring and improvement of patient flow through hospitals may be required. This has already been mooted by respiratory leaders, bringing the concept of respiratory support units to the fore, 7 but these may not be the only solution.

Emerging information technology systems with ED blood gas dashboards flagging acute hypercapnic respiratory acidosis to the relevant (respiratory/critical care) team will be a welcome quality improvement. However, alongside continual local Quality Improvement (QI) projects, prospective multicentre studies are needed that incorporate interventions and provide high-quality evidence about their potential for improvement of NIV service quality. These should be designed with the most suitable outcomes based on the relevant standards and performance metrics, for example using the decision-to-mask time quality metric, as used above, as opposed to door-to-mask time which is confounded by whole system delays including wait times in ambulances outside of hospitals. 4 Studies are needed that evaluate new promising automated oxygen administration systems. The potential of automated oxygen titration systems has been shown in a retrospective study where they saw a decrease in time patients spent with hypoxaemia and an increase in time with target oxygen saturations. 8 This study also demonstrated the potential of these systems to lower time patients spent with hyperoxia, which is known to increase mortality in COPD. 9 The benefit of these systems now needs to be demonstrated in larger prospective multicentre studies longitudinally with the incorporation of various outcomes such as reversal of mild acidosis, pre-empting the need for acute NIV; prevention of escalation to critical care; and reduction in the length of hospital stay, especially in patients with COPD exacerbations. A study from Australia showed no difference in outcomes when NIV was delivered in the intensive care unit, high-dependency unit or a ward. 10 However, in the ward model, more patients received NIV, which was also more cost effective. Increasing the number of negative pressure rooms to directly admit patients requiring acute NIV set ups to the wards would be the most obvious way forward and further studies are needed to assess the efficacy of portable partitions (e.g., Room Divider 360 Portable Partitions and Polycarbonate Covid Cubicles) in the continued utilization of ward bays where NIV recipients could be cohorted.

In summary, COVID-19 poses an unprecedented challenge to health care and calls for innovative approaches to manage the surge in demand for specific services. However, on a positive note, emerging data indicate that there is a significant decrease in the total rate of nosocomial infection during the COVID-19 pandemic, most likely due to stringent implementation of infection control protocols. 11 Multicentre prospective studies on the mode of NIV service delivery during the pandemic therefore need to focus on the incorporation of the infection control protocols, which has a potential to be a welcome improvement for vulnerable respiratory patients receiving NIV. 

Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis

The National Confidential Enquiry into Patient Outcome and Death. Inspiring change. A review of the quality of care provided to patients receiving acute non-invasive ventilation. London: NCEPOD

Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome

British Thoracic Society Quality Standards for acute non-invasive ventilation in adults

Reduction in hospitalised COPD exacerbations during COVID-19: A systematic review and meta-analysis

COVID-19: infection prevention and control guidance. PHE publications gateway number: GW-1250, version 3. 2020

British Thoracic Society Reports: respiratory support units: guidance on development and implementation

Automatic versus manual oxygen administration in the emergency department

Note: Unless otherwise stated, data are expressed as median (IQR) and statistical analysis was performed using Mann-Whitney U test

Abbreviations: ABG, arterial blood gas

COPD, chronic obstructive pulmonary disease

RR, respiratory rate; in prehospital setting: randomised controlled trial

Models of care for non-invasive ventilation in the Acute COPD Comparison of three Tertiary hospitals (ACT3) study

The impact of COVID-19 on acute non-invasive ventilation services: A case for change

ORCID Alastair Watson https://orcid.org/0000-0002-6735-2567 Alice M. Turner https://orcid.org/0000-0002-5947-3254 Rahul Mukherjee https://orcid.org/0000-0003-4466-0660