Respiratory home care: take the pulmonary specialist out of the hospital!

The last three decades have witnessed significant modifications in long-term management of chronic respiratory disorders, in parallel with variations of epidemiological trends and introduction and development of new treatment options to be delivered not only in the traditional health care settings, such as hospitals or out-patient facilities, but also directly at home. A paradigmatic example is represented by a frequent condition of rapidly increasing prevalence, such as COPD (chronic obstructive pulmonary disease); strong evidence has been acquired about the possibility of improving the survival rate and quality of life with timely diagnosis and appropriate treatments (e.g. smoking cessation, inhaled drugs, long-term oxygen therapy, rehabilitation) [1]. This means that more and more patients reach the last phases of the natural history of the disease later in life, when it becomes more difficult in relation to familial or socio-economic problems and major physical disability occur as a result of respiratory failure and co-morbidities. At this point in time, apart from hopefully limited situations where long-term institutional care is needed, the management of such a complex patient may require quite an intense level of home care provision in case of oxygen therapy and mechanical ventilation. According to the American Thoracic Society home care is defined in general as the provision of services and equipment in place of residence of individuals and families who have needs resulting from acute illness, longterm health conditions, permanent disability, or terminal illness [2]. General goals of respiratory home care are to increase survival, reduce morbidity, improve quality of life and function, educate to self-management and positive health behaviours, and support independence. In the case of children with severe respiratory disorders major goals are also to promote optimal growth and development [2]. Apart from COPD, many other conditions of chronic respiratory failure of pulmonary or extrapulmonary origin can be assisted with the advantage of home care, with particular regard to patients dependent on mechanical ventilation (including children), such as subjects affected by progressive neuromuscular disorders. A national survey [3] and the more recent Eurovent study carried out in 16 European countries with the involvement of 329 Centres and 21526 patients, reported a prevalence of patients on home mechanical ventilation (HMV) of 6.6/100,000 in Europe and 3.9/100,000 in Italy [4]. These figures probably underestimate the real prevalence of HMV, because in several countries, including Italy, a national register of patients on HMV had not yet been constructed at the time of the survey. Adequate management of patients with severe chronic respiratory failure in the different phases of the disease requires a network integrating different levels of treatment and care including acute-care hospitals, weaning centres, long-term health care centres, pulmonary rehabilitation facilities and respiratory care programmes within home care services [5, 6]. The care of ventilator-dependent patients in particular requires a multidisciplinary approach, gathering the expertise of many specialists from areas such as pulmonary medicine, respiratory and physical therapy, psychology, speech and swallowing evaluation; nurses must be skilled in the management of airways problems and ventilator care needs. The need to organise respiratory home care services dates back to the beginning of the 1980s with the development of long-term oxygen therapy [6]. At follow up it became clear that many clinical and technical problems occurred at home and that there had not been foreseen during hospitalisation. In particular, many patients manifested a progressive reduction in time of compliance to the prescribed treatment, nullifying the efficacy of longterm oxygen therapy [6]. These problems have been further amplified by the introduction of HMV [7, 8]. The rapid progression of problems concerning the organisation and the clinical aspects in respiratory home care prompted the major scientific associations of pulmonary Medicine in North America and Europe (including Italy) to promote guidelines on long-term home mechanical ventilation, with a particular emphasis on patients’ and care-givers’ education about management of HMV outside the respiratory intensive care unit [9, 10]. A few Italian regions have also adopted local guidelines on respiratory home care [11, 12]. In the near future a strong demand can be foreseen to implement programmes for patients who may require occasional or regular respiratory care at home, integrating hospital, primary care and companies providing technical products and services. Recen-tly, the American Thoracic Society Monaldi Arch Chest Dis 2009; 71: 3, 93-95.