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Models of care for non‐invasive ventilation in the A cute COPD C omparison of three T ertiary hospitals (ACT3) study
Author(s) -
Parker Kerry,
Perikala Vara,
Aminazad Ali,
Deng Zheng,
Borg Brigitte,
Buchan Catherine,
Toghill Jo,
Irving Louis B.,
Goldin Jeremy,
Charlesworth David,
Mahal Ajay,
Illesinghe Suhith,
Naughton Matthew T.,
Young Alan
Publication year - 2018
Publication title -
respirology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.857
H-Index - 85
eISSN - 1440-1843
pISSN - 1323-7799
DOI - 10.1111/resp.13228
Subject(s) - medicine , glasgow coma scale , copd , intensive care unit , arterial blood , anesthesia , mechanical ventilation , observational study , ventilation (architecture) , emergency medicine , mechanical engineering , engineering
Background and objective Non‐invasive ventilation (NIV) improves clinical outcomes in hypercapnic acute exacerbations of COPD (AECOPD), but the optimal model of care remains unknown. Methods We conducted a prospective observational non‐inferiority study comparing three models of NIV care: general ward (Ward) (1:4 nurse to patient ratio, thrice weekly consultant ward round), a high dependency unit (HDU) (1:2 ratio, twice daily ward round) and an intensive care unit (ICU) (1:1 ratio, twice daily ward round) model in three similar teaching tertiary hospitals. Changes in arterial blood gases (ABG) and clinical outcomes were compared and corrected for differences in AECOPD severity ( B lood urea > 9 mmol/L, A ltered mental status (Glasgow coma scale (GCS) < 14), P ulse > 109 bpm, age > 65 (BAP‐65)) and co‐morbidities. An economic analysis was also undertaken. Results There was no significant difference in age (70 ± 10 years), forced expiratory volume in 1 s (FEV 1 ) (0.84 ± 0.35 L), initial pH (7.29 ± 0.08), partial pressure of CO 2 in arterial blood (PaCO 2 ) (72 ± 22 mm Hg) or BAP‐65 scores (2.9 ± 1.01) across the three models. The Ward achieved an increase in pH (0.12 ± 0.07) and a decrease in PaCO 2 (12 ± 18 mm Hg) that was equivalent to HDU and ICU. However, the Ward treated more patients (38 vs 28 vs 15, P < 0.001), for a longer duration in the first 24 h (12.3 ± 4.8 vs 7.9 ± 4.1 vs 8.4 ± 5.3 h, P < 0.05) and was more cost‐effective per treatment day ($AUD 1231 ± 382 vs 1745 ± 2673 vs 2386 ± 1120, P < 0.05) than HDU and ICU. ICU had a longer hospital stay (9 ± 11 vs 7 ± 7 vs 13 ± 28 days, P < 0.002) compared with the Ward and HDU. There was no significant difference in intubation rate or survival. Conclusion In acute hypercapnic Chronic obstructive pulmonary disease (COPD) patients, the Ward model of NIV care achieved equivalent clinical outcomes, whilst being more cost‐effective than HDU or ICU models.