New national guidelines aim to help hospital-based health professionals manage patients with life-threatening respiratory failure more effectively.
Successful implementation could prolong, and save, many lives a year across UK.
The Joint British Thoracic Society/Intensive Care Society Guidelines which have been published online as a supplement to Thorax, provide evidence-based advice for emergency department, respiratory and intensive care health professionals on managing acute hypercapnic respiratory failure (AHRF) - a condition in which there is a build-up of carbon dioxide in the blood.
- causes 50,000 hospital admissions a year
- can be fatal if not treated quickly and effectively
- complicates 20% of hospital admissions for chronic obstructive pulmonary disease (COPD), an overall term covering a number of lung diseases - including chronic bronchitis and emphysema
- also occurs in other lung conditions, and those associated with weak or ineffective breathing muscles, such as Muscular Dystrophy and Motor Neurone Disease
The Guidelines are needed because national audits have shown that;
- there is variability in the delivery of non-invasive ventilation (where a close fitting face mask helps the patient take deeper breaths) in our hospitals
- this treatment, which has revolutionised care of AHRF, is often not being given until patients are severely unwell and often not in suitably equipped ward areas
- there is the risk that the use of non-invasive ventilation (NIV) is delaying admission to intensive care when this is indicated
The Guideline provides clinical advice on;
- avoiding harm through the use of excessive amounts of oxygen in breathless patients
- the most effective way of providing NIV
- how to recognise when admission to the ICU is required and when invasive ventilation is needed
- ways to make the necessary treatments more comfortable for patients
- the clinical needs for delivering a NIV service
- recognition of when palliative and end of life care is needed
The Guidelines make the case for discussing advance care plans with patients at risk of hypercapnic respiratory failure and suggest hospitals employ specific patient pathways to co-ordinate care between different specialist teams. They suggest that the sensitive topics of intubation and resuscitation should be addressed with patients in advance of a medical emergency whenever possible.
Essential elements of an effective NIV service are also outlined - these include:
- A designated lead clinician
- NIV treatment being delivered in appropriately staffed and resourced areas
- Locally developed protocols and access to expert technical support 24/7
- Regular audit and rolling staff training programmes
The Guideline authors suggest a co-ordinated effort is needed by national respiratory, intensive & acute care organisations to improve the diagnosis, treatment and care for patients with this type of respiratory failure and the need to lift the quality of care provided in some of our hospitals.
Dr Martin Allen, lung specialist, and Honorary Secretary of the British Thoracic Society (BTS) said:
'Some patients with this type of respiratory failure are suffering, and even dying, unnecessarily because of not always receiving timely expert-delivered treatments in the right hospital setting. Data shows us that more critically ill patients might survive if they were treated in Intensive Care Units (ICU) and we need to find the means and resources to ensure they can get appropriate access to such care when they need it.
This Guideline provides clear advice on how to deliver the right treatment, in the right environment at the right time to save lives. We believe that delivering clear patient pathways on AHRF will help bring different professionals and parts of the NHS together.
The Guideline also provides a great resource for respiratory, emergency and intensive care organisations to help create positive change in NHS practice. Although there are areas of good practice in the NHS, we must do better to ensure patients with acute lung failure receive consistent good quality treatment and care.'
Dr Gary Masterson, President Elect of the Intensive Care Society (ICS) said:
'This guideline emphasises the importance of collaborative work between respiratory medicine and critical care medicine to determine the delivery of optimal care on a case by case basis. Within this, early joint decision-making about which patients may or may not benefit from critical admission is vital.'
The full Guideline, can be downloaded here.
The Guidelines were produced by the British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group. The Guideline has been endorsed by The Royal College of Physicians, London, The College of Emergency Medicine and The Royal College of Anaesthetists.