Clinical View – Jon
Consultant Nurse Respiratory, Derriford Hospital, Plymouth
Jon has worked in the home mechanical ventilation (HMV) team at Derriford Hospital for the past 17 years and prior to this worked on the respiratory ward.
We talked to Jon about COPD and what patients might expect if they are advised to use home non-invasive ventilation (NIV) which can also be referred to as home mechanical ventilation (HMV).
What is COPD and what are typical symptoms?
COPD is a disease often resulting from a combination of two different diseases, emphysema where there is damage to the air sacs (alveoli) in the lungs and chronic bronchitis where there is inflammation of the airways.
It’s often, but not always, caused by smoking. The longer and more a patient smokes, the more chance they have of getting COPD – although not everyone is susceptible to the condition.
Most patients are older, although there is a condition called alpha antitrypsin deficiency disorder which is a rare condition that can cause COPD in younger patients, particularly those who smoke.
Symptoms include breathlessness and a chronic cough, and patients have a particular susceptibility to seasonal changes, i.e., in the winter COPD patients are more likely to pick up infections and experience progressive breathlessness, coughing and phlegm. However, symptoms vary from patient to patient so, for example, not everyone will cough up phlegm.
What are typical co-morbidities for COPD patients?
These are often smoking-related and include heart disease and lung cancer. Patients can also be overweight, due to mobility issues and suffer from heart failure due to reduced blood flow in the lungs.
Anxiety and depression are also very common.
Those patients who are overweight may also have obstructive sleep apnoea. This is where the airway closes when they go to sleep, resulting in multiple ‘apnoeas’ where they stop breathing and sleep disturbance results.
General sleep disturbance can be common due to reduced oxygen levels at night
What is HMV and how does it benefit patients?
HMV, often referred to as home mechanical ventilation, is a very simple technique that uses a device that is the size of a radio alarm clock. The device has a tube that links the machine to the patient via a face mask and it has a turbine which blows air and supports the patient’s breathing, recognising the different patterns of breathing in and out.
The face mask can be a small nasal mask but more often patients have a full face mask.
Using HMV improves oxygen levels and removes carbon dioxide from the blood. It can also reduce anxiety and breathlessness in those who struggle for breath.
If a patient with COPD uses HMV for a minimum of four hours a night it can reduce the likelihood of being admitted to hospital with an exacerbation. It can increase length of life and can reduce the severity of symptoms such as poor-quality sleep, falling asleep during the day and waking up in the morning with a headache.
If patients have tolerated HMV in the hospital, they are likely to benefit from using it at home if the carbon dioxide level remains high in the blood. There are no significant side effects of using the treatment (although we cover off these aspects later).
It is important to note that some patients struggle to use the machine, or simply don’t want to extend their life. If this is the case, health care professionals will respect this view, but it is important to have this discussion so that a patient’s wishes are clear.
What are typical patient concerns about going onto HM
For most patients, they will be started on home HMV after an acute exacerbation and the main concern is how they will cope with the machine and wearing the mask.
However, it is important to remember that using HMV at home is often very different to a hospital setting where the patient will be anxious and extremely unwell. The home HMV unit is much more compact, the masks are more comfortable, and the patient is likely to be less anxious in the home environment.
Healthcare professionals provide help and support for both physiological and physical issues. So, for example, the team will work with patients who feel claustrophobic when they first wear the mask to minimise this and perhaps try different types of mask. Most of time these problems can be overcome.
Particularly since the pandemic, there are also remote services available in most teams to provide support at home. Healthcare professionals can access the data from the machines remotely, and this data is used in conjunction with a video or telephone call to follow up with patients.
What is the typical response from a patient after using HMV for a few weeks?
For those who are successful in using home HMV, it can make a huge difference to the patient’s quality of life. They are more alert and awake, sometimes less breathless. Even after 17 years of working in this area, I continue to be surprised by the extent of the life-changing impact many patients experience after using home HMV.
Many can go out again and socialise, while others find that instead of falling asleep in front of the television, they are able to enjoy a full programme or stay awake to read a book. These activities, which may seem simple, are vitally important to a COPD patient who may not be able to get about very easily and for whom watching the television or reading a book, is key to their quality of life.
One patient who comes to mind is a WW2 veteran for whom it was very important that he went to the D-day celebration in Brittany, an anniversary that he had celebrated every year. He was very determined, and this drove his success at adapting to home NIV. As a result, he was able to attend the commemoration in person one last time, a journey that would have been impossible without HMV.
But not everyone can tolerate HMV so if this is the case it’s important that patients recognise that they haven’t failed. If they’ve tried it and it’s not for them, healthcare professionals will understand and talk through their options.
What other therapies are used alongside home HMV?
HMV is used in conjunction with other therapies and complements these treatments. COPD patients are likely to have inhalers to use alongside the HMV and may also have long term oxygen therapy (LTOT) for a minimum of 16 hours a day.
Pulmonary rehabilitation exercises are also important and have been proven to help breathlessness, anxiety, and depression in COPD patients.
Are there any side effects of using HMV?
There are very few. Some patients feel claustrophobic but support and changes to the interface can address this in most cases.
Also wearing the mask for long periods of time can mark the face and occasionally cause ulceration, particularly on the bridge of the nose. This is typically because the patient doesn’t have the right mask for them, or the fitting isn’t right. However, mask technology has improved considerably in recent years, and a healthcare professional will be able to help with this.
Very rarely a patient may experience a condition called aerophagia. This is where air blows or is swallowed into the tummy. This is more common when high pressure is used on the HMV machine. In most cases this will lead to a bit of bloating and flatulence but very occasionally this may cause abdominal pain. If this happens a healthcare professional will be able to help.
In all these cases, there is usually a remedy, and the issue can be overcome for most patients.