Marieke Leontine Duiverman

Objective: In addition to the already positive outcomes of initiating home mechanical ventilation (HMV) at home, we aimed to explore the economic impact of implementation of initiating HMV at home versus traditional clinical settings, focusing on the Dutch healthcare system. Methods: An Excel-based cost calculator model was used adhering to International Society of Pharmacoeconomics and Outcomes Research (ISPOR) budget impact analysis guidelines and based on the estimated population of HMV patients from 2023 to 2027 in the Netherlands. We compared home initiation of HMV against inpatient initiation in two scenarios based on patient eligibility and assessed financial impact from both health payer and societal perspectives. Results: Substantial cost savings in both scenarios were observed, with significant reductions in hospital admission days and in waiting time among patients who initiated treatment at home. The main scenario (55% of patients initiated at home) indicated savings of €8.4 million for health payers and €10.0 million from a societal perspective over 5 years. The high-uptake scenario (85% of patients initiated at home) showed even greater savings: €13.8 million for health payers and €16.4 million from a societal perspective over 5 years. Tornado diagrams highlighted the low risk of unsuccessful implementation and potential for greater benefits than projected. Conclusion: Initiating HMV at home yields substantial budget savings for payers and society in the Netherlands without compromising previously demonstrated clinical outcomes. These findings support broader implementation of home-based HMV initiation and may inform reimbursement reform and wider adoption of home-based HMV initiation.

Extract Home mechanical ventilation (HMV) is increasingly used to manage chronic respiratory failure across different conditions such as COPD, obesity–hypoventilation syndrome, neuromuscular diseases, and restrictive thoracic disorders [1]. Shareable abstract Artificial intelligence for telemonitoring in home mechanical ventilation https://bit.ly/4q9XxCa

Introduction: Acute exacerbations of COPD without respiratory acidosis lack reliable and practical physiological markers to monitor treatment response or predict clinical deterioration. Methods: In this prospective observational study, 51 hospitalised acute exacerbations of COPD (AECOPD) patients without respiratory acidosis underwent diaphragm ultrasound and surface electromyography within 48 h of admission and at discharge. Associations between study parameters and dyspnoea (Borg scores and modified Medical Research Council scales) were assessed, and their predictive value for clinical outcomes (progression to noninvasive ventilation or in-hospital death, and 30-day readmission). Results: An increase in diaphragm excursion during maximal inspiration associated weakly, yet significantly, with improvements in Borg scores (r _s =−0.365, p=0.011). A higher diaphragmatic excursion tidal breathing/maximal inspiration ratio at admission was associated with in-hospital deterioration (OR per 0.1-unit increase 1.59, 95% CI 1.05 to 2.41; p=0.029) and exploratory analysis suggested discriminative value of the excursion-to-surface electromyography (sEMG) ratio (0.941, 95% CI 0.855 to 1.000; p=0.013), although interpretation is limited by few events. Higher Borg scores (OR 2.19, 95% CI 1.22 to 3.94; p=0.009) and lower thickening fraction (area under the receiver operating characteristic curve 0.807, 95% CI 0.687 to 0.927; p=0.004) at discharge were independently associated with 30-day readmission. Conclusion: Bedside ultrasound and sEMG provide potential physiological markers associated with clinical deterioration in non-acidotic AECOPD patients. These exploratory findings suggest a role in identifying at-risk patients and guiding personalised care. Validation in larger cohorts with more events is needed. Furthermore, we found that short-term readmission risk may be predicted by a simple bedside question: “How breathless do you feel right now?”

Background: High-flow nasal therapy (HFNT) is a widely used non-invasive respiratory support technique, but data on its clinical application remain limited. This study aimed to assess clinicians’ self-reported practices, perceptions and barriers regarding HFNT use in acute and chronic respiratory failure. Methods: A cross-sectional web-based survey was disseminated among members of the European Respiratory Society’s respiratory intensive care, rehabilitation and chronic care, and allied respiratory professionals assemblies from September to November 2023. Descriptive analysis was performed, with results presented as frequencies and percentages. Results: A total of 1176 clinicians from 104 countries participated, primarily pulmonologists (78.3%) and respiratory therapists (9.7%). HFNT was most commonly used for de novo acute respiratory failure (56.2%) and interstitial lung disease exacerbations (56.3%), with lower utilisation for chronic obstructive pulmonary disease with hypercapnia (47.4%) and trauma/atelectasis (41.5%). Despite guideline recommendations, 67% of respondents initiated HFNT only after conventional oxygen therapy failure. HFNT was also frequently used for symptom relief in palliative care, despite limited supporting evidence. Respiratory distress was the primary clinical trigger for HFNT initiation, while the ROX (Respiratory Rate-Oxygenation) index was rarely used to guide escalation of care (32%). Barriers to HFNT adoption included equipment costs (23%), lack of funding (22%) and limited clinician knowledge (18%). HFNT use increased during the COVID-19 pandemic (84%), but long-term application for chronic respiratory failure remained rare (16%). Conclusions: This survey highlights significant variability in HFNT practices and a disconnect between guidelines and real-world implementation. Addressing financial and educational barriers may improve adherence to evidence-based recommendations.

Background: Flexible bronchoscopy (FB) is a key diagnostic and therapeutic procedure in the intensive care unit (ICU). However, significant heterogeneity exists regarding indications, peri-procedural management, training and safety practices across ICUs. Data on real-world practices remain limited. Methods: An international, online cross-sectional survey was conducted by the European Respiratory Society's Acute Critical Care Group between May and December 2023. The questionnaire, designed according to Checklist for Reporting Of Survey Studies (CROSS) and Academy of Critical Care: Development, Evaluation and Methodology (ACCADEMY) standards, targeted healthcare professionals performing FB in ICUs. It addressed procedural protocols, sedation, ventilation strategies, complications, microbiologic sampling, tracheostomy practices and training. Only fully completed responses were included in the analysis. Results: Data from 266 respondents across 73 countries were analysed. Training in FB varied widely: 41% reported no formal training, and only 61% had access to a 24/7 bronchoscopy service. Sedation practices were heterogeneous. Ventilator settings were adjusted differently based on ICU certification, with ICU-certified physicians more likely to reduce positive end-expiratory pressure during FB (55% versus 42%; p=0.031). Bronchoalveolar lavage was the most common sampling method, with a median saline volume of 60–120 mL and a recovery rate of 48±18%. Microbiological findings led to therapeutic changes in 48±21% of cases. FB guidance during percutaneous tracheostomy was applied in only 56% of cases. Conclusion: Substantial variability exists in FB practices across ICUs, particularly in training, sedation, ventilation adjustments and microbiologic sampling. Despite frequent therapeutic consequences, standardised approaches are lacking. These findings underscore the need for international consensus guidelines and structured training programmes to harmonise FB practices in critical care settings.

Thoracic ultrasound (TUS) is becoming a key diagnostic tool in pulmonary medicine. However, use of this tool may vary between older pulmonologists with less TUS experience and younger generations, including residents, who see the need for TUS training. This review explores nationwide differences in ultrasound training and seeks to improve education quality. We surveyed all Dutch pulmonary medicine programme directors and residents with four sections: baseline questions, applicability, skills and attitude, and future perspectives. Between March and June 2024, we distributed the questionnaire to 193 residents and 26 programme directors. 72 residents (37%) and 19 programme directors (78%) responded. While ultrasound was widely available (95%), the integration with electronic health records remained limited (53%). The majority of respondents considered TUS an essential skill: 92% of the residents and 78% of programme directors (p=0.279). However, several barriers hindered effective training, including a lack of supervisors (reported by 67% of residents), supervisor time constraints (35%), limited access to ultrasound equipment (28%) and resident time constraints (28%). Pulmonary education must move beyond the mentor–apprentice model for ultrasound training, due to a lack of experienced mentors. This review highlights the need for a structured, standardised TUS training programme with proper infrastructure, supervision and hands-on practice.

Background: With the increasing prevalence of patients on home mechanical ventilation (HMV), changing indications, shortage of hospital resources and rapidly evolving technology, there is an urgent need for evaluating the added value of telemedicine in initiation and follow-up of HMV. This European Respiratory Society (ERS) clinical practice guideline provides evidence-based recommendations on the use of telemedicine in HMV. Methods: The ERS Task Force consisted of 20 members, including a patient representative and her caregiver. The Task Force addressed five PICO (Population, Intervention, Comparison, Outcome) questions and three narrative questions. Systematic searches were performed in MEDLINE, Embase, Cochrane and CINAHL. Evidence was synthesised by conducting meta-analyses, when possible, or when not, narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations Assessment, Development and Evaluation) guidance. The Evidence-to-Decision framework was used to decide on the direction and formulate strengths of recommendations. Results: The panel makes a conditional recommendation for the initiation of HMV with telemedicine in patients with neuromuscular diseases or restrictive thoracic diseases and in patients with COPD. No recommendation could be made for obesity hypoventilation syndrome. The panel conditionally recommends the use of telemedicine for the follow-up of patients on HMV, although could not make recommendations on parameters to be monitored. Suggestions were mainly based on theoretical benefits and patient preferences, as our confidence in the evidence was low. Conclusions: With these guidelines, clinical practice recommendations are provided for the use of telemedicine in HMV. Technological advances and the use of advanced data processing algorithms and artificial intelligence were identified as drivers for future research and telemedicine use.

Purpose: Chronic noninvasive ventilation (NIV) is an effective treatment for patients with chronic hypercapnia due to COPD, but the improvement in health-related quality of life (HRQoL) varies significantly among individuals. We conducted a cluster analysis to identify clusters of patients based on their HRQoL response to chronic NIV. Patients and methods: Patients with COPD and an indication for chronic NIV were prospectively followed. Gas exchange, lung function, exercise capacity and HRQoL were measured at baseline and at 6 months. HRQoL was measured with the Severe Respiratory Insufficiency questionnaire (SRI). The cluster analysis was performed using the self-organising map–Ward's method. In addition, we compared patient and disease characteristics, changes in outcomes and survival differences between the clusters. Results: A total of 301 participants were included in the analysis and 214 patients completed the 6-month follow-up. We identified three distinct clusters of patients with equal NIV use but different HRQoL response: a “good responder” phenotype of patients, characterised by a clinically relevant improvement on the SRI, a high number of exacerbations, poor baseline HRQoL and high rates of mood disorders; a “moderate responder” phenotype, characterised by milder gas exchange and lung function impairment, and relatively preserved baseline HRQoL; and a “poor responder” phenotype of patients in whom HRQoL worsened and survival was greatly impaired. This cluster included patients with the most severe lung function and gas exchange impairment and low rates of systemic comorbidities. Conclusion: Our cluster analysis suggests that chronic NIV is most likely beneficial in patients with frequent exacerbations, severely impaired HRQoL and a high incidence of mood disorders. Future randomised controlled trials should investigate whether the different HRQoL responses between the clusters are caused by NIV.