Having your cake and eating it too: Improving care and saving money with noninvasive ventilation

By Pamela Nelson-Artibey

In these economically challenging times, healthcare providers are under intense pressure to find ways to control costs without compromising the quality of care they provide. And so it may come as a surprise to discover that there is in fact a proven medical technology capable of simultaneously reducing costs of care while improving clinical outcomes and the patient experience. Noninvasive ventilation (NIV), when used in the appropriate patient population, has the ability to improve patient mortality, address patient comfort, and reduce costs through shorter lengths of stay. There is strong evidence supporting the application of NIV in patients with congestive heart failure, chronic obstructive pulmonary disease (COPD) exacerbation, immunocomprised patients, and COPD patients being weaned from mechanical ventilation. Furthermore, there is also moderately strong evidence to support NIV in patients with asthma, cystic fibrosis, postoperative respiratory failure, obesity hypoventilation and DNI (do not intubate) patients. Sounds too good to be true? Read on.

While NIV offers significant cost advantages over traditional ventilation via endotracheal intubation, it also offers equally significant benefits to patients in the form of decreased length of stay, reduced sedation associated with intubation, and decreased morbidity and mortality rates. Furthermore, many patients in respiratory distress may be spared the misery of endotracheal intubation, which takes away their ability to communicate, and the accompanying sedation, which deprives them of their cognitive abilities. Although the need for invasive ventilation will always exist, many patients can be successfully and cost-effectively treated with NIV. Best of all, the practice of noninvasive ventilation has considerable room to grow from where it is today.

Conventional Invasive Ventilation

The distinction between noninvasive and invasive ventilation derives from the fact that noninvasive ventilation does not require an endotracheal tube. Even a properly placed endotracheal tube has undesirable side effects due to its 'invasive' nature. Contaminated bacteria that may occur as the direct result of intubation can result in a lung infection, frequently referred to as VAP (ventilator-associated-pneumonia). Ventilator-associated pneumonia not only has clinical consequences for the patient - it also carries significant financial consequences for the medical center. To wit, the Centers for Medicare and Medicare Services (CMS) has indicated that it has added VAP to the hospital acquired conditions for which reimbursement will be denied.

Ventilator-associated pneumonia

Whenever a patient is intubated, they run the risk of contracting VAP - one of the most significant risks facing intubated patients on a ventilator. According to the Centers for Medicare and Medicaid Services, the average cost of a VAP infection runs about $135,795 per hospital stay with an estimated 30,867 reported cases of VAP in the US each year. In a statement by the Center for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS) in their 2002 report, patients receiving continuous mechanical ventilation were six to 21 times more at risk for developing healthcare-associated pneumonia than those patients who were not receiving mechanical ventilation.

In reviewing cohort studies by various physicians, their findings suggested that implementing NIV results in a decreased rate of nosocomial pneumonia and infections. Dr. Dean Hess compared 12 studies relating to NIV being administered to patients at risk for pneumonia. The study revealed that compared to patients receiving invasive mechanical ventilation (in four studies), the rate of pneumonia was lower with the use of NIV. In addition, Dr. Hess suggested that ventilator associated pneumonia is a misnomer, and perhaps "endotracheal-tube-associated-pneumonia" is a more accurate term. With NIV, because there is no intubation, there is virtually no risk of VAP.

NIV in the hospital

The economic benefits of using NIV in the hospital setting are well documented for both acute and chronic patients. Many studies have shown not only the cost effectiveness of NIV, but the beneficial aspects to patient care.

In the United Kingdom, a randomized control trial was conducted in 14 participating centers. They found that noninvasive ventilation reduced the need for intubation by 44 percent and that in-hospital mortality decreased by 50 percent in patients with severe exacerbation of chronic pulmonary disease. Another review in the United States concluded that NIV was associated with lower rates of pneumonia, intubation and mortality.

Dr. Nava et al. explained that NIV is widely used today as a valid treatment to avoid intubation and its complications. While conventional invasive ventilation is a life-saving procedure, the most important risk factor is in fact endotracheal intubation. Therefore, NIV should be considered in early treatment of established acute respiratory failure (ARF) patients to avoid further deterioration and intubation. Dr. Arroliga, head of Critical Care Medicine at the Cleveland Clinic, believes that NIV avoids the complications of intubation, incurs shorter stays in the hospital, lowers mortality rates and lowers healthcare costs. Another advantage he pointed out is that NIV is more comfortable for patients as they can retain the ability to speak, swallow, and protect their airway.

NIV for COPD

COPD is one of the leading causes of death, illness and disability in the United States. In one particular study, the cost-effectiveness of NIV, added to the standard treatment, was reviewed and analyzed from the data obtained by several studies. The primary outcomes that the authors were looking for was to see a reduction in hospital mortality and endotracheal intubations. Their cost analysis revealed that using NIV instead of endotracheal intubation in patients with acute exacerbation of COPD resulted in cost savings of $3244 per patient admission.

NIV success factors

European countries are also seeing an increase in the use of NIV for the treatment of patients with COPD. An article featured in the European Respiratory Journal cited that a lack of training was the leading reason NIV was not implemented more often. According to Leger et al., any hospital that has the potential for treating patients with acute and chronic respiratory failure should have NIV available to them. It was also stated that the experience and training of staff to adequately monitor the patient was clearly linked to the success of NIV. This article revealed that with proper training and education, NIV is a very successful tool for the treatment of patients with COPD.

With a mounting body of evidence now available for review, NIV is clearly very cost-effective and a more efficient form of treatment for patients who are within the treatment criteria. Today, NIV represents one of the current medical technologies proven to help reduce length of stay, morbidity, mortality, risks of infection and cost of care. As NIV eliminates the financial and clinical consequences of unnecessary endotracheal intubations in both the hospital and pre-hospital settings, it behooves hospital administrators and clinicians, in close association with their EMS partners, to expand the use of NIV. While NIV may not be appropriate for all patient types, understanding NIV protocols and guidelines through training will help clinicians make better decisions for their patients and their institutions.

Biography

Pamela is a Respiratory Therapist with over 20 years of clinical experience. Her background includes being a Program Director for a respiratory college and working as a Team Lead Therapist at the Mayo Clinic Hospital in Arizona. Currently, she is the Education Manager within Philips' Hospital Respiratory Care group.