Initiation of NIV
Location of initiation
A range of locations should be available for initiating patients on non-invasive ventilation (NIV).
The most appropriate place to initiate NIV depends on patient choice, complexity, safety and the planned speed of initiation.
Outpatient and day-case initiation should be considered for most patients. Our research found some evidence that both methods are as effective as inpatient initiation in terms of adherence and ventilation and may address patient anxiety which can be a major barrier to hospital admission. It may even improve outcomes by reducing the delay in initiating patients, meaning patients do not die or develop acute respiratory failure whilst waiting to come into hospital.
In one Australian study, the team switched from inpatient to day-case initiation time with good success. Median waiting time for initiation fell from 30 days with inpatient admission to 13.5 days with day-case, and the number of deaths or acute admissions with respiratory failure decreased from four to zero. Daytime arterial carbon dioxide levels were equivalent in both groups and median post-initiation survival was extended from 278 to 580 days.
Staff initiating in a domiciliary setting need to be appropriately trained and equipped to detect and deal with emergencies arising such as respiratory collapse and aspiration. Inpatient initiation may be best reserved for those patients with complex needs (eg those with severe bulbar impairment) as they may require greater attention and more intensive or overnight monitoring.
Patients with signs of respiratory crisis require admission. Signs of respiratory crisis include
extremely rapid deterioration
severe respiratory infections
In the following video, Debbie Freeman described where she sets patients up on NIV and the key considerations to have when setting people up at home.
Good practice points
Outpatient or domiciliary initiation should be considered for most patients and may improve outcomes by reducing delays in initiation.
Patients with complex needs or signs of respiratory crisis require inpatient admission.