Home mechanical ventilation (HMV) has been used to treat chronic hypercapnic respiratory failure secondary to obstructive and restrictive diseases for the last 20 years.1 Use of HMV has increased markedly worldwide over the last 25 years, but utilization rates vary widely between centers2 and countries.3 The first large-scale evaluation of home NIV usage in Europe, the EuroVent survey,3 was published almost 15 years ago, and showed that management of HMV across a range of indications varied widely between geographical areas, particularly with respect to duration of ventilation, ventilatory modes, type of ventilators, and pathologies treated. Other studies also showed a differences in clinical practice in non-invasive ventilation (NIV) for the management of acute respiratory failure.4 In some diseases, variability in NIV practice is very high,4 despite the availability of national5 and international6,7 guidelines and recommendations. Nevertheless, there are a number of important topics that have not previously been evaluated, including the differing healthcare professionals (HCPs) involved in the care of patients undergoing HMV, monitoring protocols, healthcare infrastructure, and the use and impact of new technology such as built-in monitoring software, telemonitoring and new ‘intelligent’ ventilation modes. As a result, there is a need for survey data to determine the real-world application of the latest HMV technologies and differences in clinical practice between countries. This could highlight potential limitations in training and technology availability between similar countries.

The Iberian Respiratory Care (iCARE) program was initiated in 2013 to facilitate better knowledge of HMV through the collaboration of a group of experts and different activities, and generate consensus on HMV practices through debate. As part of the iCARE program, this study investigated and compared current management and usage of HMV in Spain and Portugal.

Despite the increasing use of HMV there is a lack recent data on real-life use of this technology. To the best of our knowledge, this is the first survey that provides a detailed analysis of therapeutic habits in HMV in the context of up-to-date technology in two countries with a similar socio-health context. The findings revealed several differences between Spain and Portugal in how HMV was used and managed. These mainly related to the main indication for HMV, the level of involvement of HCPs, practices for initiation and monitoring of NIV, and approach to patient follow-up.

The response rate to our questionnaire was quite good, at 70%, and was similar to that in other surveys.3,4 Our findings were also consistent with those of the EuroVent survey, which showed several differences between European countries in the number of centers per user, profile of the institution, duration of ventilation, ventilators used, and the pathologies submitted to NIV.4 Given the geographic and cultural similarities between Spain and Portugal, it might be expected that differences in practice would be less, but this was not the case. One of the most notable differences between the two countries was in the profile of the HCP in charge of monitoring patients using HMV. In Portugal, physiotherapists played a prominent role while in Spain, this role was taken almost exclusively by pulmonologists. This is most likely due to the historical role of respiratory physiotherapists and respiratory function/sleep technologists in the management of patients using HMV in Portugal.8 There are a number of other factors that could potentially contribute to between-country differences in HMV practice. Although generally similar, subtle variations in the healthcare systems and professional profiles between Spain and Portugal might have driven practice decisions. Practices may also vary by region within countries (e.g. rural versus urban), and any differences between countries in the proportions of patients managed in more remote areas could potentially influence our findings.

The results of another recently published survey showed that COPD was a common indication for home NIV, but prescription rates varied between countries.9 In that survey, which did not include Portugal, Spain had one of the lowest rates of home NIV prescription for COPD (approximately 20% of all HMV prescriptions were for this indication). This was similar to our findings where the most common indications for NIV in Spain were NMD (32% of respondents) and OHS (31%), with obstructive diseases (including COPD) less commonly reported as an indication for HMV (20% of respondents). A survey of all Madrid area public hospitals found that OHS was the most common pathology for which home NIV was prescribed, although there was variation between centers.10 This was consistent with our data from Spanish respondents. In contrast, respondents from Portugal in our survey cited obstructive diseases as the most common HMV indication (32%). This is consistent with data from the HMV group of the Portuguese Respiratory Society showing that most patients receiving HMV had obstructive lung diseases.8 At the time our survey was conducted, physicians should have been aware of randomized clinical trial data showing significant reductions in mortality and hospital readmission with HMV in stable COPD patients with chronic hypercapnia.11,12 Therefore, lack of evidence should not have been a valid reason for non-use of HMV in this patient group by our respondents.

Access to new NIV technology, such as the built-in respiratory software analysis,13,14 was a well-accepted and widespread clinical practice in both countries according to our survey. However, the use and interest in intelligent modes of ventilation15 was very low. Classic modes of ventilation still appeared to be preferred by HCPs in both countries.

Overall rates of telemonitoring use in our survey were very low. This was particularly the case in Spain where use of this technology was almost non-existent. Crimi et al. also identified low usage of telemedicine solutions for ongoing monitoring of HMV in Europe (reported by only 5% of respondents in their survey).9 Nevertheless, over the last 4 years telemonitoring has been progressively adopted into daily practice routines, which was exponentially accelerated over last year due to the Covid19 pandemic in Spain, but also in Portugal. As a consequence of this evolution and practice change, the Spanish Society of Pulmonology and Thoracic Surgery published a position paper on telemedicine use for sleep-disordered breathing and mechanical ventilation establishing recommendation from diagnostics to patient monitoring which reflect significant changes in clinical practice for the management of HMV in Spain, that are not reflected in our study. In this document, for example, the use of telemedicine is recommended in all patient with HMV particularly in the beginning of treatment or according to medical criteria, surely, still outside the reality of care.16

Education to improve physician awareness and knowledge of telemonitoring in the setting of HMV might help to improve uptake of this technology, contributing to improvement in clinical practice.16,17 Respondents did identify improvements in HMV equipment and technology as one of their hopes for the future. Personalized medicine, rather than just the underlying pathology, should guide use of HMV to manage patients with ventilatory failure.18

With improvements in technology over time and the growth of HMV as a valid treatment option for patients with a variety of underlying conditions, there is an important need to increase physician competency in this field to facilitate provision of ventilator equipment and consumables, ongoing management of ventilator settings, and careful risk management. The competence in sleep medicine although it is advisable,19 it is about to establish its real utility in the adaptation to the mechanical ventilation home.20 In addition, the requirement to adequately train caregivers and their patients about HMV should not be underestimated.

A number of limitations need to be taken into account when interpreting the results of our study. The data are based on reports from healthcare professionals rather than actual clinical data and may therefore be subject to bias (e.g. recall bias). In addition, the inclusion of healthcare professionals with experience in NIV is a biased sample but this is the most relevant group for determining NIV practice. The questionnaire used was developed for this study only and has not been widely validated, therefore the findings are descriptive only. In addition, the results are only applicable to the two countries in which they were obtained and cannot be generalized more widely. Furthermore, the majority of respondents to our survey were from urban areas, limiting the applicability of the findings to rural settings in the countries studied. Use of HMV patient databases might be an alternative approach to help overcome this issue.21

The present study highlighted significant differences in clinical practice for the management of HMV between Spain and Portugal, which are most likely due to different training processes, and differences in administrative and health infrastructure. Increasing use of HMV will require the implementation of appropriate training and guidelines to ensure optimization and standardization of practices, both between centers and between countries, so that the between-country differences in practices seen in our study are minimized. In addition, better understanding of NIV-related clinical routines should help facilitate targeted education and training to ensure optimal management of patients using HMV.

This work was funded by ResMed. Representatives and scientists from the ResMed participated in the study including design, data collation, data analysis, and critical review of the paper.

A Antóna, S Díaz Lobatob, MJ Guimarãesc, ML Alonso-Álvarezd and M Gonçalvesf report grants from the ResMed iCare program in 2015.

S. Correia is an employee of ResMed.