title: Telemedicine in home NIV: developing Health Informatics, assessing Physiological response, and Improving Patient Outcomes (THE HIPPO study)
Creators: name: McDowell, Grace Marie
Publisher: name: University of Glasgow
Year: 2021
Subjects: subject: Telemedicine, home non-invasive ventilation, health informatics, physiology, patient outcomes, sleep disordered breathing, severe Chronic Obstructive Pulmonary Disease.

description: The landscape of digital technology innovations which can assist healthcare provision has expanded rapidly over the past decade. With the adoption of consumer and healthcare-based technologies including mobile device and network access, the use of tele-monitoring in the management of chronic medical conditions will be incorporated into routine clinical care within this generation. Remote patient monitoring has an established role in the management of patients with obstructive sleep apnoea syndrome who require positive airway pressure support. However, the use of two-way remote monitoring via a cloud-based platform to initiate and optimise home non-invasive ventilation (NIV) is novel. Rising obesity rates and new evidence supporting the use of home NIV in patients with severe chronic obstructive pulmonary disease (COPD) and chronic hypercapnic respiratory failure has resulted in increased referrals for breathing support assessment and treatment. Chronic hypercapnic respiratory failure develops as a consequence of imbalance in the respiratory load capacity drive relationship and is associated with high morbidity and mortality. Advanced physiological measurements such as parasternal electromyography (EMG) to quantify neural respiratory drive and forced oscillometry technique to quantify airway resistance and reactance are well established in research but evidence for their clinical application in disease monitoring in patients with sleep disordered breathing and chronic hypercapnic respiratory failure is lacking. The anticipation is that big data from remote monitoring of home breathing support therapies and serial advanced physiological measurements will provide mechanistic insights of chronic respiratory failure, facilitate early optimisation of treatment, prompt early recognition of treatment failure and prioritise at risk patients to provide a personalised approach to the management of chronic respiratory disease. The aim of this thesis was to evaluate the adoption of two-way remote monitoring in patients with sleep disordered breathing and hypercapnic severe COPD and determine the feasibility of serial advanced physiological measurements in chronic respiratory disease. Methods A summary of the evolution of clinical pathways for two-way remote monitored breathing support and home ventilation in NHS Greater Glasgow and Clyde are detailed. A retrospective review of the clinical outcomes in observational cohorts of patients who were managed with two-way remote monitored home NIV for hypercapnic severe COPD and obesity related respiratory failure were evaluated. Clinical outcomes were compared to those of patients who survived a life-threatening exacerbation of COPD with persistent hypercapnic failure who were not referred for breathing support assessment (controls). Four physiological studies were performed. Firstly, the optimisation of parasternal EMG signals using different skin preparation and electrodes was explored. Secondly, inter-observer variability of parasternal EMG analysis between two UK based respiratory physiology research centres was assessed. Thirdly, the simplification of neural respiratory drive index analysis by using EMG signals to estimate respiratory rate to determine the feasibility of future omission of additional sensors improving accessibility. The fourth study explored the feasibility of serial advanced physiological measurements alongside standard care in a wide range of respiratory diseases. Results Clinical pathways for remote management of breathing support patients are now routine clinical care within NHS Greater Glasgow and Clyde. It is feasible and safe to use remote monitored home ventilation in patients with hypercapnic severe COPD. Continued use of two-way remote monitored home NIV prolonged time to re-admission or death in patients with hypercapnic severe COPD when compared to the control cohort. Continued use of remote monitored home NIV in hypercapnic severe COPD resulted in a median reduction of 14 occupied bed days per annum. Continued use of remote NIV prolonged time to re-admission or death in patients with obesity related respiratory failure compared to those non-adherent or discontinued NIV. Two-way remote home NIV can facilitate safe day case initiation of home NIV in patients with stable hypercapnic respiratory failure. It is feasible to use long term cardiac electrodes for parasternal electromyography measurements. Acceptable reproducibility of parasternal EMG analysis between two UK research centres has been demonstrated. The derivation of respiratory rate from parasternal EMG signals is feasible. Serial advanced physiological measurements can be incorporated into standard care in a wide range of respiratory diseases. Serial oscillometry measurements in patients with obstructive sleep apnoea syndrome has provided novel insight into the role a small airways disease. Conclusion The work undertaken in this thesis enabled significant service improvement within NHS Greater Glasgow and Clyde. The utilisation of remote monitoring in disease management provides realistic service provision with tangible service and cost efficiencies, addressing increased service demands and justifying future cost-effective analysis. This work has been a catalyst for ongoing digital innovation projects incorporating EHRs, ambulatory physiological monitoring and home device data into a multi-media multi-disciplinary platform for high-risk COPD patients. Serial advanced physiology data has advocated ongoing studies in acute respiratory failure secondary to COVID-19 infection. Adoption of these new technologies into routine clinical care will address increasing service demands, improve patient outcomes, and provide physiological insights into chronic respiratory failure and COVID-19 related respiratory failure.