Knut Dybwik

Fighting the system: Families caring for ventilator-dependent children and adults with complex health care needs at home

BackgroundAn increasing number of individuals with complex health care needs now receive life-long and life-prolonging ventilatory support at home. Family members often take on the role of primary caregivers. The aim of this study was to explore the experiences of families giving advanced care to family members dependent on home mechanical ventilation.MethodsUsing qualitative research methods, a Grounded Theory influenced approach was used to explore the families experiences. A total of 15 family members with 11 ventilator-dependent individuals (three children and eight adults) were recruited for 10 in-depth interviews.ResultsThe core category, fighting the system, became the central theme as family members were asked to describe their experiences. In addition, we identified three subcategories, lack of competence and continuity, being indispensable and worth fighting for. This study revealed no major differences in the families experiences that were dependent on whether the ventilator-dependent individual was a child or an adult.ConclusionsThese findings show that there is a large gap between family members expectations and what the community health care services are able to provide, even when almost unlimited resources are available. A number of measures are needed to reduce the burden on these family members and to make hospital care at home possible. In the future, the gap between what the health care can potentially provide and what they can provide in real life will rapidly increase. New proposals to limit the extremely costly provision of home mechanical ventilation in Norway will trigger new ethical dilemmas that should be studied further.

Home mechanical ventilation and specialised health care in the community: Between a rock and a hard place

BackgroundHome mechanical ventilation probably represents the most advanced and complicated type of medical treatment provisioned outside a hospital setting. The aim of this study was both to explore the challenges experienced by health care professionals in community health care services when caring for patients dependent on home mechanical ventilation, continual care and highly advanced technology, and their proposed solutions to these challenges.MethodsUsing qualitative research methods, a grounded theory influenced approach was used to explore the respondents experiences and proposed solutions. A total of 34 multidisciplinary respondents from five different communities in Norway were recruited for five focus groups.ResultsThe core category in our findings was what health care professionals in community health care services experience as between a rock and a hard place, when working with hospitals, family members, and patients. We further identified four subcategories, to be a guest in the patients home, to be accepted or not, who decides, and how much can we take. The main background for these challenges seems to stem from patients living and receiving care in their private homes, which often leads to conflicts with family members. These challenges can have a negative effect on both the community health caregivers work environment and the community health services provision of professional care.ConclusionsThis study has identified that care of individuals with complex needs and dependent on home mechanical ventilation presents a wide range of immense challenges for community health care services. The results of this study point towards a need to define the roles of family caregivers and health care professionals and also to find solutions to improve their collaboration. The need to improve the work environment for caregivers directly involved in home-care also exists. The study also shows the need for more dialogue concerning eligibility requirements, rights, and limitations of patients in the provision and use of ventilatory support in private homes.

Why does the provision of home mechanical ventilation vary so widely

There is wide variation in the provision of home mechanical ventilation (HMV) throughout Europe, but the provision of home mechanical ventilation can also vary within countries. In 2008, the overall prevalence of HMV in Norway was 19.9/100,000, and there were huge regional differences in treatment prevalence. The aim of this study is to find explanations for these differences. We gathered multidisciplinary respondents involved in HMV treatment from five hospitals in five different counties to six focus group conversations to explore respondents’ views of their experiences systematically. We based the analysis on grounded theory. We found that uneven distribution of ‘‘enthusiasm’’ between hospitals seems to be an important factor in the geographical distribution of HMV. Furthermore, we found that the three subcategories, ‘‘high competence,’’ ‘‘spreading competence,’’ and ‘‘multidisciplinary collaboration,’’ are developed and used systematically in counties with ‘‘enthusiasm.’’ This culture is the main category, which might explain the differences, and is described as ‘‘wise enthusiasm.’’ The last subcategory is ‘‘individual attitudes’’ about HMV among decision-making physicians. The most important factor is most likely the uneven distribution of highly skilled enthusiasm between hospitals. Individual attitudes about HMV among the decision makers may also explain why the provision of HMV varies so widely. Data describing regional differences in the prevalence of HMV within countries is lacking. Further research is needed to identify these differences to ensure equality of provision of HMV.

Combined inhibition of complement and CD14 improved outcome in porcine polymicrobial sepsis

IntroductionSepsis is an exaggerated and dysfunctional immune response to infection. Activation of innate immunity recognition systems including complement and the Toll-like receptor family initiate this disproportionate inflammatory response. The aim of this study was to explore the effect of combined inhibition of the complement component C5 and the Toll-like receptor co-factor CD14 on survival, hemodynamic parameters and systemic inflammation including complement activation in a clinically relevant porcine model of polymicrobial sepsis.MethodsNorwegian landrace piglets (4u2009±u20090.5xa0kg) were blindly randomized to a treatment group (nu2009=u200912) receiving the C5 inhibitor coversin (OmCI) and anti-CD14 or to a positive control group (nu2009=u200912) receiving saline. Under anesthesia, sepsis was induced by a 2xa0cm cecal incision and the piglets were monitored in standard intensive care for 8xa0hours. Three sham piglets had a laparotomy without cecal incision or treatment. Complement activation was measured as sC5b-9 using enzyme immunoassay. Cytokines were measured with multiplex technology.ResultsCombined C5 and CD14 inhibition significantly improved survival (pu2009=u20090.03). Nine piglets survived in the treatment group and four in the control group. The treatment group had significantly lower pulmonary artery pressure (pu2009=u20090.04) and ratio of pulmonary artery pressure to systemic artery pressure (pu2009<u20090.001). Plasma sC5b-9 levels were significantly lower in the treatment group (pu2009<u20090.001) and correlated significantly with mortality (pu2009=u20090.006). IL-8 and IL-10 were significantly (pu2009<u20090.05) lower in the treatment group.ConclusionsCombined inhibition of C5 and CD14 significantly improved survival, hemodynamic parameters and inflammation in a blinded, randomized trial of porcine polymicrobial sepsis.

Ethical challenges in home mechanical ventilation: A secondary analysis

The aim of this study was to explore the ethical challenges in home mechanical ventilation based on a secondary analysis of qualitative empirical data. The data included perceptions of healthcare professionals in hospitals and community health services and family members of children and adults using home mechanical ventilation. The findings show that a number of ethical challenges, or dilemmas, arise at all levels in the course of treatment: deciding who should be offered home mechanical ventilation, respect for patient and family wishes, quality of life, dignity and equal access to home mechanical ventilation. Other challenges were the impacts home mechanical ventilation had on the patient, the family, the healthcare services and the allocation of resources. A better and broader understanding of these issues is crucial in order to improve the quality of care for both patient and family and assist healthcare professionals involved in home mechanical ventilation to make decisions for the good of the patient and his or her family.

Late complications after percutaneous tracheostomy and oral intubation: Evaluation of 1,628 procedures.

In large international studies, upper airway–related stenosis, granulomas, malacias, and laryngeal nerve palsies following percutaneous tracheostomy have an estimated incidence of 6% to 31%. The incidence following prolonged oral intubation is estimated to be 10% to 22%. The purpose of this study was to assess the incidence of late complications in our unit.

Combined inhibition of C5 and CD14 efficiently attenuated the inflammatory response in a porcine model of meningococcal sepsis

BackgroundFulminant meningococcal sepsis, characterized by overwhelming innate immune activation, mostly affects young people and causes high mortality. This study aimed to investigate the effect of targeting two key molecules of innate immunity, complement component C5, and co-receptor CD14 in the Toll-like receptor system, on the inflammatory response in meningococcal sepsis.MethodsMeningococcal sepsis was simulated by continuous intravenous infusion of an escalating dose of heat-inactivated Neisseria meningitidis administered over 3xa0h. The piglets were randomized, blinded to the investigators, to a positive control group (nu2009=u200912) receiving saline and to an interventional group (nu2009=u200912) receiving a recombinant anti-CD14 monoclonal antibody together with the C5 inhibitor coversin.ResultsA substantial increase in plasma complement activation in the untreated group was completely abolished in the treatment group (pu2009=u20090.006). The following inflammatory mediators were substantially reduced in plasma in the treatment group: Interferon-γ by 75% (pu2009=u20090.0001), tumor necrosis factor by 50% (pu2009=u20090.01), Interleukin (IL)-8 by 50% (pu2009=u20090.03), IL-10 by 40% (pu2009=u20090.04), IL-12p40 by 50% (pu2009=u20090.03), and granulocyte CD11b (CR3) expression by 20% (pu2009=u20090.01).ConclusionInhibition of C5 and CD14 may be beneficial in attenuating the detrimental effects of complement activation and modulating the cytokine storm in patients with fulminant meningococcal sepsis.

A successful new method for single left lobe recruitment

Any gas will flow down the path of least resistance and highest compliance. This is a problem in the treatment of severe unilateral lung disease in the intensive care unit (ICU). Deep sedation interferes with the diaphragms ability to distribute air into the lower lung. Spontaneous breathing in a conscious patient, in combination with mechanical ventilation via an endotracheal tube inserted into the left main stem bronchus, can recruit collapsed alveoli.