The Ottawa Hospital CANVent Program

From left to right: Respiratory Therapists; Kathy Walker, Charge Respiratory Therapist; Carole LeBlanc, Medical Director; Dr. Douglas McKim, Administration; Sue Stevens, Respiratory Therapists; Joan Norgren

Missing from photo: Respiratory Therapists Reneé Longpré and Paula Baxter, Nurse; Nancy Hodgins

CANVent is an acronym for Canadian Alternatives in Non-invasive Ventilation. The clinic itself is housed at the Rehabilitation Centre but the Program is active throughout the Ottawa Hospital. The medical director is Dr. Douglas McKim and care is provided by the Charge Respiratory Therapist, Carole LeBlanc and by a number of expert Respiratory Therapists and Clinic Nurse. While the care of patients with Neuro-Respiratory complications has always been a responsibility of the Respiratory Rehabilitation Program this component has grown tremendously to constitute at least half of the clinical care provided and has therefore evolved in to the CANVent Program.

What is uniquely valuable about the CANVent Program is its’ central role within the Ottawa Hospital and the Community in identifying patients who are at risk of serious or life-threatening complications such as respiratory failure and working to prevent this. Through its work the Program has raised the level of awareness among specialists in Internal Medicine, Respirology, Physical Medicine and Rehabilitation, Neurology and Critical Care that individuals with Neuromuscular Diseases (NMD), whether in hospital or the community are at high risk for respiratory complications and that education and non-invasive airway clearance strategies may significantly reduce or eliminate this risk. Patients have been referred from the Gatineau area as well as from great distances. These skills are not widely practiced and indeed a number of patients travel from the Greater Toronto area to receive care in non-invasive airway management. These individuals have conditions which include ALS, Muscular Dystrophy, Spinal Cord Injury, Multiple Sclerosis, Post-Polio Syndrome and others.

The care that the CANVent Program provides offers critical support to patients in the community who would otherwise require Emergency visits or Critical Care admissions as a result of something as benign as an upper respiratory tract infection. Through an enhanced awareness patients are identified, referred and evaluated for their risk for respiratory failure, sleep-related respiratory insufficiency and limitation in airway clearance. Simple but effective strategies are taught to patients and care givers in order to recognize illness, increase cough capacities and ensure adequate airway clearance. Patients are taught to use a hand-held resuscitation bag or glossopharyngeal breathing to increase lung volumes above their own capacity (which is limited by muscle weakness or respiratory mechanics) in order to increase cough flows and to improve or maintain respiratory compliance. This skill alone may be sufficient to prevent a Critical Care admission for each patient at significant risk. Visual feed back is provided using the individuals pulmonary function results to reinforce the effectiveness of the technique.

Individuals with significant neuro-respiratory limitation may in fact be experiencing respiratory failure when they are first evaluated or are at high risk for respiratory failure related to sleep. For patients with diaphragm weakness or respiratory muscle weakness, sleep and particularly REM sleep, may be associated with severe reductions in oxygen and elevation of carbon dioxide which could be life-threatening. Due to the challenges and preferences of patients and care givers the CANVent Program provides entirely outpatient initiation of non-invasive ventilation (NIV), a treatment for which equivalent institutions require much more costly hospital admission1. Initiation of NIV is followed by overnight home oximetry, offered through the clinic as well as down-loaded information from non-invasive ventilators to confirm adequate mechanical ventilation and make adjustments as required. This obviates the need for costly and inconvenient sleep studies in most patients. Most individuals are followed indefinitely through the CANVent Program. This support, combined with non-invasive airway clearance techniques, may be sufficient to prevent Critical Care admissions and prolonged invasive tracheostomy ventilation which diminishes quality of life and contributes enormously to ICU costs while reducing access to Critical Care beds. Over 350 patients have benefitted from the entirely outpatient provision of NIV through the CANVent program.

In addition to the outpatient care provided, the CANVent Program works closely with inpatient units including the Critical Care areas in the Ottawa Hospital and the Heart Institute in order to help transition patients from invasive endotracheal or tracheostomy ventilation, which may prevent discharge from Critical Care or hospital, to non-invasive ventilation which, due to its effectiveness but lesser complexity, may be critical in facilitating discharge back in to the community. The CANVent Program has been integral to the development of weaning strategies in the Critical Care units to enable patients with spinal cord injury and others to leave the ICU and participate in life quality-enhancing Rehabilitation. Patients with tracheostomy and non-invasive forms of ventilatory support are also assessed and recommendations and care provided in hospital by the CANVent Program.

One of the unique skills and supports provided by the CANVent Program includes 24 hour NIV which includes night time mask ventilation and day time NIV using a mouth piece from a ventilator mounted to a patients wheel chair. A number of patients in Canada undergo unnecessary tracheostomy ventilation which increases the complexity and cost of ventilation as well as potentially preventing a return to the community. In patients who simply need more than just night time ventilation but who are still able to speak, swallow safely and protect their airway tracheostomy ventilation is rarely necessary, or similarly could be discontinued. 24 hour NIV using a mouthpiece during the daytime ventilation prevents unnecessary tracheostomy placement, unnecessary hospitalization and Critical Care admissions. Speech and swallowing abilities are enhanced and quality of life is improved particularly as the patient may remain at home.

Although only recently involved in research and the recipient of over $200,000 in grant support and a number of articles accepted for publication, the clinical experience and results of the clinical care have attracted over 25 invitations for International presentations and invitations to speak in almost every major city in Canada. Dr. McKim has chaired the Canadian Thoracic Society Clinical Assembly for Home Mechanical Ventilation who recently completed the first Canadian Guidelines on Home Mechanical Ventilation2. The approaches to care pioneered by the CANVent Program have been adopted in a number of jurisdictions in Canada and Internationally. Medical Residents and Fellows in programs across Canada and some International trainees have requested training fellowships in the clinic in order to establish similarly successful services in their home institutions. While at the same time saving the Ontario health care system millions of dollars in Critical Care/Hospital/Sleep Laboratory costs, the CANVent Program continues to enhance the quality of life and survival of patients with Neuro-Respiratory illnesses in the Champlain Region and remains an example of academic, cost-effective and collaborative health care for a population of patients who might otherwise be forced to live in hospital using invasive ventilation and suffer from a seriously diminished level of health and wellness.

For more information about the CANVent Program, please contact Carole LeBlanc at cleblanc@ottawahospital.on.ca

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1. Brooks D, De Rosie J, Mousseau M, Avendaño M, Goldstein RS. Long term follow-up of ventilated patients with thoracic restrictive or neuromuscular disease. <http://www.ncbi.nlm.nih.gov/pubmed/11972163?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=10> Can Respir J. 2002 Mar-Apr;9(2):99-106.

2. McKim DA, Road J, Avendano M, et al. Canadian Thoracic Society Clinical Practice Guidelines; Home Mechanical Ventilation. Can Respir J 2011;18(4):197-215.