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Abstract
Introduction Non-invasive ventilation (NIV) treatment combined with pronation in patients with COVID-19 respiratory failure has been shown to be effective in improving respiratory function and better patient outcomes. These patients may experience discomfort or anxiety that may reduce adherence to treatment.
Objective The aim of this study was to explore and describe the subjective experiences of patients undergoing helmet NIV and pronation during hospitalisation for COVID-19 respiratory failure, with a focus on the elements of care and strategies adopted by patients that enabled good adaptation to treatments.
Method A qualitative descriptive study, using face-to-face interviews, was carried out with a purposeful sample of 20 participants discharged from a pulmonary intensive care unit who underwent helmet continuous positive airway pressure and pronation during hospitalisation for COVID-19.
Results Content analysis of the transcripts revealed feelings and experiences related to illness and treatments, strategies for managing one’s own negative thoughts, and practical strategies of one’s own and healthcare workers to facilitate adaptation to pronation and helmet. Experience was reflected in five major topics related to specific time points and settings: feelings and experiences, helmet and pronation: heavy but beneficial, positive thinking strategies, patients’ practical strategies, support of healthcare professionals (HCPs).
Conclusions This study may be useful to HCPs to improve the quality and appropriateness of care they provide.
- COVID-19
- Adult intensive & critical care
- Patient-Centered Care
- Patient Reported Outcome Measures
- Patient Satisfaction
- Respiratory Distress Syndrome
Data availability statement
Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article. We are unable to publicly share the full transcripts due to the sensitive nature of the information collected. All data relevant to the study are included in the manuscript. Other data can be requested as a reasonable request to the corresponding authors.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- COVID-19
- Adult intensive & critical care
- Patient-Centered Care
- Patient Reported Outcome Measures
- Patient Satisfaction
- Respiratory Distress Syndrome
STRENGTHS AND LIMITATIONS OF THIS STUDY
The use of a qualitative design allows us to more fully understand the experience of patients undergoing helmet and pronation and to add insights to these treatments.
Consistently with a qualitative approach, a heterogeneous group was recruited based on clinical severity, duration of pronation and non-invasive ventilation (NIV) to explore the variability of experiences.
The perspectives of participants who were admitted to intensive care unit and underwent invasive mechanic ventilation were not explored, due to the difficulty for them to recover memories prior to intubation. However, this could limit the generalisability of the findings to the patients who failed with NIV.
In-depth insights are from perspectives and lived experiences in a selected geographical region, and therefore, may not be generalisable at the national level or to other sociocultural settings.
Introduction
In recent years, non-invasive ventilation (NIV), including non-invasive variable positive airway pressure ventilation and continuous positive airway pressure (CPAP), has progressively gained a key role in the therapy of both hypoxaemic and hypercapnic acute respiratory failure.1 2
About 15% of patients with severe acute hypoxaemic respiratory failure (AHRF) have been treated with NIV in recent years, with an important increase during the COVID-19 pandemic.3 4
Helmet CPAP (HCPAP), significantly reduces intubation rates and increases patient survival, may, however, be associated with possible claustrophobia, high noise level, skin breakdown in the armpits and neck that may lead to intolerance to HCPAP.5 6
In the same way, pronation has also proven to be an effective intervention to optimise lung recruitment and improve oxygenation in hypoxic patients with COVID-19.7 In the absence of effective therapies for COVID-19, the implementation of supportive care has been essential, and prone positioning has been suggested as a standard of care by international guidelines, despite the fact that prior to the pandemic it was an intervention studied predominantly on patients undergoing invasive mechanical ventilation.8
Prone positioning in awake, spontaneous-breathing COVID-19 patients can improve oxygenation, reduce work of breathing, and therefore, reduce the risk of intubation. Despite these advantages, maintaining the prone position can be particularly challenging, as poor comfort has been described as the main cause of prone disruption. NIV failure is a major problem because it is associated with adverse clinical outcomes, such as mortality and prolonged mechanical ventilation.9
Few studies have been conducted on the experience of patient adaptation during NIV with mask or helmet and pronation with the patient awake and mostly on patients with COPD, none during the combination of these two treatments.10–13 This knowledge gap does not give the patient a voice, risks limiting the ability of healthcare providers and missing out on those elements of care intrinsic to the patient, which can lead to better adherence and compliance.
Therefore, the aim of this study was to explore and describe the subjective experiences of patients undergoing helmet NIV and pronation during hospitalisation for COVID-19 respiratory failure, with a focus on the elements of care and strategies adopted by patients that enabled good adaptation to ventilatory treatment and pronation.
Methods
Study design
The study used a qualitative descriptive design by following the method of Sandelowski and Barroso.14 This design is commonly used to capture the experiences of individuals for better understanding of phenomena or events. Qualitative descriptive is considered the most appropriate technique for obtaining information that can inform the development of policies or interventions, making it a suitable methodology for the study.15
Face-to-face interviews were carried out with a purposeful sample of participants who underwent HCPAP and pronation during hospitalisation for COVID-19. The methods and results of the study were reported according to the consolidated criteria for reporting qualitative research (COREQ) .16
Setting and participants
The study involved participants discharged from a 12-bed pulmonary intensive care unit (ICU) of a first-level hospital in Northern Italy, which provided non-invasive monitoring and respiratory support for patients with HARF due to COVID-19.
The nurse to patient staffing ratio was 1:4. There were two pulmonologists in the morning shift and one in the afternoon/night shifts; and a physiotherapist for a few hours per day. The treatment of choice consisted of HCPAP with positive end-expiratory pressure (PEEP) 10 cm H2O, alternating with 60 L/min high-flow nasal cannula (HFNC) and variable FiO2 depending on the level of Oxygen saturation (SpO2) maintained by the individual.
A maximum variation purposive sampling was used to recruit participants discharged from hospital for at least 4 weeks but no more than 4 months in the period from October 2020 to May 2021.17 The inclusion criteria were: adults aged >18 years, patients who had been treated with NIV for at least 72 hours and had experienced pronation. The participants had to be native or Italian speaking and to give informed consent to participate in the study. The exclusion criteria were cognitive impairment and transfer to an ICU due to need of invasive mechanic ventilation with no readmission to the pulmonary ICU. Eligible participants were approached by telephone by a researcher, informed about the study and asked their willingness to participate. If they consented to participate, they were asked to be interviewed. Participant recruitment continued until data saturation was reached.
Data collection
Data were collected using face-to- face, semistructured, audiorecorded interviews. These were conducted in a place feasible and desirable for the participants in the period between May and October 2021, and lasted from 40 to 90 min. To achieve their research objective, the team developed an interview guide by conducting a literature review and leveraging their expertise in the field. The guide was then validated by three experts with experience in pulmonology, respiratory support and qualitative studies. Prior to use, the interview guide was piloted with two participants (refer to box 1).
Interview semistructured guide
How would you describe your illness experience during your stay in the respiratory intensive care unit? If you think back to the most significant days and moments, what do you remember?
Helmet
How do you describe the experience of wearing a helmet?
What strategies have helped you to live with the presence of the helmet?
Pronation
How would you describe the experience of pronation while awake?
What strategies did you implement to remain in that position as much as possible? How did you spend your time?
Strategies
What did help you to get through that period?
How and with whom did you communicate?(with carers, with other patients in the room, with family members)
If you had to give one piece of advice to a patient, what would you advise him/her to do to cope with an experience like yours?
A female PhD-level researcher (EA) and a male nurse with advanced education (GC), both with prior qualitative research training and expertise, conducted the interviews. During transcription/summarising, all personal identifiers were removed.
Participants were asked to narrate their experience with HCPAP and pronation. Depending on what emerged, participants were asked questions to elicit their perspectives about effective strategies to maintain the helmet and the prone position. The researchers left room for the participants’ emotions and experiences to emerge, and finally also investigated their communication with healthcare workers and between participants, as well as the intensity and manner of their contacts with the outside world.
Data on patients’ sociodemographic characteristics such as gender and age, as well as clinical data, were retrieved from the electronic records management system. The mortality risk on admission was evaluated using the Simplified Acute Physiology Score II (SAPSII), which comprises 12 physiological variables, age, type of admission and three underlying disease variables.18 The SAPSII score ranges from 0 to 163, and the predicted mortality ranges from 0% to 100%.18
To determine the risk of clinical instability, the National Early Warning Score 2 (NEWS2) scale was used, which is based on the combined scoring of six physiological parameters, including respiratory rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion and body temperature.19 Additionally, two points are added for patients who require supplementary oxygen treatment. A NEWS2 score of 5 or 6 is considered a critical threshold, which may indicate clinical deterioration and prompt an urgent response from healthcare professionals (HCPs).
Both the SAPSI II and the NEWS2 scoring charts were routinely used in the hospital’s patient care practice.
Data analysis
An inductive analysis of interview transcripts was conducted independently by three researchers (AB, EA and GC). No qualitative analysis software was used. An inductive thematic analysis of the data was performed, where the most descriptive content was identified to obtain codes. Subsequently, the groups of codes that presented a common meaning (categories) were identified, until the themes describing participants’ experience were obtained. Each researcher performed the coding and analysis of codes and categories. Subsequently, meetings were held, where the results obtained were shared and compared, and themes were identified. In the event of different opinions, a decision was reached by consensus. Descriptive statistics were used to characterise the sample. Mean and SD were calculated for continuing variables, sums and percentage for categorical variables.
Patient and public involvement
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Results
Twenty interviews were conducted, and saturation was reached after 20 interviews. The characteristics of the participants are shown in table 1.
Demographic and clinical characteristics of participants
The mean age was 63.1 years with a range of 49–73 years comparable to that of patients admitted during the pandemic period to the pulmonary ICU considered. Regarding clinical severity, the participants differed from each other. Out of all the participants, every one of them was prescribed with pronation. Out of these participants, 17 maintained a prone position, with or without HCPAP, for 6–14 hours per day. These hours were divided into cycles of varying duration, with at least 2 hours per cycle, unless they experienced complications. However, three participants did not practise prone position due to obesity or lower back pain, which increased discomfort while in a prone position.
Content analysis of the transcripts revealed feelings and experiences related to illness and treatments, strategies for managing one’s own negative thoughts, and practical strategies of one’s own and healthcare workers to facilitate adaptation to pronation and helmet.
Feelings and experiences from the disease and treatments
Sense of helplessness and unconsciousness
When participants describe their experience of illness they report feelings of helplessness, fear, uncertainty and feeling close to the limit. Participants felt ‘extremely frail and vulnerable’ because of the inability to make the slightest effort without breathlessness, ‘feeling powerless to do a natural action like breathing, at that moment the breath was not coming and had to be helped by something else (helmet). Such a vital function was no longer under my control’ (P 4). The feeling of helplessness was exacerbated by the perception that they had reached the limit and needed to use all their resources, described as follows by two participants: ‘Always being on the edge and having to pick up the last crumbs of inner resources to cross that threshold that was always moving a little further’ (P 5). ‘I could see that they were raising the oxygen (…) and on the monitor 98 then 97,…86 (SpO2)…you're on the edge and you can't do anything’ (P 20).
Eight of the 20 participants realised only in hindsight the real severity of what they had gone through, in the acute phase of illness they had no awareness of their real clinical criticism: ‘honestly I was very quiet, I felt no particular ills. They said I had breathlessness, but it seemed to me that I was breathing well (…) obviously that was not true’ (P 12). ‘I didn't realize it, but my saturation was 88 when I was admitted’ (P 15). At the same time, half of the participants reported that they were afraid of getting worse and what might happen if things did not get better: ‘you are afraid of dying. The word I used most, I was saying, is dramatic. It is a dramatic experience… I perceived it that way, as a very dramatic thing, I was afraid to die’ (P 4).
Helmet and pronation: heavy but beneficial
Participants reported a temporal evolution of feelings about the helmet and pronation: an initial frightening impact from the feeling of not breathing and gradually the perception of benefit and relief given by their use.
Helmet heavy experience
The first difficult hours
All participants described the first few hours of HCPAP as the heaviest due to the fears of suffocation given by ‘wearing something that wraps around your whole head’ or ‘being enclosed in a bag’ (P 18, 5). Participants described helmet as a barrier between them and reality, using the terms like ‘flask’, ‘diving suit’ and one of them states: ‘you are like a fish inside an aquarium, you see others, but you can't scream and communicate’ (P 5).
Deafening noise and discomfort, dryness of the air and pressure from the suspenders and sheathing
Participants’ first thought thinking back to the helmet was the ‘continuous deafening noise that sounded like a jackhammer’ (P 16) and interfered with rest and sleep. Most of them experienced ‘a dry feeling’ (P 2) in the throat and nostrils, especially with HFNC used during breaks ‘would get too much oxygen in my nose, it would bother me (…) it felt like someone was blowing cold air into my nose. An obnoxious thing,’ (P 17).
Participants also reported discomfort in the first few days due to constant pressure in the armpit cavity: ‘I felt a little squeezed under my armpits’ (P 19), and later the reduction of the sheath’s adherence to your neck and a cold feeling in your back and chest: ‘(…) the sheath closing makes this crazy air come out from underneath’ ‘(…) and you felt cold down your back’ (P 4, 13).
Minimal freedom of movement
Participants experienced limitation to their ability to move, even to the simplest ones such as ‘scratching’ a part of their face, they also spoke of their fear of disconnecting some parts of the NIV circuit: ‘At the beginning you can only turn your head with the helmet, if you want to turn or move your hair you have to call: there are all those tubes…’ (P 7).
Pronation heavy experience
In the same way, pronation was described in interviews as difficult ‘I could not turn over, during the night sleeping like this is a nightmare (…) the body says: -no, turn over!- It’s a torture that you know will last 8 hours after which they pull it out of you’ (P 13). Three participants failed to practice pronation: ‘I was doing everything they told me, but pronation, that was not, I was dancing on the bed because of my belly, and I couldn't stay’ (P3).
Discomfort and looking for the right position
Participants reported that it is critical to find and maintain the right position: ‘It’s not easy, but it’s not impossible either. You look for the position (…) you do it with the pillow, trying to put it crooked, to put your hand under the pillow, to keep one arm down or on the sideboard’ (P 6). It also emerged that the prone or semiprone sleeping habit facilitated to accept pronation while awake, even with a helmet.
A long time without contact
Partecipants recalled pronation as a waiting and long time to spend ‘in that position, in that waiting, hoping to get better’ (P 5). The time was aggravated by the reduction in the possibility of having contact added to the noise of the helmet ‘prone you were dialoguing with the pillow and that’s all, with the helmet then (…) there was also noise’ (P 14).
Helmet and pronation beneficial experience
Participants also gradually expressed the perceived and seen benefit of the helmet and pronation, mostly related to the ‘saturation improvement’: ‘With the helmet I could see from the monitor that my saturation was good. When they took my helmet off to eat, … it was drama. With the slightest movement, even simply swallowing, I would see the saturation drop 90–89… and I would say: -oh my God put my helmet back on before it drops any more’ (P 20).
(…) I stood there and stayed most of the night. I had the video on it, and I could see the saturation going up. It was 83 and it went up to 90, a good step for me. That was the right way (P 1).
Activate positive thinking strategies
The content analysis of the interviews revealed the actions implemented by the participants to cope with the treatments. The partecipant activated positive thinking strategies and turned away from negative thoughts.
Considering treatments the only way out
Almost all participants used as a strategy for accepting the treatments (helmet and pronation) considering them the only way out and trusting them and the team.
I experienced it (the helmet) as a tool that would heal me, not a friend, but a useful object (P 8). I was convinced that it was something (pronation) that would help me get through that moment. (…) a system to expand the lungs better. (P 9)
Thinking about positive features
Some participants reported how important it was to focus thinking on the positive features of the treatments. ‘I could drink and then I saw that I could keep my glasses on, so I could also look at my cell phone, text. It was not pleasant clearly, but not so bad either’ (P 14). ‘ thought: there is a zipper and if there is a zipper I can open this, right? It’s soft not a hard thing’ (P 4).
Moving beyond difficulties with willpower and hope
Participants reported having ‘shifted their thinking’ from difficulties to something else. ‘or a hospitalized person this is a way to fight and be positive in the face of what they are facing’ (P 10).
Don't give up, don't just look at the present, look forward, look beyond, there is hope, chase away the black thoughts, the negative thoughts and believe that you too will make it (P 5).
Try to see it as something you absolutely need to heal, so to have hope, because you can only have that. It just takes patience and hope (P 15).
Activate practical strategies
Filling time
To fill the time of pronation with helmet, which passed slowly, the interviewees implemented some strategies reconcilable with the situation: ‘reading was impossible then I realized that a headset headphone was enough, and I listened to music: I listened to whole piano concerts and those relaxed me’ (P 1). ‘I fell asleep when I listened to the hustle and bustle: who was cleaning, who was bringing you food…’ (P 7).
Turning noise into sound
Many participants refused the earplugs so as not to lose touch with reality and recount that they ‘transported themselves with their minds’ to another place and associated the noise with something relaxing. ‘I thought it was a nice noise, if I had to put up with it (…) with my husband we have traveled the world, seen many seas. I thought it sounded like waves breaking on rocks (…) and finally I told myself it was a nice feeling, that maybe it would even make me sleep’ (P 6).
Keeping in touch with reality
Participants perceived being able to see the outside world as positive: ‘Luckily there was a window in the room, you see the sun, the mountains’ (P 18), ‘I could see the clock, I wanted to see the time passing’(P 19) ‘You kept in touch with reality and not only with your illness. You also needed to distract yourself (…) I was looking out the window’(P 20).
Maintaining contact with loved ones
For the respondents, it had been crucial to be able to keep in touch with loved ones through phone calls or video calls during times of detachment from treatments. About half of them in the early days preferred to limit contact to the bare minimum aware that they were regularly and constantly informed by treatment teams.
Support among roommates
Participants positively remember the ‘roommates’ and the relationships with them, which in moments of fragility were a support for them: ‘They came to the room and said:—Look we have to intubate you—. And he said:—Come on come on I'm waiting for you, you have to come out on your own, on the double, go! - … it’s those little things that still help at that time. A little psychological support even between bedfellows is good’ (P 19). ‘We were already towards the end and I had a bit of a crisis, of nostalgia, that is. One night, though, I had those who came right there, my roommates were the first ones who helped me’ (P 1). For some, roommate relationships continued even months after discharge.
The support of HCPs
Participants described how receiving time and attention from the care team was decisive in coping with the illness experience.
Informing by encouraging
All respondents appreciated the ‘humanity’ of HCPs and perceived the encouragement they received and the ‘reassuring presence’ as decisive in overcoming discomfort and difficulties. ‘He explained what I was up against, I get emotional thinking about it, he held my hands and very calmly explained the seriousness of it, but with great humanity. He really gave me courage’ (P 4).
The fact of stopping those extra minutes (nurses, doctors), while having a lot of things to do, (…) is to be put on the same level as medication (P 2).
The doctor when she spoke to me was not standing, she was sitting on my bed, on the same level. It is very important to feel that we are on the same level, that’s it. I felt like a fellow traveler (P 5).
Ensuring a reassuring presence
Participants considered the care team’s ‘surveillance’ described as awareness of their presence and quick response to problems as reassuring.
Every time you called them, they came, they were constantly checking on you (P 9).
They were attentive (…) nurses and doctors would stop by to see. They followed up with you so well that you didn't even need to ask (P 14).
Nurturing hope participants
In describing their conversations with healthcare providers tell how they were constantly motivated through an ongoing dialogue about their condition and improvements.
They would encourage you by saying:—Good, good! They were cheering, complimenting you even if it was just because you were trying hard. It helped and pleased me (P 15).
To nurture hope even in the effort of waiting is to receive energy from outside and to see the goodness of what you are experiencing. (…) to see that the treatment is working and so you yourself try to contribute by enduring the discomfort of the moment (P 5).
Provide time to converse about other things
The narratives show how participants were able to distract themselves and relax during conversations with practitioners.
They would just ask you what you had, but also where you are from, what you do. That is, also things that helped you relax your mind (P 1).
They also talked about personal life, about their children. Even with the nurses, one told me about her issue with separation. We were also able to get to know each other (P 10).
Paying attention to comfort
In recounting episodes of care, participants emphasised time spent on comfort and concrete actions implemented by healthcare providers: ‘applying the hair cap to the face,’ ‘earplugs to reduce noise in the helmet,’ or ‘before zipping up, they put my glasses on…I could read’. (P 1,2,10)
Providing pharmacological help
Four participants reported that they were helped in tolerating and accepting the prone position by anti-anxiety therapy: ‘And I remember that I stayed there, accomplice also a few drops of relaxant that they gave me’ (P 10).
Two participants, on the other hand, reported that they were also able to tolerate prone position by steroid therapy, which had dulled some chronic joint pain: ‘Strangely enough, thanks to the cortisone, I was not in pain, so I was able to sleep on my stomach, always with my arms wide apart, out of bed, with my helmet on, without a pillow’ (P8).
Discussion
This paper analyses the perception of patients with AHRF and COVID-19 undergoing pronation and HCPAP. In order to explore the variability of experiences consistently with the qualitative approach, a heterogeneous group was assembled based on clinical severity, duration of pronation and NIV (see table 1).
Their experience was reflected in five major topics related to specific time points and settings: feelings and experiences, helmet and pronation: heavy but beneficial, positive thinking strategies, patients’ practical strategies, support of HCPs. Feelings of helplessness, fragility and fear played an important role in this phase, mostly related to the breathlessness experience rather than to the personal awareness of the severity of clinical condition.20 There are no studies on these combined treatments in this type of patient. We have discussed our results with those of other studies, which are not always qualitative and conducted on patients with chronic obstructive pulmonary disease (COPD) or other chronic diseases, which does not always make them comparable.
Regarding the use of pronation and HCPAP, our study showed how these treatments were considered by participants as the only way out of the acute phase of the disease. This result confirmed those of previous studies focused on the experience of COPD patients undergoing NIV with a face mask during disease exacerbation.10 21
All the participants described the first hours with the combined treatment (pronation+HCPAP) as an overall heavy experience. Deafining noise, dryness of the air, pressure from the suspenders and sheathing, were the most burdensome physical factors related to the helmet, while discomfort and back ache, those related to pronation. Similar perceptions of discomfort emerged in a recent study of covid-9 patients with helmet-CPAP treatment postextubation.22
From these experience reports, we may define some healthcare interventions to improve patient’s adherence through comfort actions, such as paying attention to comfort: helping the patient to find the right position, applying a hair cap, earplugs or earbuds and glasses (to let patients listen to their favourite music or read something). These practical measures allow patients to better overcome the discomfort caused by noise and the time of treatments. About the emotional issues, participants reported fear of suffocation and isolation, due to helmet barrier and lack of contacts. Neverthelss, participants gradually went beyond these initial negative perceptions when they saw and felt the treatment benefits and when these were emphasised by HCPs.23 Moreover, in the breaks from helmet, many participants reported higher discomfort with HFNC than with helmet, as previously discovered by Grieco et al.24
HCPs should be aware of this emotional impact and adopt strategies to foster positive thinking, and the reassuring presence of HCPs relationship and communication that conveyed hope.
Relational support and the possibility of communicating with a family member or friend via social media were found to be important factors in reducing loneliness and stress, in line with the findings of other studies that emphasise the importance of assistance but do not describe in what manner.10 25
The strategies adopted by participants that have emerged in other studies also correspond to those found in our study and may suggest some healthcare interventions in the relationship with patients that could improve treatment adherence.22 Giving news about clinical conditions in an encouraging way and making improving parameters visible on monitor, report clear feedback on the evolution and benefits of the treatments and how it is going. Moreover, providing support to patients with information and explanations on the physiological needs and tangible benefits related to the treatments, before starting to use the device, can establish a relationship of trust with the patient and alleviate fears. The latter aspect is also emphasised in other previous studies.22 25
In terms of limitations, all participants were recruited from a single centre and were Italian speaking, suggesting some sociodemographic homogeneity. The time between discharge and interview may represent a selection bias, it would be important to include patients who have just been discharged. It would be useful to know the perspectives of patients who failed with the NIV. However, this involved admission to the ICU and made it difficult to recover memories prior to intubation. In addition, although we have attempted to identify and address potential investigator bias, as in all qualitative work, this is difficult to eliminate. An important strength of this and other qualitative research is that it allows deep exploration of a topic facilitating the development of insights, which can be used to drive further enquiry, qualitative and quantitative. We recognise that the patients’ perspective, although central, is not enough to understand the whole picture; particularly regarding the practical strategies it would be interesting to assess the health professionals’ views and experiences in future studies. Only by integrating the perspective of the different stakeholders involved the process of care, will it be possible to identify the major drawbacks and enhance the experience of providing care.
Conclusions
To date, there are no studies known to have investigated the patients’ point of view on these interventions practised simultaneously, on this target patient population. Our study enriches understanding of this complex experience by shedding light on the burdens of HCPAP and pronation, and motivations to endure.
This study describes the experience of patients with HARF treated with NIV and pronation. This knowledge may be useful to HCPs to ensure interventions and care in line with what can help patients most.
To involve patient and facilitate adherence to the two treatments—NIV and pronation—healthcare providers can take several steps:
Information: Patients should be informed about the benefits of the treatments and why they are important. HCPs should provide information about what to expect during the treatment and how it can improve their health outcomes.
Communication: Patients need to be in constant communication with HCPs concerning their treatment progress, ask questions and share their concerns about the treatment. Dialogues regarding potential risks and benefits of the treatments can also help foster trust and support between patients and care team.
Listening to the patient’s voice: It can improve involvement in care and tailor treatments to their needs.
Support: Patients need support in undergoing treatments. HCPs can offer support through proper positioning, monitoring of vital signs and providing pain medications if necessary;
Comfort measures: HCPscan take steps to make the treatment as comfortable as possible for the patient. This includes adjusting machine settings to the patient’s comfort, providing pillows or other support to alleviate discomfort caused by prolonged pronation and implementing mental relaxation techniques;
Family involvement: Involving family members in the treatment plan can also help with adherence. Family members can help by encouraging patients to undergo the treatment and providing emotional and physical support.
To initiate reflection and education, it is recommended that the aforementioned suggestions be taken as a starting point for both basic and continuing training. As NIV is increasingly used as a first-line treatment in intensive and semi-intensive units, further research in this field could be beneficial to enhance the perception of HCPls and ensure patient comfort during treatment. Additionally, research could be carried out to comprehend the impact of medical monitoring on symptom burden.
Data availability statement
Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article. We are unable to publicly share the full transcripts due to the sensitive nature of the information collected. All data relevant to the study are included in the manuscript. Other data can be requested as a reasonable request to the corresponding authors.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants andthis study was conducted in line with the Declaration of Helsinki and received approval from the ethics committee of the hospital involved (ID: P12705/2021). Written informed consent was obtained from all participants prior to data collection. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank all the patients who generously gave their time to support this study. We thank all participants for sharing personal memories and emotions regarding the period of illness experienced.
References
Footnotes
Twitter @Gabriele Chini
Contributors AB: study design and supervision, data interpretation and analysis, prepared the article; GC: study design,data collection and analysis; RS: data collection; EA: study design, prepared the article, data analysis.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.