
==== Front
Ann Am Thorac Soc
Ann Am Thorac Soc
AnnalsATS
Annals of the American Thoracic Society
2329-6933
2325-6621
American Thoracic Society

202405-458LE
10.1513/AnnalsATS.202405-458LE
Letters
Reply: Specialists in Chronic Respiratory Failure Should Serve More Than Just Ventilator-Dependent Patients
Cao Michelle 1 *
Katz Sherri Lynne 2
Hansen-Flaschen John 3
1 Stanford University
Stanford, California
2 University of Ottawa
Ottawa, Ontario, Canada
3 University of Pennsylvania
Philadelphia, Pennsylvania
* Corresponding author (e-mail: michellecao@stanford.edu).
1 9 2024
1 9 2024
1 9 2024
21 9 13441344
Copyright © 2024 by the American Thoracic Society
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0. For commercial usage and reprints, please e-mail Diane Gern.
==== Body
pmcFrom the Authors:

In their comment on our article (1), Currow and coauthors draw attention to an important problem that we acknowledged up front in our article: no international consensus document currently defines chronic respiratory failure. Currow and colleagues are prominent palliative care and pulmonary physicians who share an interest in advancing comprehensive, symptom-focused care for people with chronic breathlessness. From that perspective, they advocate for a broadly encompassing understanding of the term “chronic respiratory (ventilatory) failure (insufficiency)” that extends all the way to include people who chronically experience Modified Medical Research Council dyspnea scale level 1 breathlessness (shortness of breath when hurrying on level ground or walking up a slight hill) despite optimal treatment of the underlying causes.

Under the heading “What Do We Mean by Chronic Respiratory Failure?” we set forth a more restricted understanding of the term that coincides with common usage within the pulmonary, critical care, and neurology communities. By this definition, chronic respiratory failure denotes an inability to maintain healthy ventilation at rest. The hallmark is symptomatic hypoventilation with nocturnal or continuous hypercapnia. Most hypercapnic children and adults benefit from long-term mechanically assisted ventilation during sleep. Many with more severe disease depend on near continuous assisted ventilation for life support.

Dramatic recent advances in home assisted ventilation technology are enabling more people to live longer at home with chronic respiratory failure, thereby substantially increasing the prevalence of the condition. Subspecialists who focus on the clinical care of these people play an emerging role within the specialty of pulmonary (respiratory) medicine analogous to that of specialists in chronic heart, liver, or kidney failure within their respective specialties. Although those with dyspnea and less advanced respiratory insufficiency are also deserving of expert care, our intent is to focus on additional specialized training in pulmonary medicine on the management of a subpopulation of individuals who have more advanced disease and who are technologically dependent on advanced respiratory devices to breathe.

We take a strong issue with the statement by Currow and colleagues that “mechanical ventilation is no protection against breathlessness.” The one reference they cite to support that statement documented dyspnea in 40% of hospitalized, critically ill adults undergoing mechanical ventilation for acute respiratory failure, a condition far removed from that of our patients with chronic respiratory failure who comfortably use noninvasive ventilation during their regular lives at home. The impact of optimized home assisted ventilation on breathlessness and quality of life varies according to the underlying disease and other determinants but is often highly favorable (2, 3).

We applaud the efforts of clinicians across all specialties who provide comprehensive palliative care for people with chronic breathlessness, but we caution that such practices are substantially incomplete without access to expertly managed home assisted ventilation for people at the severe end of the spectrum of breathlessness. We contend that the knowledge and skills needed to manage chronic respiratory failure and the prevalence of the condition have advanced to the point that specialized training, continuing education, and focused research are needed to ensure the best available care for children and adults who need assistive technology to breathe.

Author disclosures are available with the text of this letter at www.atsjournals.org.
==== Refs
References

1 Cao M Katz SL Hansen-Flaschen J Roadmap for advancing a new subspecialty in pulmonary medicine devoted to chronic respiratory failure Ann Am Thorac Soc 2024 21 692 695 38445980
2 Ribeiro C Jácome C Oliveira P Conde S Windisch W Nunes R Patients experience regarding home mechanical ventilation in an outpatient setting Chron Respir Dis 2022 19 14799731221137082 36417310
3 D’Cruz RF Kaltsakas G Suh E-S Hart N Quality of life in patients with chronic respiratory failure on home mechanical ventilation Eur Respir Rev 2023 32 220237 37137507
