Advice
The technology
The technology
The Vest (Hill‑Rom) is an airway clearance system that delivers high-frequency chest wall oscillation (HFCWO). An air-pulse generator rapidly inflates and deflates a garment (available in different styles and sizes), which gently compresses and releases the chest wall. This action is designed to mobilise mucus from smaller to larger airways, which can then be coughed up or removed by suction.
The Vest has 3 programmes with different combinations of frequency, pressure and treatment time. A treatment session usually takes 10 to 30 minutes. The system can be used by the person having treatment, but people who are immobile may need help from a carer. Specialist commentators noted that The Vest and manual techniques should not be used until at least 1 hour after the person having treatment has eaten.
If The Vest were adopted, it would replace chest wall percussion, which is physically demanding and time-consuming for the carer.
The Vest is contraindicated in people with a head or neck injury that has not been stabilised or in people with an active haemorrhage with haemodynamic instability. It should be used with caution in some people, as described in the company's instructions for use; this includes people with rib fractures or people with osteomyelitis of the ribs.
Innovations
The company claims The Vest is unique from other manual airway clearance therapy because it delivers a standardised therapy in a consistent way.
Current care pathway
There are no published guidelines on airway clearance in people with complex neurological needs. Specialist commentators confirmed that they are usually referred to community respiratory physiotherapy teams. Chest wall physiotherapy is the standard treatment for managing airway clearance and involves manual techniques aimed at clearing the lungs by percussion (clapping), vibration, deep breathing and huffing or coughing. Community respiratory physiotherapy teams train carers to do chest wall percussion. A typical session takes about 30 minutes but can range from 10 to 60 minutes. People will usually need 2 to 4 sessions a day, but if they have a respiratory infection they may need up to 6 sessions. There are other complementary treatments used to help with airway clearance including cough assist devices, suction devices and nebulisers. People who have repeat respiratory infections or recurrent or prolonged hospital admissions may be offered treatment with The Vest.
Population, setting and intended user
People with complex neurological needs and airway clearance problems usually have their care managed by a community respiratory physiotherapy team, but their day-to-day needs are typically met by carers. Specialist respiratory physiotherapy teams, where these exist, would need to train users or carers in how to use The Vest, and design specific respiratory care plans. The Vest would most likely be used in a person's home to replace chest wall percussion done by respiratory physiotherapists or trained carers. The Vest should only be considered on the recommendation of an experienced respiratory physiotherapist.
Costs
Technology costs
The list price of The Vest is £6,995 per device, excluding VAT; volume discounts may apply. The air-pulse generator has an expected lifespan of between 5 and 10 years. The inflatable garments come in various styles and sizes and need to be replaced about every 2 to 4 years (garment prices range from £275 to £295). An estimated annual cost for treatment with The Vest is £817.50 (based on 10 years of use with 4 garment replacements) to £1,517 (based on 5 years of use with 2 garment replacements) per person. The company claims that The Vest does not need routine maintenance.
Costs of standard care
The company states that chest wall physiotherapy is usually done by carers so there is no ongoing cost to the NHS. However, there are costs associated with specialist training of carers to use The Vest. One specialist commentator said that in their service, it takes 3 sessions to train a carer. Repeated training sessions and monitoring of the effectiveness of the therapy may also be needed.
Resource consequences
The Vest would represent an additional cost compared with standard care; the subsequent resource consequences are uncertain and depend on the patient group in which it is used, and the configuration and availability of local specialist physiotherapy services. The additional costs might be offset if using The Vest resulted in fewer respiratory complications needing treatment or admission to hospital. There is no published economic evidence to judge this.
People with complex neurological needs and their carers would usually have 1 or 2 training sessions at their home on how to use the technology and 1 or 2 follow‑up calls to make sure treatment is being delivered correctly. Training and follow‑up calls would be done by the community respiratory physiotherapy team or specialist centre if community teams do not offer this; they would have had training from the company. The company offers training at no additional cost using a 'train-the-trainer' approach. The Vest is usually used for 6 weeks on a trial basis before a decision is made on longer-term treatment.
The company has stated that The Vest is currently being used in at least 36 NHS organisations across the UK. Specialist commentators have said that where The Vest is funded by the NHS, it is usually through an individual funding request.
Several specialists commented that The Vest is being used infrequently in NHS clinical practice but 1 stated that it is being used in children with complex neurological needs who have frequent chest infections or hospital admissions.