Chronic respiratory failure in patients with chronic obstructive pulmonary disease under home noninvasive ventilation: Real-life study

[Quality of Care in Home Mechanical Ventilation]

Home mechanical ventilation has developed rapidly over the last 20 years. Today's most common positive pressure ventilation can be performed either non-invasively via face masks or invasively via endotracheal intubation or tracheal cannula. Non-invasive ventilation (NIV) in particular has gained in importance in recent years as positive evidence for a variety of indications for home mechanical ventilation has become increasingly available. In order to ensure a high quality of treatment for the steadily increasing number of patients, specific guidelines for different patient groups have been developed and regularly updated. The appropriate care structures for these partly multimorbid patient cohorts are strongly discussed, since the capacity limits of the existing care structure are reached by the rapid development in home mechanical ventilation. This development shows, that a critical evaluation of the existing care structures is necessary in order to develop a patient-centered, customized and resource-saving healthcare structure on the basis of the existing structures and taking into account the national characteristics of the German healthcare system.

Current Practices in Home Mechanical Ventilation for Chronic Obstructive Pulmonary Disease: A Real-Life Cross-Sectional Multicentric Study

Purpose

Home mechanical ventilation (HMV) use in chronic obstructive pulmonary disease (COPD) is becoming increasingly widespread. The aim of this study was to provide an accurate description of the current practices and clinical characteristics of COPD patients on HMV in Portugal.

Methods

The study was designed as a cross-sectional, multicenter real-life study of COPD patients established on HMV for at least 30 days. Data related to clinical characteristics, adaptation and ventilatory settings were collected.

Results

The study included 569 COPD patients on HMV from 15 centers. The majority were male, with a median age of 72 years and a high prevalence of obesity (43.2%) and sleep apnea (45.8%). A high treatment compliance was observed (median 8h/day), 48.7% with inspiratory positive airway pressure ≥20 cmH₂O and oronasal masks were the preferred interface (91.7%). There was an equal distribution of patients starting HMV during chronic stable condition and following an exacerbation. Patients in stable condition were initiated in the outpatient setting in 92.3%. Despite the differences in criteria and setting of adaptation and a slightly lower BMI in patients starting HMV following an exacerbation, we found no significant differences regarding age, gender, ventilation pressures, time on HMV, usage, severity of airflow obstruction or current arterial blood gas analysis (ABGs) in relation to patients adapted in stable condition.

Conclusion

Patients were highly compliant with the therapy. In agreement with most recent studies and recommendations, there seems to be a move towards higher ventilation pressures, increased use of oronasal masks and an intent to obtain normocapnia. This study shows that chronic hypercapnic and post exacerbation patients do not differ significantly regarding patient characteristics, physiological parameters or ventilatory settings with one exception: chronic hypercapnic patients are more often obese and, subsequently, more frequently present OSA.

Risk factors of unfavorable outcomes in chronic obstructive pulmonary disease patients treated with noninvasive ventilation for acute hypercapnic respiratory failure

BACKGROUND-AIM

Noninvasive mechanical ventilation (NIV) failure rate is reported to be 5%-60% of intensive care unit (ICU) patients. Despite all precautions and well-known reasons, the risk factors of NIV failure are unclear for chronic obstructive pulmonary disease (COPD) with acute respiratory failure (ARF). The aim of this study was to examine risk factors for NIV failure in COPD patients with ARF, other than well defined.

METHODS

The retrospective cohort study was done in ICU of a chest disease hospital. All consecutive COPD patients with hypercapnic ARF were enrolled in study. Demographics, comorbidities, arterial blood gases, reasons of ARF and length of ICU stay were recorded. NIV success was defined as discharge from ICU and NIV failure was defined as need for intubation or died during NIV. Patients were grouped into; NIV failure and success. The groups were compared and NIV failure risk factors were analyzed.

RESULTS

About 265 NIV success and 142 NIV failure patients were enrolled into the study. Logistic regression test showed the risk factors for NIV failure; higher APACHE-II (≥ 29) (OR:11.71, CI95%4.39-31.18, P < 0.001), culture positivity (OR:7.59, CI95%3.21-17.92, P < 0.001), sepsis (OR:6.53 CI95%3.59-11.85, P < 0.001) and pneumonia (OR:3.71 CI95%0.60-2.02, P < 0.043) significantly. COPD patients using home-based NIV had less risk for NIV failure (OR: 0.49 CI95%0.28-0.87, P < 0.014).

CONCLUSIONS

APACHE II ≥ 29 score, culture positivity, sepsis and pneumonia are the risk factors for NIV failure in COPD patients with ARF. COPD patients previously on home-based NIV showed half times less risk for NIV failure.

Association of Home Noninvasive Positive Pressure Ventilation With Clinical Outcomes in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis

IMPORTANCE

The association of home noninvasive positive pressure ventilation (NIPPV) with outcomes in chronic obstructive pulmonary disease (COPD) and hypercapnia is uncertain.

OBJECTIVE

To evaluate the association of home NIPPV via bilevel positive airway pressure (BPAP) devices and noninvasive home mechanical ventilator (HMV) devices with clinical outcomes and adverse events in patients with COPD and hypercapnia.

DATA SOURCES

Search of MEDLINE, EMBASE, SCOPUS, Cochrane Central Registrar of Controlled Trials, Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, and Scopus for English-language articles published from January 1, 1995, to November 6, 2019.

STUDY SELECTION

Randomized clinical trials (RCTs) and comparative observational studies that enrolled adults with COPD with hypercapnia who used home NIPPV for more than 1 month were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction was completed by independent pairs of reviewers. Risk of bias was evaluated using the Cochrane Collaboration risk of bias tool for RCTs and select items from the Newcastle-Ottawa Scale for nonrandomized studies.

MAIN OUTCOMES AND MEASURES

Primary outcomes were mortality, all-cause hospital admissions, need for intubation, and quality of life at the longest follow-up.

RESULTS

A total of 21 RCTs and 12 observational studies evaluating 51 085 patients (mean [SD] age, 65.7 [2.1] years; 43% women) were included, among whom there were 434 deaths and 27 patients who underwent intubation. BPAP compared with no device was significantly associated with lower risk of mortality (22.31% vs 28.57%; risk difference [RD], -5.53% [95% CI, -10.29% to -0.76%]; odds ratio [OR], 0.66 [95% CI, 0.51-0.87]; P = .003; 13 studies; 1423 patients; strength of evidence [SOE], moderate), fewer patients with all-cause hospital admissions (39.74% vs 75.00%; RD, -35.26% [95% CI, -49.39% to -21.12%]; OR, 0.22 [95% CI, 0.11-0.43]; P < .001; 1 study; 166 patients; SOE, low), and lower need for intubation (5.34% vs 14.71%; RD, -8.02% [95% CI, -14.77% to -1.28%]; OR, 0.34 [95% CI, 0.14-0.83]; P = .02; 3 studies; 267 patients; SOE, moderate). There was no significant difference in the total number of all-cause hospital admissions (rate ratio, 0.91 [95% CI, 0.71-1.17]; P = .47; 5 studies; 326 patients; SOE, low) or quality of life (standardized mean difference, 0.16 [95% CI, -0.06 to 0.39]; P = .15; 9 studies; 833 patients; SOE, insufficient). Noninvasive HMV use compared with no device was significantly associated with fewer all-cause hospital admissions (rate ratio, 0.50 [95% CI, 0.35-0.71]; P < .001; 1 study; 93 patients; SOE, low), but not mortality (21.84% vs 34.09%; RD, -11.99% [95% CI, -24.77% to 0.79%]; OR, 0.56 [95% CI, 0.29-1.08]; P = .49; 2 studies; 175 patients; SOE, insufficient). There was no statistically significant difference in the total number of adverse events in patients using NIPPV compared with no device (0.18 vs 0.17 per patient; P = .84; 6 studies; 414 patients).

CONCLUSIONS AND RELEVANCE

In this meta-analysis of patients with COPD and hypercapnia, home BPAP, compared with no device, was associated with lower risk of mortality, all-cause hospital admission, and intubation, but no significant difference in quality of life. Noninvasive HMV, compared with no device, was significantly associated with lower risk of hospital admission, but there was no significant difference in mortality risk. However, the evidence was low to moderate in quality, the evidence on quality of life was insufficient, and the analyses for some outcomes were based on small numbers of studies.

A Low-Cost Breath Analyzer Module in Domiciliary Non-Invasive Mechanical Ventilation for Remote COPD Patient Monitoring

Smart Breath Analyzers were developed as sensing terminals of a telemedicine architecture devoted to remote monitoring of patients suffering from Chronic Obstructive Pulmonary Disease (COPD) and home-assisted by non-invasive mechanical ventilation via respiratory face mask. The devices based on different sensors (CO₂/O₂ and Volatile Organic Compounds (VOCs), relative humidity and temperature (R.H. & T) sensors) monitor the breath air exhaled into the expiratory line of the bi-tube patient breathing circuit during a noninvasive ventilo-therapy session; the sensor raw signals are transmitted pseudonymized to National Health Service units by TCP/IP communication through a cloud remote platform. The work is a proof-of-concept of a sensors-based IoT system with the perspective to check continuously the effectiveness of therapy and/or any state of exacerbation of the disease requiring healthcare. Lab tests in controlled experimental conditions by a gas-mixing bench towards CO₂/O₂ concentrations and exhaled breath collected in a sampling bag were carried out to test the realized prototypes. The Smart Breath Analyzers were also tested in real conditions both on a healthy volunteer subject and a COPD suffering patient.