Home non-invasive ventilation use following acute hypercapnic respiratory failure in COPD

Home Noninvasive Ventilation in COPD

Evidence is increasing that long-term noninvasive ventilation (LTNIV) can improve outcomes in individuals with severe, hypercapnic COPD. Although the evidence remains unclear in some aspects, LTNIV seems to be able to improve patient-related and physiologic outcomes like dyspnea, FEV1 and partial pressure of carbon dioxide (Pco2) and also to reduce rehospitalizations and mortality. Efficacy generally is associated with reduction in Pco2. To achieve this, an adequate interface (mask) is essential, as are appropriate ventilation settings that target the specific respiratory physiologic features of COPD. This will ensure comfort, synchrony, and adherence that will result in physiologic improvements. This article briefly reviews the newest evidence and current guidelines on LTNIV in severe COPD. It describes an actual patient who benefitted from the therapy. Finally, it provides strategies for initiating and optimizing this LTNIV in COPD, discussing high-pressure noninvasive ventilation, optimization of triggering, and control of inspiratory time. As demand increases, clinicians will need to be familiar with this therapy to reap its benefits, because inadequately adjusted LTNIV will not be tolerated or effective.

The rate of hypercapnic respiratory failure in a pulmonary function test laboratory database

Hypercapnia rates are in the range 3.6-12% among those with abnormal spirometry and FEV1 ≥80% pred, and 53-58% among those with FEV1 <35% pred. Both airflow obstruction and preserved ratio impaired spirometry are associated with higher risk of CHRF. https://bit.ly/3H8DlfM.

Mortality in individuals with COPD on long-term home non-invasive ventilation

BACKGROUND

Real-world evidence regarding survival of patients with chronic obstructive pulmonary disease (COPD) using chronic non-invasive ventilation (NIV) is scarce.

RESEARCH QUESTION

How do obesity and other factors relate to mortality in patients with COPD on chronic NIV?

STUDY DESIGN

and Methods: We retrospectively analyzed data from COPD patients enrolled in a home ventilation program between 2014 and 2018. Survival was compared between obese and non-obese groups using the Kaplan-Meier method. Factors associated with mortality were identified using multivariable Cox proportional regression analyses with Least Absolute Selection and Shrinkage Operator (LASSO) regularization. Univariable analyses were also done stratified by obesity.

RESULTS

Median survival was 80.0 (95% CI: 71.0-NA) months among obese (n = 205) and 30.0 (95%CI: 19.0-42.0) months in non-obese (n = 61) patients. NIV adherence was high in both groups. Mortality was associated with male gender [HR 1.44], chronic opioids or benzodiazepines use [HR 1.07], home oxygen use [HR 1.82], fixed pressure mode of ventilation [HR 1.55], NIV inspiratory pressure [HR 1.05], and thoracic cancer [HR 1.27]; obesity [HR: 0.43], age [HR 0.99] and NIV expiratory pressure [HR 0.94] were associated with decreased mortality. In the obese, univariable analyses revealed that chest wall disease, thoracic cancer, home oxygen use, FEV1% predicted, and ventilation parameters were associated with mortality. In the non-obese, male gender and respiratory comorbidities were related to mortality.

INTERPRETATION

Obesity is associated with improved survival in COPD patients highly adherent to NIV. Other factors associated with mortality reflect disease severity and ventilator parameters, with differences between obese and non-obese patients.

Noninvasive Home Mechanical Ventilation for Stable Hypercapnic COPD: A Clinical Respiratory Review from Canadian Perspectives

Acute short-term noninvasive ventilation (NIV) for hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD) has well-established benefits; however, the role of long-term home NIV remains controversial. In the past decade, studies utilizing aggressive NIV settings to maximally reduce carbon dioxide levels (PaCO2) have resulted in several positive clinical trials and led to updated guidelines on home NIV for stable hypercapnic COPD patients. This clinical respiratory review discusses the high-intensity NIV approach, summarizes recent key trials and guidelines pertaining to home NIV in COPD, and considers key clinical questions for future research and application in the Canadian context. With recent evidence and Canadian Thoracic Society (CTS) guidelines supporting the use of NIV in carefully selected COPD patients with persistent daytime hypercapnia, we believe it is time to reconsider our approach.

Participation of ASK-1 in the cardiomyocyte-protective role of mechanical ventilation in a rat model of myocardial infarction

Non-invasive positive-pressure ventilation (NIPPV) has been demonstrated to exhibit a cardioprotective function in a rat model of myocardial infarction (MI). However, the mechanism underlying NIPPV-mediated MI progression requires further investigation. We aimed to investigate the effectiveness and corresponding mechanism of NIPPV in an acute MI-induced heart failure (HF) rat model. Thirty each of healthy wild type (WT) and apoptosis signal-regulating kinase 1 (ASK-1)-deficient rats were enrolled in this study. MI models were established via anterior descending branch ligation of the left coronary artery. The corresponding data indicated that NIPPV treatment reduced the heart infarct area, myocardial fibrosis degree, and cardiac function loss in MI rats, and ameliorated apoptosis and reactive oxygen species (ROS) levels in the heart tissue. Furthermore, the expression level of ASK-1 level, a key modulator of the ROS-induced extrinsic apoptosis pathway, was upregulated in the heart tissues of MI rats, but decreased after NIPPV treatment. Meanwhile, the downstream cleavage of caspase-3, caspase-9, and PARP, alongside p38 phosphorylation and FasL expression, exhibited a similar trend to that of ASK-1 expression. The involvement of ASK-1 in NIPPV-treated MI in ASK-1-deficient rats was examined. Although MI modeling indicated that cardiac function loss was alleviated in ASK-1-deficient rats, NIPPV treatment did not confer any clear efficiency in cardiac improvement in ASK-1-knockdown rats with MI modeling. Nonetheless, NIPPV inhibited ROS-induced extrinsic apoptosis in the heart tissues of rats with MI by regulating ASK-1 expression, and subsequently ameliorated cardiac function loss and MI-dependent pathogenic changes in the heart tissue.

Home noninvasive ventilation use in patients hospitalized with COPD

INTRODUCTION

The study objective was to estimate the prevalence of chronic hypercapnic respiratory failure (CHRF) and home noninvasive ventilation (NIV) use in a high-risk population, individuals with a history of at least one COPD-related hospitalizations.

METHODS

We retrospectively analyzed electronic medical record data of patients with at least one COPD-related hospitalization between October 1, 2011, and September 30, 2017, to the Iowa City VA Medical Center. We excluded individuals with no obstructive ventilatory defect.

RESULTS

Of 186 patients, the overall prevalence of compensated hypercapnic respiratory failure (CompHRF), defined as PaCO2  > 45 mmHg with a pH = 7.35-7.45, was 52.7%, while the overall prevalence of home NIV was 4.3%. The prevalence of CompHRF was 43.6% and home NIV was 1.8% in those with one COPD-related hospitalization. Among those with ≥4 COPD-related hospitalizations, the prevalence of CompHRF was 77.8% (14 of 18), and home NIV was 11.1% (2 of 18).

CONCLUSION

Approximately half of individuals with at least one COPD-related hospitalization have CompHRF, but only 8.2% of those use home NIV. Future studies should estimate CHRF rates and the degree of underutilization of home NIV in larger multicenter samples.

Domiciliary noninvasive ventilation for chronic respiratory diseases

Patients with chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), neuromuscular diseases, kyphoscoliosis and obstructive sleep apnoea-obesity hypoventilation syndrome (OSA-OHS), are at a higher risk of decompensation in the form of hypercapnic respiratory failure leading to intensive care unit (ICU) admission and increased mortality. This article reviews the evidence of role of domiciliary noninvasive ventilation (NIV) in patients with diseases with chronic ventilatory failure, including the mechanism of the effect of (NIV).

Sleep in hospitalized patients with chronic obstructive pulmonary disease: an observational study

STUDY OBJECTIVES

The aim of this study was to compare the risk of undiagnosed sleep disorders among medical patients with chronic obstructive pulmonary disease (COPD) compared with those without COPD.

METHODS

In a prospective cohort study, hospitalized medical ward patients without a known sleep disorder were screened, using validated questionnaires, for sleep disorders, such as obstructive sleep apnea and insomnia. Daily sleep duration and efficiency in the hospital were measured via wrist actigraphy. Participants were classified into two groups: those with a primary or secondary diagnosis of COPD and those without a history of COPD diagnosis. Sleep outcomes were compared by COPD diagnosis.

RESULTS

From March 2010 to July 2015, 572 patients completed questionnaires and underwent wrist actigraphy. On admission, patients with COPD had a greater adjusted risk of obstructive sleep apnea (adjusted odds ratio 1.82, 95% confidence interval 1.12-2.96, P = .015) and clinically significant insomnia (adjusted odds ratio 2.07, 95% confidence interval 1.12-3.83, P = .021); no differences were observed for sleep quality or excess sleepiness on admission. After adjustment, compared with patients without COPD, patients with COPD averaged 34 fewer minutes of nightly sleep (95% confidence interval 4.2-64.0 minutes, P = .026), as well as 22.5% lower odds of normal sleep efficiency while in the hospital (95% confidence interval 3.3%-37.9%, P = .024). No statistically significant differences were observed for in-hospital sleep quality, soundness, or ease of falling asleep.

CONCLUSIONS

Among hospitalized patients in medical wards, those with COPD have higher risk of OSA and insomnia and worse in-hospital sleep quality and quantity compared with those without COPD.

Does testing for sleep-disordered breathing pre-discharge versus post-discharge result in different treatment outcomes?

STUDY OBJECTIVES

Treatment of sleep-disordered breathing (SDB) may improve health related outcomes post-discharge. However timely definitive sleep testing and provision of ongoing therapy has been a challenge. Little is known about how the time of testing-during hospitalization vs. after discharge-affects important outcomes such as treatment adherence.

METHODS

We conducted a 10-year retrospective study of hospitalized adults who received an inpatient sleep medicine consultation for SDB and subsequent sleep testing. We divided them into inpatient and outpatient sleep testing cohorts and studied their clinical characteristics, follow-up and PAP adherence, and hospital readmission.

RESULTS

Of 485 patients, 226 (47%) underwent inpatient sleep testing and 259 (53%) had outpatient sleep testing. The median age was 68 years old (IQR=57-78), and 29.6% were females. The inpatient cohort had a higher Charlson Comorbidity Index (CCI) (4 [3-6] vs 3[2-5], p=<0.0004). A higher CCI (HR=1.14, 95%CI:1.03-1.25, p=0.001), BMI (HR=1.03, 95%CI:1.0-1.05, p=0.008) and stroke (HR=2.22, 95%CI:1.0-4.9, p=0.049) were associated with inpatient sleep testing. The inpatient cohort kept fewer follow-up appointments (39.90% vs 50.62%, p=0.03) however PAP adherence was high among those keeping follow-up appointments (88.9% [inpatient] vs 85.71% [outpatient], p=0.55). The inpatient group had an increased risk for death (HR: 1.82 95%CI 1.28-2.59, p=<0.001) but readmission rates did not differ.

CONCLUSIONS

Medically complex patient were more likely to receive inpatient sleep testing but less likely to keep follow-up, which could impact adherence and effectiveness of therapy. Novel therapeutic interventions are needed to increase sleep medicine follow-up post-discharge which may result in improvement in health outcomes in hospitalized patients with SDB.

Noninvasive ventilation acutely improves endothelial function in exacerbated COPD patients

PURPOSE

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is associated with an elevated risk of cardiovascular events, which can be linked to endothelial dysfunction. In this study, we aimed to investigate whether noninvasive ventilation (NIV) acutely changes endothelial function in hospitalized AECOPD patients.

METHODS

Twenty-one AECOPD patients were assessed in a hospital ward setting from 24 to 48 h after admission. NIV was applied using a ventilator with bilevel pressure support. Before and after NIV protocol, patients were evaluated regarding (1) endothelium-dependent function, assessed non-invasively using the flow-mediated dilation (FMD) method; (2) arterial blood gas analysis. Other baseline evaluations included clinical and anthropometric data, and laboratory tests.

RESULTS

The total group showed a significant improvement in FMD as a result of NIV effect (P = 0.010). While arterial carbon dioxide and oxygen were not altered, oxygen saturation increased after NIV (P = 0.045). The subgroup comparison of responders (FMD ≥ 1%) and non-responders (FMD < 1%) showed significant baseline differences in body mass index (BMI) (P = 0.019) and predicted forced expiratory volume in one second (FEV₁) (P = 0.007). In univariate and multivariate analyses, both BMI and FEV₁ were determinant for endothelial response to NIV.

CONCLUSION

NIV acutely improves endothelial function in hospitalized AECOPD patients. Overweight and COPD severity may represent important characteristics for the magnitude of peripheral vascular response.

The impact of a telemedicine intervention on home non-invasive ventilation in a rural population with advanced COPD

INTRODUCTION

Rural regions have unique challenges with the implementation of new therapies upon discharge from the hospital due to multiple barriers.

OBJECTIVES

We investigated the effect of home non-invasive ventilation (NIV) plus the implementation of a call center following hospitalization for acute exacerbations of COPD (chronic obstructive lung disease) on NIV usage and readmissions.

METHODS

In this prospective pilot study, consecutive patients were screened at our institution for diagnosis of hypercarbic respiratory failure or COPD exacerbation from 2018 to 2019. Patients with more than two admissions in the last year were reviewed for eligibility. Of the 82 patients screened, 22 were eligible. There were 10 participants randomized to the intervention (NIV and call center) arm and 10 to NIV alone.

RESULTS

A total of 20 patients were randomized (mean age of 64, 45% males, BMI of 32). At three months, average usage was 32.1 days out of 90, 35%. When comparing the call center group to the standard group, there was a statistically significant difference in total days of device usage 48.7 compared to 15.5 (significant U-value of 16, critical value of U at p<.05 of 27) and cumulative use in hours 284 versus 87.7 (significant U-value of 20). Participants in the call center group were readmitted on average 4.2 times compared to 2.4 in the control group which was not statistically different (non-significant U-value of 42). In the follow-up period, 9/20 (45%) of the participants died.

CONCLUSION

This pilot study highlights the challenges in implementing care for advanced COPD in a rural population. Our data suggest that telemedicine may favorably address therapy adherence.

Management of Chronic Respiratory Failure in Chronic Obstructive Pulmonary Disease: High-Intensity and Low-Intensity Ventilation

A significant body of literature supports the benefit of noninvasive ventilation (NIV) for acute hypercapnia in the setting of exacerbations of chronic obstructive pulmonary disease (COPD). In those with severe COPD with chronic hypercapnic respiratory failure, however, the role of NIV has been more controversial. This article reviews the physiologic basis for considering NIV in patients with COPD, summarizes existing evidence supporting the role of NIV in COPD, highlights the patient population and ventilatory approach most likely to offer benefit, and suggests a potential clinical pathway for managing patients.

Effects and Mechanism of Noninvasive Positive-Pressure Ventilation in a Rat Model of Heart Failure Due to Myocardial Infarction

BACKGROUND Impaired heart function induced by myocardial infarction is a leading cause of chronic heart failure (HF). This study aimed to investigate the effects and mechanism of noninvasive positive-pressure ventilation (NIPPV) in a rat model of HF due to myocardial infarction. MATERIAL AND METHODS To explore the therapeutic effect and mechanism of NIPPV on acute myocardial infarction-induced HF, we established a rat model of HF by ligating the anterior descending branch of the left coronary artery and confirmed by ultrasonic cardiography and brain natriuretic peptide 45 detection. RESULTS The levels of heat-shock protein (HSP)-70 increased and matrix metalloproteinase (MMP)-2, MMP-9, and tumor necrosis factor (TNF)-alpha decreased in the group that received NIPPV treatment compared with the control group. In addition, the histopathologic results showed less severe inflammatory infiltration and a smaller area of myocardial fibrosis in the NIPPV treatment group. CONCLUSIONS In a rat model of HF due to myocardial infarction, NIPPV resulted in increased levels of HSP70 and reduced expression of MMP2, MMP9, and TNF-alpha and reduced myocardial neutrophil infiltration and fibrosis. Taken together, we showed that NIPPV is an effective treatment for HF induced by myocardial infarction by inhibiting the release of inflammatory factors and preventing microvascular embolism.

Non-invasive ventilation at home improves survival and decreases healthcare utilization in medicare beneficiaries with Chronic Obstructive Pulmonary Disease with chronic respiratory failure

BACKGROUND

Patients with Chronic Obstructive Pulmonary Disease with chronic respiratory failure (COPD-CRF) experience high mortality and healthcare utilization. Non-invasive home ventilation (NIVH) is increasingly used in such patients. We examined the associations between NIVH and survival, hospitalizations, and emergency room (ER) use in COPD-CRF Medicare beneficiaries.

MATERIALS AND METHODS

Retrospective cohort study using the Medicare Limited Data Set (2012-2018). Patients receiving NIVH within two months of CRF diagnosis (treatment group) were matched on demographic and clinical characteristics to patients never receiving NIVH (control group). CRF diagnosis was identified using ICD-9-CM/ICD-10-CM codes. Time to death, first hospitalization, and first ER visit were estimated using Cox regressions.

RESULTS

After matching, 517 patients receiving NIVH and 511 controls (mean age: 70.6 years, 44% male) were compared. NIVH significantly reduced risk of death (aHR: 0.50; 95%CI: 0.36-0.65), hospitalization (aHR: 0.72; 95%CI: 0.52-0.93), and ER visit (aHR: 0.48; 95%CI: 0.38-0.58) at diagnosis. The NIVH risk reduction became smaller over time for mortality and ER visits, but continued to accrue for hospitalizations. One-year post-diagnosis, 28% of treated patients died versus 46% controls. For hospitalizations and ER visits, 55% and 72% treated patients experienced an event, respectively, versus 67% and 92% controls. The relative risk reduction was 39% for mortality, 17% for hospitalizations, and 22% for ER visits. Number needed to treat were 5.5, 9, and 5 to prevent a death, hospitalization, or ER visit one-year post-diagnosis, respectively.

CONCLUSION

NIVH treatment is associated with reduced risk of death, hospitalizations, and ER visits among COPD-CRF Medicare beneficiaries.

Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease

The role of noninvasive positive pressure ventilation (NIV) in severe chronic obstructive pulmonary disease (COPD) has been controversial. Over the past two decades, data primarily obtained from Europe have begun to define the clinical characteristics of patients likely to respond, the role of high-intensity NIV, and the potential best timing of initiating therapy. These approaches, however, have not been validated in the context of the U.S. healthcare delivery system. Use of NIV in severe COPD in the United States is limited by the practicalities of doing in-hospital titrations as well as a complex system of reimbursement. These systematic complexities, coupled with a still-emerging clinical trial database regarding the most effective means to deliver NIV, have led to persistent uncertainty regarding when in stable severe COPD treatment with NIV is actually appropriate. In this review, we propose an assessment algorithm and treatment plan that can be used in clinical practice in the United States, but we acknowledge that the absence of pivotal clinical trials largely precludes a robust evidence-based approach to this potentially valuable therapy.

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.

CE: Managing Stable COPD: An Evidence-Based Approach

: Chronic obstructive pulmonary disease (COPD) affects as many as 16 million Americans and is expected to be the third leading cause of death worldwide by 2020. To increase awareness of COPD, encourage related research, and improve care of patients with this chronic disease, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was launched in 1998 and published an evidence-based report on COPD prevention and management strategies in 2001 that has been revised regularly. The fourth major revision, which was published in 2017 and revised in 2018, includes significant changes related to COPD classification, as well as to pharmacologic, nonpharmacologic, and comorbidity management. The authors discuss the changes to the GOLD recommendations and, using a patient scenario, explain their application to clinical practice.

Is positive airway pressure therapy underutilized in chronic obstructive pulmonary disease patients?

INTRODUCTION

The role of noninvasive positive pressure ventilation (NIPPV) in patients with stable chronic obstructive pulmonary disease (COPD) in the home-setting remains controversial. Despite studies suggesting potential benefits, there is an apparent underutilization of such therapy in patients with stable COPD in a domiciliary setting. Areas covered: The reasons for underutilization in the home-setting are multifactorial, and we provide our perspective on the adequacy of scientific evidence and implementation barriers that may underlie the observed underutilization. In this article, we will discuss continuous PAP, bilevel PAP, and non-invasive positive pressure ventilation using a home ventilator (NIPPV). Expert commentary: Many patients with stable COPD and chronic respiratory failure do not receive NIPPV therapy at home despite supportive scientific evidence. Such underutilization suggests that there are barriers to implementation that include provider knowledge, health services, and payor policies. For patients with stable COPD without chronic respiratory failure, there is inadequate scientific evidence to support domiciliary NIPPV or CPAP therapy. In patients with stable COPD without chronic respiratory failure, studies aimed at identifying patient characteristics that determine the effectiveness of domiciliary NIPPV therapy needs further study. Future implementation and health-policy research with appropriate stakeholders are direly needed to help improve patient outcomes.

Long-term outcomes after acute hypercapnic COPD exacerbation : First-ever episode of non-invasive ventilation

BACKGROUND

Non-invasive ventilation (NIV) is used to treat acute hypercapnic respiratory failure (AHRF) in patients with chronic obstructive pulmonary disease (COPD); however, long-term outcomes following discharge are largely unknown. This study aimed to characterize long-term outcomes and identify associated markers in patients with COPD after surviving the first episode of HRF requiring NIV.

METHODS

This study retrospectively analyzed 122 patients, mean age 62 ± 8 years, 52% female and forced expiratory volume in 1 s (FEV1) predicted 30 ± 13%, admitted with an acute hypercapnic exacerbation of COPD and receiving a first-ever NIV treatment between 2000 and 2012.

RESULTS

A total of 40% of the patients required hospital readmission due to respiratory reasons within 1 year. Persistent hypercapnia leading to the prescription of domiciliary NIV, older age and lower body mass index (BMI) were risk factors for readmission due to respiratory reasons. Survival rates were 79% and 63% at 1 and 2 years after discharge, respectively. A shorter time to readmission and recurrent hypercapnic failure, lower BMI and acidemia on the first admission, as well as hypercapnia at hospital discharge were correlated with a decreased long-term survival.

CONCLUSION

Patients with COPD surviving their first episode of AHRF requiring NIV are at high risk for readmission and death. Severe respiratory acidosis, chronic respiratory failure and a lower BMI imply shorter long-term survival.

Does Adherence to Domiciliary NIMV Decrease the Subsequent Hospitalizations Rates and Cost for Patients Diagnosed with COPD?

Domiciliary noninvasive mechanical ventilation (NIMV) is used for treating patients with hypercapnic chronic obstructive pulmonary disease (COPD). We aimed to evaluate the association between adherence to the treatment and subsequent hospitalizations and costs. Data from 54 (27 adherent; 27 non-adherent) patients with COPD who were undergoing NIMV treatment at home for 6 months. We assessed adherence based on digitally recorded data and checked hospital records for clinical and laboratory data, rehospitalization rates, and costs during the following 6 months. Nocturnal NIMV usage, mean daily usage of the device, and time to first hospitalization were higher in the treatment-adherent group (p < .001, p < .001, and p=.006, respectively). The percentage of active smokers, device leaks above 30 L/min, length of hospital stay, rehospitalization rates, and costs were significantly higher in the treatment-non-adherent group (p = 05, p = 006, p = 004, p = 006, and p = 01, respectively). The most frequent reasons for not using NIMV in the treatment-non-adherent group were a decreased need, dry mouth, mask incompatibility, and gastrointestinal complaints. Adherence to NIMV treatment decreases the subsequent hospitalizations rates and noncompliance leads to complications. Findings of this study may help physicians in convincing patients diagnosed with COPD of the need for correct NIMV use to prevent hospitalizations and reduce the costs of COPD treatment.

[Home non-invasive ventilation for chronic obstructive pulmonary disease]

INTRODUCTION

The benefits of long-term non-invasive ventilation (NIV) in the management of chronic obstructive pulmonary disease (COPD) patients remain controversial.

AIM

To analyze the characteristics of COPD patients under home NIV and to evaluate its impact among this population.

METHODS

We carried out a retrospective study between January 2002 and April 2016 of COPD patients under long-term NIV at "la Rabta" and the Military Hospital.

RESULTS

There were 27 patients with an average age of 64 and a sex ratio (M/F) of 0.92. Active smoking was reported in 96.3%. A persistent hypercapnia following an acute exacerbation of COPD with failure to wean the NIV was the main indication of long-term NIV. We noted a reduction in hospital admissions in the first year of 60% and in intensive care of 83.3% (P<10^-3). There was no non-significant decrease of PaCO₂ (4.5mmHg). There was no modification in FEV 1 and in FVC (P>0.05). The survival rate was 96.3% at 1 year, 83.3% at 2 years and a median survival of 24 months.

CONCLUSIONS

Our study suggests that home NIV contributes to the stabilization of some COPD patients by reducing the hospitalizations rates for exacerbation. More prospective studies are needed to better assess the impact of NIV on survival and quality of life and to better define the COPD patients who require NIV.

The use of home non-invasive ventilation and the reduction of inhospital mortality of patients with respiratory failure

OBJECTIVES

To establish the relationship between the use of home non-invasive ventilation (NIV) and inhospital mortality in people admitted due to exacerbation of their respiratory disease.

METHODS

Retrospective cohort study with 191 cases of patients attended at the emergency department of the Reina Sofía General University Hospital in Murcia due to ARF of any cause and who required NIV as supportive treatment.

RESULTS

Mortality among patients using NIV as routine home treatment was 6.45%, compared to 20.1% among those who did not use it (P<.05).

CONCLUSIONS

routine domiciliary treatment with NIV has been shown to be a protective factor against inpatient hospital mortality for patients who underwent NIV during their admission, through the emergency department, for acute respiratory failure or acute chronic disease, regardless of the triggering pathology.

Respiratory parameters predict poor outcome in COPD patients, category GOLD 2017 B

Background

Respiratory parameters are important predictors of prognosis in the COPD population. Global Initiative for Obstructive Lung Disease (GOLD) 2017 Update resulted in a vertical shift of patients across COPD categories, with category B being the most populous and clinically heterogeneous. The aim of our study was to investigate whether respiratory parameters might be associated with increased all-cause mortality within GOLD category B patients.

Methods

The data were extracted from the Czech Multicentre Research Database, a prospective, noninterventional multicenter study of COPD patients. Kaplan-Meier survival analyses were performed at different levels of respiratory parameters (partial pressure of oxygen in arterial blood [PaO₂], partial pressure of arterial carbon dioxide [PaCO₂] and greatest decrease of basal peripheral capillary oxygen saturation during 6-minute walking test [6-MWT]). Univariate analyses using the Cox proportional hazard model and multivariate analyses were used to identify risk factors for mortality in hypoxemic and hypercapnic individuals with COPD.

Results

All-cause mortality in the cohort at 3 years of prospective follow-up reached 18.4%. Chronic hypoxemia (PaO₂ <7.3 kPa), hypercapnia (PaCO₂ >7.0 kPa) and oxygen desaturation during the 6-MWT were predictors of long-term mortality in COPD patients with forced expiratory volume in 1 second ≤60% for the overall cohort and for GOLD B category patients. Univariate analyses confirmed the association among decreased oxemia (<7.3 kPa), increased capnemia (>7.0 kPa), oxygen desaturation during 6-MWT and mortality in the studied groups of COPD subjects. Multivariate analysis identified PaO₂ <7.3 kPa as a strong independent risk factor for mortality.

Conclusion

Survival analyses showed significantly increased all-cause mortality in hypoxemic and hypercapnic GOLD B subjects. More important, PaO₂ <7.3 kPa was the strongest risk factor, especially in category B patients. In contrast, the majority of the tested respiratory parameters did not show a difference in mortality in the GOLD category D cohort.

Update: non-invasive ventilation in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) remains a common cause of morbidity and mortality worldwide. Patients with COPD and respiratory failure, whether acute or chronic have a poorer prognosis than patients without respiratory failure. Non-invasive ventilation (NIV) has been shown to be a useful tool in both the acute hospital and chronic home care setting. NIV has been well established as the gold standard therapy for acute decompensated respiratory failure complicating an acute exacerbation of COPD with reduced mortality and intubation rates compared to standard therapy. However, NIV has been increasingly used in other clinical situations such as for weaning from invasive ventilation and to palliate symptoms in patients not suitable for invasive ventilation. The equivocal evidence for the use of NIV in chronic hypercapnic respiratory failure complicating COPD has recently been challenged with data now supporting a role for therapy in selected subgroups of patients. Finally the review will discuss the emerging role of high flow humidified therapy to support or replace NIV in certain clinical situation.

Role of Domiciliary Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease Patients Requiring Repeated Admissions with Acute Type II Respiratory Failure: A Prospective Cohort Study

Background:

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with acute hypercapnic respiratory failure (AHRF) is associated with high mortality and increased risk for further exacerbations and hospitalization. While there is ample evidence regarding the benefit of noninvasive ventilation (NIV) during AECOPD, evidence supporting long-term noninvasive ventilation (LTNIV) for more stable COPD patients is limited.

Objective:

The aim of this study is to assess the effectiveness of LTNIV in COPD patients requiring frequent hospital admissions and NIV support for AHRF.

Materials and Methods:

A prospective cohort study including 120 patients having survived an admission requiring NIV support for AHRF due to COPD, with a history of ≥3 similar episodes in the past year. Patients were advised LTNIV (30) with standard treatment, or (90) standard treatment alone. Both groups were followed up for 1 year. Among non-NIV group 10 died, and 8 lost follow-up, whereas two died in NIV group. The primary endpoint was death. Data of remaining 100 patients were analyzed for other objectives-number of readmissions, AHRF, Intensive Care Unit (ICU)/ventilator requirement, dyspnea, quality of life, exercise tolerance, lung function, and arterial blood gases.

Results:

LTNIV group had 40% reduction in mortality (6.6% vs. 11.1%). There was significant reduction in number of hospital admissions (28.6% vs. 84.7%: P <0.05), ICU admissions (7.1% vs. 56.9%: P = 0.01), ventilator requirement (3.6% vs. 30.6%: P = 0.003), AHRF (7.1% vs. 48.6%: P = 0.000) and improvement in partial arterial CO₂ pressure (39.8 ± 2.1 vs. 57.03 ± 3.7 mmHg) and severe respiratory insufficiency score (P < 0.05) among LTNIV group, but no significant change in lung function and exercise tolerance.

Conclusion:

Patients tolerated LTNIV well and had a better outcome compared to those without NIV. LTNIV may be considered in patients with recurrent AHRF.

Chronic obstructive pulmonary disease and sleep related disorders

PURPOSE OF REVIEW

Sleep related disorders are common and under-recognized in the chronic obstructive pulmonary disease (COPD) population. COPD symptoms can disrupt sleep. Similarly, sleep disorders can affect COPD. This review highlights the common sleep disorders seen in COPD patients, their impact, and potential management.

RECENT FINDINGS

Treatment of sleep disorders may improve quality of life in COPD patients. Optimizing inhaler therapy improves sleep quality. Increased inflammatory markers are noted in patients with the overlap syndrome of COPD and obstructive sleep apnea versus COPD alone. There are potential benefits of noninvasive positive pressure ventilation therapy for overlap syndrome patients with hypercapnia. Nocturnal supplemental oxygen may be beneficial in certain COPD subtypes. Nonbenzodiazepine hypnotic therapy for insomnia has shown benefit without associated respiratory failure or worsening respiratory symptoms. Melatonin may provide mild hypnotic and antioxidant benefits.

SUMMARY

This article discusses the impact of sleep disorders on COPD patients and the potential benefits of managing sleep disorders on respiratory disease control and quality of life.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 report focuses primarily on the revised and novel parts of the document. The most significant changes include: (1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (2) for each of the groups A to D, escalation strategies for pharmacologic treatments are proposed; (3) the concept of deescalation of therapy is introduced in the treatment assessment scheme; (4) nonpharmacologic therapies are comprehensively presented; and (5) the importance of comorbid conditions in managing chronic obstructive pulmonary disease is reviewed.

Practical Insight to Monitor Home NIV in COPD Patients

Home noninvasive ventilation (NIV) is used in COPD patients with concomitant chronic hypercapnic respiratory failure in order to correct nocturnal hypoventilation and improve sleep quality, quality of life, and survival. Monitoring of home NIV is needed to assess the effectiveness of ventilation and adherence to therapy, resolve potential adverse effects, reinforce patient knowledge, provide maintenance of the equipment, and readjust the ventilator settings according to the changing condition of the patient. Clinical monitoring is very informative. Anamnesis focuses on the improvement of nocturnal hypoventilation symptoms, sleep quality, and side effects of NIV. Side effects are major cause of intolerance. Screening side effects leads to modification of interface, gas humidification, or ventilator settings. Home care providers maintain ventilator and interface and educate patients for correct use. However, patient's education should be supervised by specialized clinicians. Blood gas measurement shows a significant decrease in PaCO₂ when NIV is efficient. Analysis of ventilator data is very useful to assess daily use, unintentional leaks, upper airway obstruction, and patient ventilator synchrony. Nocturnal oximetry and capnography are additional monitoring tools to assess the impact of NIV on gas exchanges. In the near future, telemonitoring will reinforce and change the organization of home NIV for COPD patients.

Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline

This document provides clinical recommendations for treatment of chronic obstructive pulmonary disease (COPD) exacerbations.Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of COPD experts.After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made: 1) a strong recommendation for noninvasive mechanical ventilation of patients with acute or acute-on-chronic respiratory failure; 2) conditional recommendations for oral corticosteroids in outpatients, oral rather than intravenous corticosteroids in hospitalised patients, antibiotic therapy, home-based management, and the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge; and 3) a conditional recommendation against the initiation of pulmonary rehabilitation during hospitalisation.The Task Force provided recommendations related to corticosteroid therapy, antibiotic therapy, noninvasive mechanical ventilation, home-based management, and early pulmonary rehabilitation in patients having a COPD exacerbation. These recommendations should be reconsidered as new evidence becomes available.

Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: (i) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (ii) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; (iii) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; (iv)non-pharmacological therapies are comprehensively presented and (v) the importance of co-morbid conditions in managing COPD is reviewed.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: 1) the assessment of COPD has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; 2) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; 3) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; 4) nonpharmacologic therapies are comprehensively presented and; 5) the importance of comorbid conditions in managing COPD is reviewed.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: 1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; 2) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; 3) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; 4) nonpharmacologic therapies are comprehensively presented and; 5) the importance of comorbid conditions in managing COPD is reviewed.

Effects of ventilator settings, nebulizer and exhalation port position on albuterol delivery during non-invasive ventilation: an in-vitro study

Background

Few studies have investigated the factors affecting aerosol delivery during non-invasive ventilation (NIV). Our aim was to investigate, using a bench-top model, the effect of different ventilator settings and positions of the exhalation port and nebulizer on the amount of albuterol delivered to a lung simulator.

Methods

A lung model simulating spontaneous breathing was connected to a single-limb NIV ventilator, set in bi-level positive airway pressure (BIPAP) with inspiratory/expiratory pressures of 10/5, 15/10, 15/5, and 20/10 cmH₂O, or continuous positive airway pressure (CPAP) of 5 and 10 cmH₂O. Three delivery circuits were tested: a vented mask with the nebulizer directly connected to the mask, and an unvented mask with a leak port placed before and after the nebulizer. Albuterol was collected on a filter placed after the mask and then the delivered amount was measured with infrared spectrophotometry.

Results

Albuterol delivery during NIV varied between 6.7 ± 0.4% to 37.0 ± 4.3% of the nominal dose. The amount delivered in CPAP and BIPAP modes was similar (22.1 ± 10.1 vs. 24.0 ± 10.0%, p = 0.070). CPAP level did not affect delivery (p = 0.056); in BIPAP with 15/5 cmH₂O pressure the delivery was higher compared to 10/5 cmH₂O (p = 0.033) and 20/10 cmH₂O (p = 0.014). Leak port position had a major effect on delivery in both CPAP and BIPAP, the best performances were obtained with the unvented mask, and the nebulizer placed between the leak port and the mask (p < 0.001).

Conclusions

In this model, albuterol delivery was marginally affected by ventilatory settings in NIV, while position of the leak port had a major effect. Nebulizers should be placed between an unvented mask and the leak port in order to maximize aerosol delivery.

Preventing Hospitalizations From Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive lung disease is among the leading causes of adult hospital admissions and readmissions in the United States. Preventing acute exacerbations is the primary approach in therapy. Combinations of smoking cessation, pulmonary rehabilitation, vaccinations and inhaled and oral medications may all reduce the overall risk of acute exacerbations. When prevention is unsuccessful, treatment of exacerbations often does not require hospitalization but can be safely executed in the outpatient setting. In the patient who does not require mechanical ventilation or who manifests respiratory acidosis, oxygen supplementation, frequent short-acting inhaled bronchodilators, oral corticosteroids and often antibiotics can abort the decompensation and sometimes return the patient to his or her pre-attack baseline lung function. Several models exist for delivering this care in the ambulatory setting. Follow-up care after an exacerbation has resolved is important, though there are few hard data suggesting which approach is best in this setting.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

The role of NIV in chronic hypercapnic COPD following an acute exacerbation: the importance of patient selection?

Recently, clear benefits have been shown from long-term noninvasive ventilation (NIV) in stable chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure. In our opinion, these benefits are confirmed and nocturnal NIV using sufficiently high inspiratory pressures should be considered in COPD patients with chronic hypercapnic respiratory failure in stable disease, preferably combined with pulmonary rehabilitation. In contrast, clear benefits from (continuing) NIV at home after an exacerbation in patients who remain hypercapnic have not been shown. In this review we will discuss the results of five trials investigating the use of home nocturnal NIV in patients with prolonged hypercapnia after a COPD exacerbation with acute hypercapnic respiratory failure. Although some uncontrolled trials might have shown some benefits of this therapy, the largest randomized controlled trial did not show benefits in terms of hospital readmission or death. However, further studies are necessary to select the patients that optimally benefit, select the right moment to initiate home NIV, select the optimal ventilatory settings, and to choose optimal follow up programmes. Furthermore, there is insufficient knowledge about the optimal ventilatory settings in the post-exacerbation period. Finally, we are not well informed about exact reasons for readmission in patients on NIV, the course of the exacerbation and the treatment instituted. A careful follow up might probably be necessary to prevent deterioration on NIV early.

Advances and New Approaches to Managing Sleep-Disordered Breathing Related to Chronic Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a common disease affecting about 20 million US adults. Sleep-disordered breathing (SDB) problems are frequent and poorly characterized for patients with COPD. Both the well-known success of noninvasive ventilation (NIV) in the acute COPD exacerbation in the hospital setting and that NIV is the cornerstone of chronic therapy for SDBs have urged the attention of the medical community to determine the impact of NIV on chronic COPD management with and without coexisting SDBs. Early observational studies showed decreased long-term survival rates on patients with COPD with concomitant chronic hypercapnia when compared with normocapnic patients.

8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – Part 3

This paper summarizes the Part 3 of the proceedings of the 8^th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations.

This paper (Part 3) presents a section regarding Moving Across the Spectrum of Care for Long-Term Ventilation (Moving Across the Spectrum of Care for Long-Term Ventilation, New Indications for Non-Invasive Ventilation, Elective Ventilation in Respiratory Failure - Can you Prevent ICU Care in Patients with COPD?, Weaning in Long-Term Acute Care Hospitals in the United States, The Difficult-to-Wean Patient: Comprehensive management, Telemonitoring in Ventilator-Dependent Patients, Ethics and Palliative Care in Critically-Ill Respiratory Patients, and Ethics and Palliative Care in Ventilator-Dependent Patients).

High Intensity Non-Invasive Positive Pressure Ventilation (HINPPV) for Stable Hypercapnic Chronic Obstructive Pulmonary Disease (COPD) Patients

Introduction: High intensity non-invasive positive pressure ventilation (HI-NPPV) is an algorithm of non-invasive ventilation that has been shown to improve partial pressure of carbon dioxide (PaCO₂), health-related quality of life and mortality in hypercapnic chronic obstructive pulmonary disease (COPD) patients. Objective: Assess 3 months of HI-NPPV in stable hypercapnic COPD patients. Methods: A single arm, non-randomized pilot study of HI-NPPV. Patients were eligible if they had clinically stable COPD and daytime arterial PaCO₂ >50 mmHg. Results: Nine patients completed therapy. Patient characteristics: 2 male: 7 female, mean age of 64.4 years (SD ±6.6), mean forced expiratory volume in 1 second (FEV₁) of 26% (SD±6.73), 8 patients on long term oxygen therapy (LTOT) and a median body mass index (BMI) of 26.6 (interquartile range [IQR] 25.5 - 32.5). Outcomes: There was a mean reduction in daytime PaCO₂ by 4.66 mmHg (p=0.01) and bicarbonate by 2.16 mmHg (p=0.005). There was no statistically significant difference in lung function, maximal inspiratory pressures or 6 minute walk distance. There was no statistically significant difference in sleep duration, efficiency or percentage of sleep stage 3 ( N3) or rapid eye movement (REM). The Chronic Respiratory Questionnaire (CRQ) showed a trend towards improvement with an increase of 2.69 points (p=0.054), the dyspnea domain showed a statistically significant improvement (p=0.03). The Calgary Sleep Apnea Quality of Life Index (SAQLI) detected an improvement in daily functioning (p=0.007). The Severe Respiratory Insufficiency (SRI) Questionnaire showed a trend to improvement overall (p=0.05). Four patients had COPD exacerbations during the follow up period. Conclusions: HI-NPPV is able to substantially reduce PaCO₂ in hypercapnic COPD patients; we detected a positive effect on quality of life measures with no significant change in sleep quality.