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Raveling T, Vonk J, Struik FM, Goldstein R, Kerstjens HA, Wijkstra PJ, Duiverman ML. Chronic non-invasive ventilation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2021; 8:CD002878. [PMID: 34368950 PMCID: PMC8407093 DOI: 10.1002/14651858.cd002878.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Chronic non-invasive ventilation (NIV) is increasingly being used to treat people with COPD who have respiratory failure, but the evidence supporting this treatment has been conflicting. OBJECTIVES To assess the effects of chronic non-invasive ventilation at home via a facial mask in people with COPD, using a pooled analysis of IPD and meta-analysis. SEARCH METHODS We searched the Cochrane Airways Register of Trials, MEDLINE, Embase, PsycINFO, CINAHL, AMED, proceedings of respiratory conferences, clinical trial registries and bibliographies of relevant studies. We conducted the latest search on 21 December 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing chronic NIV for at least five hours per night for three consecutive weeks or more (in addition to standard care) versus standard care alone, in people with COPD. Studies investigating people initiated on NIV in a stable phase and studies investigating NIV commenced after a severe COPD exacerbation were eligible, but we reported and analysed them separately. The primary outcomes were arterial blood gases, health-related quality of life (HRQL), exercise capacity (stable COPD) and admission-free survival (post-exacerbation COPD). Secondary outcomes for both populations were: lung function, COPD exacerbations and admissions, and all-cause mortality. For stable COPD, we also reported respiratory muscle strength, dyspnoea and sleep efficiency. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. After inclusion of a study, we requested the IPD. We analysed continuous and time-to-event data using linear- and cox-regression mixed-effect models with a random effect on study level. We analysed dichotomous IPD using generalised estimating equations. We adjusted all models for age and sex. We assessed changes in outcomes after three and 12 months. We also conducted a meta-analysis on aggregated trial data. MAIN RESULTS We included 14 new RCTs in this review update, in addition to the seven previously included. Seventeen studies investigated chronic NIV in stable COPD and four studies investigated chronic NIV commenced after a severe COPD exacerbation. Three studies compared NIV to sham continuous positive airway pressure (2 to 4 cmH2O). Seven studies used a nasal mask, one study used an oronasal mask and eight studies used both interfaces. Five studies did not report the interface. The majority of trials (20/21) were at high risk of performance bias due to an unblinded design. We considered 11 studies to have a low risk of selection bias and 13 to have a low risk of attrition bias. We collected and analysed the IPD from 13 stable COPD studies (n = 778, 68% of the participants included) and from three post-exacerbation studies (n = 364, 96% of the participants included). In the stable COPD group, NIV probably results in a minor benefit on the arterial partial pressure of oxygen (PaO2) after three months (adjusted mean difference (AMD) 0.27 kPa, 95% CI 0.04 to 0.49; 9 studies, 271 participants; moderate-certainty evidence), but there was little to no benefit at 12 months (AMD 0.09 kPa, 95% CI -0.23 to 0.42; 3 studies, 171 participants; low-certainty evidence). The arterial partial pressure of carbon dioxide (PaCO2) was reduced in participants allocated to NIV after three months (AMD -0.61 kPa, 95% CI -0.77 to -0.45; 11 studies, 475 participants; high-certainty evidence) and persisted up to 12 months (AMD -0.42 kPa, 95% CI -0.68 to -0.16; 4 studies, 232 participants; high-certainty evidence). Exercise capacity was measured with the 6-minute walking distance (minimal clinical important difference: 26 m). There was no clinically relevant effect of NIV on exercise capacity (3 months: AMD 15.5 m, 95% CI -0.8 to 31.7; 8 studies, 330 participants; low-certainty evidence; 12 months: AMD 26.4 m, 95% CI -7.6 to 60.5; 3 studies, 134 participants; very low-certainty evidence). HRQL was measured with the Severe Respiratory Insufficiency and the St. Georges's Respiratory Questionnaire and may be improved by NIV, but only after three months (3 months: standardised mean difference (SMD) 0.39, 95% CI 0.15 to 0.62; 5 studies, 259 participants; very low-certainty evidence; 12 months: SMD 0.15, 95% CI -0.13 to 0.43; 4 studies, 200 participants; very low-certainty evidence). Lastly, the risk for all-cause mortality is likely reduced by NIV (adjusted hazard ratio (AHR) 0.75, 95% CI 0.58 to 0.97; 3 studies, 405 participants; moderate-certainty evidence). In the post-exacerbation COPD group, there was little to no benefit on the PaO2 after three months, but there may be a slight decrease after 12 months (3 months: AMD -0.10 kPa, 95% CI -0.65 to 0.45; 3 studies, 234 participants; low-certainty evidence; 12 months: -0.27 kPa, 95% CI -0.86 to 0.32, 3 studies; 170 participants; low-certainty evidence). The PaCO2 was reduced by NIV at both three months (AMD -0.40 kPa, 95% CI -0.70 to -0.09; 3 studies, 241 participants; moderate-certainty evidence) and 12 months (AMD -0.52 kPa, 95% CI -0.87 to -0.18; 3 studies, 175 participants; high-certainty evidence). NIV may have little to no benefit on HRQL (3 months: SMD 0.25, 95% CI -0.01 to 0.51; 2 studies, 219 participants; very low-certainty evidence; 12 months: SMD 0.25, 95% -0.06 to 0.55; 2 studies, 164 participants; very low-certainty evidence). Admission-free survival seems improved with NIV (AHR 0.71, 95% CI 0.54 to 0.94; 2 studies, 317 participants; low-certainty evidence), but the risk for all-cause mortality does not seem to improve (AHR 0.97, 95% CI 0.74 to 1.28; 2 studies, 317 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Regardless of the timing of initiation, chronic NIV improves daytime hypercapnia. In addition, in stable COPD, survival seems to be improved and there might be a short term HRQL benefit. In people with persistent hypercapnia after a COPD exacerbation, chronic NIV might prolong admission-free survival without a beneficial effect on HRQL. In stable COPD, future RCTs comparing NIV to a control group receiving standard care might no longer be warranted, but research should focus on identifying participant characteristics that would define treatment success. Furthermore, the optimal timing for initiation of NIV after a severe COPD exacerbation is still unknown.
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Affiliation(s)
- Tim Raveling
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, Netherlands
| | - Judith Vonk
- Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Fransien M Struik
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Roger Goldstein
- Division of Respiratory Medicine, West Park Healthcare Centre, University of Toronto, Toronto, Canada
| | - Huib Am Kerstjens
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, Netherlands
| | - Marieke L Duiverman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, Netherlands
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Majorski DS, Duiverman ML, Windisch W, Schwarz SB. Long-term noninvasive ventilation in COPD: current evidence and future directions. Expert Rev Respir Med 2021; 15:89-101. [PMID: 33245003 DOI: 10.1080/17476348.2021.1851601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Long-term noninvasive ventilation (NIV) is an established treatment for end-stage COPD patients suffering from chronic hypercapnic respiratory failure. This is reflected by its prominent position in national and international medical guidelines. Areas covered: In recent years, novel developments in technology such as auto-titrating machines and hybrid modes have emerged, and when combined with advances in information and communication technologies, these developments have served to improve the level of NIV-based care. Such progress has largely been instigated by the fact that healthcare systems are now confronted with an increase in the number of patients, which has led to the need for a change in current infrastructures. This article discusses the current practices and recent trends, and offers a glimpse into the future possibilities and requirements associated with this form of ventilation therapy. Expert opinion: Noninvasive ventilation is an established and increasingly used treatment option for patients with chronic hypercapnic COPD and those with persistent hypercapnia following acute hypercapnic lung failure. The main target is to augment alveolar hypoventilation by reducing PaCO2 to relieve symptoms. Nevertheless, when dealing with severely impaired patients, it appears necessary to switch the focus to patient-related outcomes such as health-related quality of life.
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Affiliation(s)
- Daniel S Majorski
- Department of Pneumology, Cologne Merheim Hospital , Cologne, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University , Witten, Germany
| | - Marieke L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital , Cologne, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University , Witten, Germany
| | - Sarah B Schwarz
- Department of Pneumology, Cologne Merheim Hospital , Cologne, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University , Witten, Germany
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3
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[Variation in ventilatory response to CO 2 in patients treated by non-invasive ventilation]. Rev Mal Respir 2020; 38:3-12. [PMID: 33246772 DOI: 10.1016/j.rmr.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 09/26/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION There are many mechanisms for improving the clinical and blood gas status of patients with the obesity hypoventilation syndrome (OHS) or chronic obstructive pulmonary disease (COPD) by non-invasive ventilation (NIV) at home. Our objective was to set up a pilot study to evaluate the potential modification of the sensitivity of the respiratory centers to CO2 by NIV in paired new COPD and OHS patients. METHODS We assessed the sensitivity of the respiratory centers to CO2 by the Read method in 3 COPD patients and 3 OHS patients newly treated by NIV and again 3 months later. We compared their results to those of 6 control subjects. RESULTS All the patients included had altered ventilatory responses to CO2 with slopes of less of than 1 L.min-1.mmHg-1. Mean coefficients of variation were significantly higher in patients than in healthy subjects (P=0.007). Patients who improved their CO2 sensitivity slope were those most observant of NIV. CONCLUSION This work showed significant changes in the ventilatory response to hypercapnia in patients with either OHS or COPD after NIV therapy. The significance of these changes deserves to be studied.
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Valentin-Caius C, Corina-Ioana B, Ana-Maria Z, Florin-Dumitru M, Oana-Claudia D. Non-Invasive Ventilation in Stable Chronic Obstructive Pulmonary Disease. CURRENT RESPIRATORY MEDICINE REVIEWS 2019. [DOI: 10.2174/1573398x15666190104123054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The benefit of non-invasive ventilation (NIV) in stable chronic obstructive pulmonary
disease (COPD) remains controversial. However, there is increasingly more evidence of NIV
efficiency, especially high-flow NIV. This review presents the old and the new evidence of NIV
effectiveness in stable COPD, considering pathophysiological arguments for NIV in COPD.
Guidelines, randomized controlled trials (RCTs) and crossover studies included in review and
metaanalysis based on patient-reported outcomes (PROs) have been analyzed. The role of NIV in
rehabilitation and in palliative care and the role of telemedicine in relation with NIV are still up for
debate. Challenges in choosing the right device and the optimal mode of ventilation still exist. There
are also discussions on the criteria for patient inclusion and on how to meet them. More studies are
needed to determine the ideal candidate for chronic NIV and to explain all the benefits of using NIV.
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Affiliation(s)
- Cosei Valentin-Caius
- Pneumology “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Borcea Corina-Ioana
- Pneumology “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Deleanu Oana-Claudia
- Pneumology “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
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5
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Duiverman ML, Vonk JM, Bladder G, van Melle JP, Nieuwenhuis J, Hazenberg A, Kerstjens HAM, van Boven JFM, Wijkstra PJ. Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial. Thorax 2019; 75:244-252. [PMID: 31484786 PMCID: PMC7063397 DOI: 10.1136/thoraxjnl-2019-213303] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/01/2019] [Accepted: 07/11/2019] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic COPD patients. While the number of patients increases, home initiation of NIV would greatly alleviate the healthcare burden. We hypothesise that home initiation of NIV with the use of telemedicine in stable hypercapnic COPD is non-inferior to in-hospital NIV initiation. METHODS Sixty-seven stable hypercapnic COPD patients were randomised to initiation of NIV in the hospital or at home using telemedicine. Primary outcome was daytime arterial carbon dioxide pressure (PaCO2) reduction after 6 months NIV, with a non-inferiority margin of 0.4 kPa. Secondary outcomes were health-related quality of life (HRQoL) and costs. RESULTS Home NIV initiation was non-inferior to in-hospital initiation (adjusted mean difference in PaCO2 change home vs in-hospital: 0.04 kPa (95% CI -0.31 to 0.38 kPa), with both groups showing a PaCO2 reduction at 6 months compared with baseline (home: from 7.3±0.9 to 6.4±0.8 kPa (p<0.001) and in-hospital: from 7.4±1.0 to 6.4±0.6 kPa (p<0.001)). In both groups, HRQoL improved without a difference in change between groups (Clinical COPD Questionnaire total score-adjusted mean difference 0.0 (95% CI -0.4 to 0.5)). Furthermore, home NIV initiation was significantly cheaper (home: median €3768 (IQR €3546-€4163) vs in-hospital: median €8537 (IQR €7540-€9175); p<0.001). DISCUSSION This is the first study showing that home initiation of chronic NIV in stable hypercapnic COPD patients, with the use of telemedicine, is non-inferior to in-hospital initiation, safe and reduces costs by over 50%. TRIAL REGISTRATION NUMBER NCT02652559.
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Affiliation(s)
- Marieke L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands .,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith M Vonk
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerrie Bladder
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joost P van Melle
- Thoraxcenter, Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jellie Nieuwenhuis
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anda Hazenberg
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Job F M van Boven
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of General Practice & Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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6
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van der Leest S, Duiverman ML. High-intensity non-invasive ventilation in stable hypercapnic COPD: Evidence of efficacy and practical advice. Respirology 2018; 24:318-328. [PMID: 30500099 DOI: 10.1111/resp.13450] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/30/2018] [Accepted: 11/11/2018] [Indexed: 01/12/2023]
Abstract
Patients with end-stage chronic obstructive pulmonary disease (COPD) frequently develop chronic hypercapnic respiratory failure (CHRF), with disabling symptoms and poor survival. The use of long-term nocturnal non-invasive ventilation (NIV) to treat CHRF in COPD has long been subject of debate due to conflicting evidence. However, since the introduction of high-intensity NIV (HI-NIV) in COPD, physiological and clinical benefits have been shown. HI-NIV refers to specific ventilator settings used for NIV aimed at achieving normocapnia or the lowest partial arterial carbon dioxide pressure (PaCO2 ) values as possible. This review will provide an overview of existing evidence of the efficacy of HI-NIV stable COPD patients with CHRF. Secondly, we will discuss hypotheses underlying NIV benefit in stable hypercapnic COPD, providing insight into better patient selection and hopefully more individually titrated HI-NIV. Finally, we will provide practical advice on how to initiate and follow-up patients on HI-NIV, with special emphasis on monitoring that should be available during the initiation and follow-up of HI-NIV, and will discuss more extended monitoring techniques that could improve HI-NIV treatment in the future.
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Affiliation(s)
- Sietske van der Leest
- Cardiovascular and Respiratory Physiology Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Marieke L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
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7
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Palman AD. [Sleep and its' disturbanses in chronic obstructive pulmonary disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:113-118. [PMID: 30059060 DOI: 10.17116/jnevro201811842113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Physiology of breathing during sleep predisposes to the development or worsening of the respiratory disorders in patients with chronic obstructive pulmonary disease (COPD) even if waking respiratory function remains relatively normal. Physicians, who assess patient's state only during the day, in some cases can underestimate this problem. Respiratory abnormalities can provoke insomnia, which additionally affects patient's quality of life. Supplemental oxygen and pressure support ventilation improve blood gases during sleep, but in many cases, insomnia persists. In many cases, such patients need the treatment with hypnotics. Widely used drugs in insomnia are benzodiazepines. They are rather effective but can cause respiratory depression and respiratory failure in patients with COPD. Z-hypnotics are comparable to classical benzodiazepines but much more safe and rarely worsen respiratory parameters. Melatonin and melatonin receptor agonists, antihistamines, antidepressants and neuroleptics can be effective in some patients with insomnia, but insufficient data about their safety in case of respiratory pathology restrict the use of these drugs in patients with COPD. The orexin receptor antagonist suvorexant is a novel hypnotic with the potential benefits for patients with COPD because it strongly improves sleep but does not depress respiration and has a minimal negative impact on daytime cognitive function.
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Affiliation(s)
- A D Palman
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
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8
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Duiverman ML. Noninvasive ventilation in stable hypercapnic COPD: what is the evidence? ERJ Open Res 2018; 4:00012-2018. [PMID: 29637078 PMCID: PMC5890025 DOI: 10.1183/23120541.00012-2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 01/27/2018] [Indexed: 12/21/2022] Open
Abstract
Long-term noninvasive ventilation (NIV) to treat chronic hypercapnic respiratory failure is still controversial in severe chronic obstructive pulmonary disease (COPD) patients. However, with the introduction of high-intensity NIV, important benefits from this therapy have also been shown in COPD. In this review, the focus will be on the arguments for long-term NIV at home in patients with COPD. The rise of (high-intensity) NIV in COPD and the randomised controlled trials showing positive effects with this mode of ventilation will be discussed. Finally, the challenges that might be encountered (both in clinical practice and in research) in further optimising this therapy, monitoring and following patients, and selecting the patients who might benefit most will be reviewed.
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Affiliation(s)
- Marieke L. Duiverman
- Dept of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute of Asthma and COPD, University of Groningen, Groningen, The Netherlands
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9
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Hind M, Polkey MI, Simonds AK. AJRCCM: 100-Year Anniversary. Homeward Bound: A Centenary of Home Mechanical Ventilation. Am J Respir Crit Care Med 2017; 195:1140-1149. [PMID: 28459325 DOI: 10.1164/rccm.201702-0285ci] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The evolution of home mechanical ventilation is an intertwined chronicle of negative and positive pressure modes and their role in managing ventilatory failure in neuromuscular diseases and other chronic disorders. The uptake of noninvasive positive pressure ventilation has resulted in widespread growth in home ventilation internationally and fewer patients being ventilated invasively. As with many applications of domiciliary medical technology, home ventilatory support has either led or run in parallel with acute hospital applications and has been influenced by medical and societal shifts in the approach to chronic care, the creation of community support teams, a preference of recipients to be treated at home, and economic imperatives. This review summarizes the trends and growing evidence base for ventilatory support outside the hospital.
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Affiliation(s)
- Matthew Hind
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Michael I Polkey
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Anita K Simonds
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
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10
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Avdeev SN. Non invasive ventilation in patients with chronic obstructive pulmonary disease in a hospital and at home. ACTA ACUST UNITED AC 2017. [DOI: 10.18093/0869-0189-2017-27-2-232-249] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Last two decades, active use of non-invasive ventilation (NIV) has provided a significant improvement in the management of chronic obstructive pulmonary disease (COPD), both in patients with acute exacerbation and in stable patients. Currently, NIV is the first-line treatment for patients with acute exacerbation of COPD and acute hypercapnic respiratory failure. This method of respiratory support is also effective after extubation, as it could facilitate weaning from the ventilator and affects positively prevention and treatment of postextubation respiratory failure. Also, NIV has been successfully used in co-morbidity of COPD and sleep apnea syndrome, COPD and pneumonia, and in early postoperative period after thoracic surgery. NIV can be used in COPD patients with chronic respiratory failure. Long-term NIV at home is more reasonable in patients with daytime hypercapnia. The most effective strategy of respiratory support in COPD is thought to be decrease in the partial pressure of carbon dioxide in the arterial blood, i.e. high-intensity NIV. Currently available portable non-invasive ventilators could improve significantly physical activity of patients with severe COPD.
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Affiliation(s)
- S. N. Avdeev
- Federal Pulmonology Research Institute, Federal Medical and Biological Agency of Russia
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11
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Duiverman ML, Maagh P, Magnet FS, Schmoor C, Arellano-Maric MP, Meissner A, Storre JH, Wijkstra PJ, Windisch W, Callegari J. Impact of High-Intensity-NIV on the heart in stable COPD: a randomised cross-over pilot study. Respir Res 2017; 18:76. [PMID: 28464911 PMCID: PMC5414301 DOI: 10.1186/s12931-017-0542-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although high-intensity non-invasive ventilation has been shown to improve outcomes in stable COPD, it may adversely affect cardiac performance. Therefore, the aims of the present pilot study were to compare cardiac and pulmonary effects of 6 weeks of low-intensity non-invasive ventilation and 6 weeks of high-intensity non-invasive ventilation in stable COPD patients. METHODS In a randomised crossover pilot feasibility study, the change in cardiac output after 6 weeks of each NIV mode compared to baseline was assessed with echocardiography in 14 severe stable COPD patients. Furthermore, CO during NIV, gas exchange, lung function, and health-related quality of life were investigated. RESULTS Three patients dropped out: two deteriorated on low-intensity non-invasive ventilation, and one presented with decompensated heart failure while on high-intensity non-invasive ventilation. Eleven patients were included in the analysis. In general, cardiac output and NTproBNP did not change, although individual effects were noticed, depending on the pressures applied and/or the co-existence of heart failure. High-intensity non-invasive ventilation tended to be more effective in improving gas exchange, but both modes improved lung function and the health-related quality of life. CONCLUSIONS Long-term non-invasive ventilation with adequate pressure to improve gas exchange and health-related quality of life did not have an overall adverse effect on cardiac performance. Nevertheless, in patients with pre-existing heart failure, the application of very high inspiratory pressures might reduce cardiac output. TRIAL REGISTRATION The trial was registered in the Deutsches Register Klinischer Studien (DRKS-ID: DRKS00007977 ).
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Affiliation(s)
- Marieke Leontine Duiverman
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands. .,Cologne Merheim Hospital, Department of Pneumology, Kliniken der Stadt Köln gGmbH Witten/Herdecke University, Faculty of Health/School of Medicine, Köln, Germany.
| | - Petra Maagh
- Department of Cardiology, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH Witten/Herdecke University, Faculty of Health/School of Medicine, Köln, Germany
| | - Friederike Sophie Magnet
- Cologne Merheim Hospital, Department of Pneumology, Kliniken der Stadt Köln gGmbH Witten/Herdecke University, Faculty of Health/School of Medicine, Köln, Germany
| | - Claudia Schmoor
- Clinical Trials Unit, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Maria Paola Arellano-Maric
- Cologne Merheim Hospital, Department of Pneumology, Kliniken der Stadt Köln gGmbH Witten/Herdecke University, Faculty of Health/School of Medicine, Köln, Germany.,Department of Pulmonary Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Axel Meissner
- Department of Cardiology, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH Witten/Herdecke University, Faculty of Health/School of Medicine, Köln, Germany
| | - Jan Hendrik Storre
- Asklepios Fachkliniken Munich-Gauting, Gauting, Germany.,Department of Pneumology, University Medical Hospital, Freiburg, Germany
| | - Peter Jan Wijkstra
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Wolfram Windisch
- Cologne Merheim Hospital, Department of Pneumology, Kliniken der Stadt Köln gGmbH Witten/Herdecke University, Faculty of Health/School of Medicine, Köln, Germany
| | - Jens Callegari
- Cologne Merheim Hospital, Department of Pneumology, Kliniken der Stadt Köln gGmbH Witten/Herdecke University, Faculty of Health/School of Medicine, Köln, Germany
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12
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Duiverman ML, Huberts AS, van Eykern LA, Bladder G, Wijkstra PJ. Respiratory muscle activity and patient-ventilator asynchrony during different settings of noninvasive ventilation in stable hypercapnic COPD: does high inspiratory pressure lead to respiratory muscle unloading? Int J Chron Obstruct Pulmon Dis 2017; 12:243-257. [PMID: 28138234 PMCID: PMC5238808 DOI: 10.2147/copd.s119959] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction High-intensity noninvasive ventilation (NIV) has been shown to improve outcomes in stable chronic obstructive pulmonary disease patients. However, there is insufficient knowledge about whether with this more controlled ventilatory mode optimal respiratory muscle unloading is provided without an increase in patient–ventilator asynchrony (PVA). Patients and methods Ten chronic obstructive pulmonary disease patients on home mechanical ventilation were included. Four different ventilatory settings were investigated in each patient in random order, each for 15 min, varying the inspiratory positive airway pressure and backup breathing frequency. With surface electromyography (EMG), activities of the intercostal muscles, diaphragm, and scalene muscles were determined. Furthermore, pressure tracings were derived simultaneously in order to assess PVA. Results Compared to spontaneous breathing, the most pronounced decrease in EMG activity was achieved with the high-pressure settings. Adding a high breathing frequency did reduce EMG activity per breath, while the decrease in EMG activity over 1 min was comparable with the high-pressure, low-frequency setting. With high backup breathing frequencies less breaths were pressure supported (25% vs 97%). PVAs occurred more frequently with the low-frequency settings (P=0.017). Conclusion High-intensity NIV might provide optimal unloading of respiratory muscles, without undue increases in PVA.
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Affiliation(s)
- Marieke L Duiverman
- Department of Pulmonary Diseases and Home Mechanical Ventilation, University Medical Centre Groningen
| | | | | | - Gerrie Bladder
- Department of Pulmonary Diseases and Home Mechanical Ventilation, University Medical Centre Groningen
| | - Peter J Wijkstra
- Department of Pulmonary Diseases and Home Mechanical Ventilation, University Medical Centre Groningen
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13
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Dretzke J, Blissett D, Dave C, Mukherjee R, Price M, Bayliss S, Wu X, Jordan R, Jowett S, Turner AM, Moore D. The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation. Health Technol Assess 2016; 19:1-246. [PMID: 26470875 DOI: 10.3310/hta19810] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic progressive lung disease characterised by non-reversible airflow obstruction. Exacerbations are a key cause of morbidity and mortality and place a considerable burden on health-care systems. While there is evidence that patients benefit from non-invasive ventilation (NIV) in hospital during an acute exacerbation, evidence supporting home use for more stable COPD patients is limited. In the U.K., domiciliary NIV is considered on health economic grounds in patients after three hospital admissions for acute hypercapnic respiratory failure. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of domiciliary NIV by systematic review and economic evaluation. DATA SOURCES Bibliographic databases, conference proceedings and ongoing trial registries up to September 2014. METHODS Standard systematic review methods were used for identifying relevant clinical effectiveness and cost-effectiveness studies assessing NIV compared with usual care or comparing different types of NIV. Risk of bias was assessed using Cochrane guidelines and relevant economic checklists. Results for primary effectiveness outcomes (mortality, hospitalisations, exacerbations and quality of life) were presented, where possible, in forest plots. A speculative Markov decision model was developed to compare the cost-effectiveness of domiciliary NIV with usual care from a UK perspective for post-hospital and more stable populations separately. RESULTS Thirty-one controlled effectiveness studies were identified, which report a variety of outcomes. For stable patients, a modest volume of evidence found no benefit from domiciliary NIV for survival and some non-significant beneficial trends for hospitalisations and quality of life. For post-hospital patients, no benefit from NIV could be shown in terms of survival (from randomised controlled trials) and findings for hospital admissions were inconsistent and based on limited evidence. No conclusions could be drawn regarding potential benefit from different types of NIV. No cost-effectiveness studies of domiciliary NIV were identified. Economic modelling suggested that NIV may be cost-effective in a stable population at a threshold of £30,000 per quality-adjusted life-year (QALY) gained (incremental cost-effectiveness ratio £28,162), but this is associated with uncertainty. In the case of the post-hospital population, results for three separate base cases ranged from usual care dominating to NIV being cost-effective, with an incremental cost-effectiveness ratio of less than £10,000 per QALY gained. All estimates were sensitive to effectiveness estimates, length of benefit from NIV (currently unknown) and some costs. Modelling suggested that reductions in the rate of hospital admissions per patient per year of 24% and 15% in the stable and post-hospital populations, respectively, are required for NIV to be cost-effective. LIMITATIONS Evidence on key clinical outcomes remains limited, particularly quality-of-life and long-term (> 2 years) effects. Economic modelling should be viewed as speculative because of uncertainty around effect estimates, baseline risks, length of benefit of NIV and limited quality-of-life/utility data. CONCLUSIONS The cost-effectiveness of domiciliary NIV remains uncertain and the findings in this report are sensitive to emergent data. Further evidence is required to identify patients most likely to benefit from domiciliary NIV and to establish optimum time points for starting NIV and equipment settings. FUTURE WORK RECOMMENDATIONS The results from this report will need to be re-examined in the light of any new trial results, particularly in terms of reducing the uncertainty in the economic model. Any new randomised controlled trials should consider including a sham non-invasive ventilation arm and/or a higher- and lower-pressure arm. Individual participant data analyses may help to determine whether or not there are any patient characteristics or equipment settings that are predictive of a benefit of NIV and to establish optimum time points for starting (and potentially discounting) NIV. STUDY REGISTRATION This study is registered as PROSPERO CRD42012003286. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Janine Dretzke
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Deirdre Blissett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Chirag Dave
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Rahul Mukherjee
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Malcolm Price
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sue Bayliss
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Xiaoying Wu
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Rachel Jordan
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Alice M Turner
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK.,Queen Elizabeth Hospital Research Laboratories, University of Birmingham, Birmingham, UK
| | - David Moore
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
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14
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Duiverman ML, Windisch W, Storre JH, Wijkstra PJ. The role of NIV in chronic hypercapnic COPD following an acute exacerbation: the importance of patient selection? Ther Adv Respir Dis 2016; 10:149-57. [PMID: 26746384 PMCID: PMC5933565 DOI: 10.1177/1753465815624645] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Marieke L Duiverman
- University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, the Netherlands
| | - Wolfram Windisch
- Lungenklinik Merheim, Kliniken der Stadt Köln GmbH, Köln, Universität Witten/Herdecke, Germany
| | - Jan H Storre
- Lungenklinik Merheim, Kliniken der Stadt Köln GmbH, Köln, Universität Witten/Herdecke, Germany, Department of Pneumology, University Hospital Freiburg, Germany
| | - Peter J Wijkstra
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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15
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Altintas N. Update: Non-Invasive Positive Pressure Ventilation in Chronic Respiratory Failure Due to COPD. COPD 2015; 13:110-21. [PMID: 26418151 DOI: 10.3109/15412555.2015.1043520] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Long-term non-invasive positive pressure ventilation (NPPV) has widely been accepted to treat chronic hypercapnic respiratory failure arising from different etiologies. Although the survival benefits provided by long-term NPPV in individuals with restrictive thoracic disorders or stable, slowly-progressing neuromuscular disorders are overwhelming, the benefits provided by long-term NPPV in patients with chronic obstructive pulmonary disease (COPD) remain under question, due to a lack of convincing evidence in the literature. In addition, long-term NPPV reportedly failed in the classic trials to improve important physiological parameters such as arterial blood gases, which might serve as an explanation as to why long-term NPPV has not been shown to substantially impact on survival. However, high intensity NPPV (HI-NPPV) using controlled NPPV with the highest possible inspiratory pressures tolerated by the patient has recently been described as a new and promising approach that is well-tolerated and is also capable of improving important physiological parameters such as arterial blood gases and lung function. This clearly contrasts with the conventional approach of low-intensity NPPV (LI-NPPV) that uses considerably lower inspiratory pressures with assisted forms of NPPV. Importantly, HI-NPPV was very recently shown to be superior to LI-NPPV in terms of improved overnight blood gases, and was also better tolerated than LI-NPPV. Furthermore, HI-NPPV, but not LI-NPPV, improved dyspnea, lung function and disease-specific aspects of health-related quality of life. A recent study showed that long-term treatment with NPPV with increased ventilatory pressures that reduced hypercapnia was associated with significant and sustained improvements in overall mortality. Thus, long-term NPPV seems to offer important benefits in this patient group, but the treatment success might be dependent on effective ventilatory strategies.
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Affiliation(s)
- Nejat Altintas
- a Department of Pulmonary Sleep and Critical Care , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania , USA
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16
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Windisch W, Storre JH, Köhnlein T. Nocturnal non-invasive positive pressure ventilation for COPD. Expert Rev Respir Med 2015; 9:295-308. [DOI: 10.1586/17476348.2015.1035260] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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17
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Díaz Lobato S, García González JL, Mayoralas Alises S. The Debate on Continuous Home Oxygen Therapy. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2014.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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19
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Wijkstra PJ, Duiverman ML. Ventilatory Support During Sleep in Patients with Chronic Obstructive Pulmonary Disease. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2014.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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The debate on continuous home oxygen therapy. Arch Bronconeumol 2014; 51:31-7. [PMID: 24976235 DOI: 10.1016/j.arbres.2014.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 05/06/2014] [Accepted: 05/07/2014] [Indexed: 01/28/2023]
Abstract
Two studies published in the early 80s, namely the Nocturnal Oxygen Therapy Trial (NOTT) and the Medical Research Council Trial (MRC), laid the foundations for modern home oxygen therapy. Since then, little progress has been made in terms of therapeutic indications, and several prescription-associated problems have come to light. Advances in technology have gone hand in hand with growing disregard for the recommendations in clinical guidelines on oxygen therapy. The introduction of liquid oxygen brought with it a number of technical problems, clinical problems related to selecting candidate patients for portable delivery devices, and economic problems associated with the rising cost of the therapy. Continuous home oxygen therapy has been further complicated by the recent introduction of portable oxygen concentrators and the development in quick succession of a range of delivery devices with different levels of efficiency and performance. Modern oxygen therapy demands that clinicians evaluate the level of mobility of their patients and the mobility permitted by available oxygen sources, correctly match patients with the most appropriate oxygen source and adjust the therapy accordingly. The future of continuous home oxygen therapy lies in developing the ideal delivery device, improving the regulations systems and information channels, raise patient awareness and drive research.
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21
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Current opinions on non-invasive ventilation as a treatment for chronic obstructive pulmonary disease. Curr Opin Pulm Med 2014; 19:626-30. [PMID: 24060980 DOI: 10.1097/mcp.0b013e3283659e4c] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review examines the current reports, the evidence and the issues surrounding the use of non-invasive ventilation (NIV) for the treatment of chronic obstructive pulmonary disease (COPD) in both the acute and domiciliary setting. RECENT FINDINGS With the increasing use of NIV, more recent studies have focused on investigating the outcomes of our current practice. Although overall morbidity and mortality outcomes in the acute setting have improved, patients who initially stabilize but then deteriorate during an acute exacerbation of COPD have a poor prognosis. The focus must be on phenotyping this high-risk group to investigate other potential rescue treatments, including extracorporeal carbon dioxide removal. Indeed, phenotyping appears to favour the obese COPD patient, which may have a protective role in reducing the risk of NIV failure and recurrent hospital admissions. Randomized controlled trial evidence to support the use of NIV in a domiciliary setting as a treatment for COPD is awaited, and until the data from a number of ongoing clinical trials are available, the wide variation in global practice will continue. Increased understanding of patient ventilator asynchrony has improved domiciliary NIV set up, which is expected to enhance the tolerability of NIV, promoting patient adherence. SUMMARY NIV is the established standard of care to treat acute hypercapnic exacerbations of COPD postoptimal medical management. NIV as a long-term treatment for COPD remains controversial based on the evidence from the published randomized controlled trials. With increasing experience of NIV therapy, patient outcomes are improving; however, further work is still required to better characterize and target the patients who will most benefit from NIV.
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22
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Bhatt SP, Peterson MW, Wilson JS, Durairaj L. Noninvasive positive pressure ventilation in subjects with stable COPD: a randomized trial. Int J Chron Obstruct Pulmon Dis 2013; 8:581-9. [PMID: 24293994 PMCID: PMC3842217 DOI: 10.2147/copd.s53619] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The use of domiciliary noninvasive positive pressure ventilation (NPPV) in stable chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure has yielded variable effects on survival, quality of life, and dyspnea. We hypothesized that use of NPPV in stable COPD and partial pressure of carbon dioxide (PaCO2) <52 mmHg might result in improvement in quality of life and dyspnea. METHODS Thirty patients with stable COPD (forced expiratory volume in the first second <50% predicted and PaCO2 <52 mmHg) were prospectively randomized to receive domiciliary NPPV (bilevel positive airway pressure, 15/5 cm H2O) or usual therapy for 6 months. Measurements were made at baseline, 6 weeks, 3 months, and 6 months. Primary outcomes were quality of life as assessed by the Chronic Respiratory Disease Questionnaire (CRQ), and dyspnea as measured by the Transitional Dyspnea Index (TDI). RESULTS Fifteen subjects in the NPPV arm and 12 controls completed all the study visits. At 6 weeks and 3 months, the NPPV arm showed significant improvement in TDI total score. However, this effect persisted only in the TDI-Task at 6 months (P=0.03). NPPV use was associated with a small improvement in the CRQ-Mastery domain (0.6 versus -0.1, P=0.04). The arterial partial pressure of oxygen (PaO2) in the control arm worsened over the period of the study, whereas it remained stable in the NPPV arm (change -7.2 mmHg versus +2.1 mmHg, respectively, P=0.02). CONCLUSION NPPV resulted in a small improvement in quality of life indices in stable COPD patients with PaCO2 <52 mmHg. Future larger studies will clarify the role of NPPV in this stable subgroup of patients with COPD.
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Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, Roy J and Lucille A, Carver College of Medicine, University of Iowa Hospital, Iowa City, IA, USA
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Struik FM, Lacasse Y, Goldstein RS, Kerstjens HAM, Wijkstra PJ. Nocturnal noninvasive positive pressure ventilation in stable COPD: a systematic review and individual patient data meta-analysis. Respir Med 2013; 108:329-37. [PMID: 24157199 DOI: 10.1016/j.rmed.2013.10.007] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/04/2013] [Accepted: 10/06/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The effects of nocturnal noninvasive positive pressure ventilation (NIPPV) in patients with stable chronic obstructive pulmonary disease (COPD) remain controversial. METHODS The Cochrane Airways group Register of Trials, MEDLINE, EMBASE and CINAHL were searched up to August 2012. Individual patient data from randomised controlled trials on NIPPV outcomes were selected for two separate meta-analyses: the first with follow-up of 3 months and the second with 12 months of follow-up. Additionally, subgroup analyses within the NIPPV group comparing IPAP levels, compliance and levels of hypercapnia on change in PaCO2 after 3 months were performed. RESULTS Seven trials (245 patients) were included. All studies were considered of moderate to high quality. No significant difference was found between NIPPV and control groups after 3 or 12 months of follow-up when looking at PaCO2 and PaO2, 6-minute walking distance, health-related quality-of-life, forced expiratory volume in 1 s, forced vital capacity, maximal inspiratory pressure and sleep efficiency. Significant differences in change in PaCO2 after 3 months were found for patients ventilated with IPAP levels of at least 18 cm H2O, for patients who used NIPPV for at least 5 h per night as well as for patients with baseline PaCO2 of at least 55 mm Hg when compared to patients with lower IPAP levels, poorer compliance or lower levels of hypercapnia. DISCUSSION At present, there is insufficient evidence to support the application of routine NIPPV in patients with stable COPD. However, higher IPAP levels, better compliance and higher baseline PaCO2 seem to improve PaCO2.
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Affiliation(s)
- F M Struik
- Department of Pulmonology, Center for Home Mechanical Ventilation, University of Groningen, Groningen University Medical Center Groningen (UMCG), Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen University Medical Center Groningen (UMCG), Groningen, The Netherlands.
| | - Y Lacasse
- Centre de Pneumologie, Institute Universitaire de Cardiologie et de Pneumologie de Québec, Hôpital Laval, Québec, Canada
| | - R S Goldstein
- Division of Respiratory Medicine, West Park Healthcare Centre, University of Toronto, Toronto, Canada
| | - H A M Kerstjens
- Department of Pulmonology, Center for Home Mechanical Ventilation, University of Groningen, Groningen University Medical Center Groningen (UMCG), Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - P J Wijkstra
- Department of Pulmonology, Center for Home Mechanical Ventilation, University of Groningen, Groningen University Medical Center Groningen (UMCG), Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen University Medical Center Groningen (UMCG), Groningen, The Netherlands
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Struik FM, Lacasse Y, Goldstein R, Kerstjens HA, Wijkstra PJ. Nocturnal non-invasive positive pressure ventilation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2013; 2013:CD002878. [PMID: 23766138 PMCID: PMC6999800 DOI: 10.1002/14651858.cd002878.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Non-invasive positive pressure ventilation (NIPPV) is effective in treating acute exacerbations of chronic obstructive pulmonary disease (COPD). Nocturnal non-invasive positive pressure ventilation (nocturnal-NIPPV) has been proposed as an intervention for stable hypercapnic patients with COPD. OBJECTIVES To assess the effects of nocturnal-NIPPV at home via nasal mask or face mask in people with COPD by using a meta-analysis based on individual patient data (IPD). SEARCH METHODS We searched the Cochrane Airways Group Specialised Register. We performed the latest search in August 2012. SELECTION CRITERIA Randomised controlled trials in people with stable COPD that compared nocturnal-NIPPV at home for at least five hours per night, for at least three consecutive weeks plus standard therapy with standard therapy alone. DATA COLLECTION AND ANALYSIS IPD were collected and two review authors assessed risk of bias independently. MAIN RESULTS This update of the systematic review on nocturnal-NIPPV in COPD (Wijkstra 2002), has led to the inclusion of three new studies, leading to seven included studies on 245 people. We obtained IPD for all participants in all included studies. The 95% confidence interval (CI) of all outcomes included zero. These included partial pressure of CO2 and O2 in arterial blood, six-minute walking distance (6MWD), health-related quality of life (HRQoL), forced expiratory volume in one second (FEV1), forced vital capacity (FVC), maximal inspiratory pressure (PImax) and sleep efficiency. The mean effect on 6MWD was small at 27.7 m and not statistically significant. Given the width of the 95% CI (-28.1 to 66.3 m), the real effect of NIPPV on 6MWD is uncertain and we cannot exclude an effect that is clinically significant (considering that the minimal clinically difference on 6MWD is around 26 m). AUTHORS' CONCLUSIONS Nocturnal-NIPPV at home for at least three months in hypercapnic patients with stable COPD had no consistent clinically or statistically significant effect on gas exchange, exercise tolerance, HRQoL, lung function, respiratory muscle strength or sleep efficiency. Meta-analysis of the two new long-term studies did not show significant improvements in blood gases, HRQoL or lung function after 12 months of NIPPV. However, the small sample sizes of these studies preclude a definite conclusion regarding the effects of NIPPV in COPD.
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Affiliation(s)
- Fransien M Struik
- University of Groningen, University Medical Center GroningenDepartment of Pulmonary Diseases and TuberculosisTriade gebouw AA62GroningenNetherlands9713 GZ
| | - Yves Lacasse
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Hôpital Laval2725 Chemin Sainte‐FoyQuébecQuebecCanadaG1V 4G5
| | - Roger Goldstein
- West Park Healthcare Centre, University of TorontoDivision of Respiratory Medicine82 Buttonwood AvenueTorontoOntarioCanadaM6M 2J5
| | - Huib A.M. Kerstjens
- University of Groningen, University Medical Center GroningenDepartment of Pulmonary Diseases and TuberculosisTriade gebouw AA62GroningenNetherlands9713 GZ
| | - Peter J Wijkstra
- University of Groningen, University Medical Center GroningenDepartment of Pulmonary Diseases and TuberculosisTriade gebouw AA62GroningenNetherlands9713 GZ
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Díaz Lobato S, Mayoralas Alises S. Situación actual de la prescripción de oxígeno domiciliario. Med Clin (Barc) 2013; 140:358-9. [DOI: 10.1016/j.medcli.2012.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 10/25/2012] [Accepted: 11/08/2012] [Indexed: 10/27/2022]
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Ameen A, Zedan M, El Shamly M. Comparison between continuous positive airway pressure and bilevel positive pressure ventilation in treatment of acute exacerbation of chronic obstructive pulmonary disease. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
The hypoventilation syndromes represent a variety of disorders that affect central ventilatory control, respiratory mechanics, or both. Obesity hypoventilation syndrome is a clinically important disorder with serious cardiovascular and metabolic consequences if unrecognized. Hypoventilation in asthma and COPD is caused by mechanical challenges imparted by airflow obstruction and increase in dead space. In neuromuscular disease, respiratory muscle weakness results in hypoventilation. Decreases in thoracic volume and limited expansion of the chest highlight the restrictive ventilatory impairments seen in hypoventilation associated with chest wall disorders. Despite the mechanism, effective hypoventilation treatment targets the underlying disease and use of noninvasive ventilation.
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Affiliation(s)
- Ahmad Chebbo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Scott and White Healthcare/Texas A&M Health Science Center, Temple, TX 76508, USA
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Dreher M, Ekkernkamp E, Walterspacher S, Walker D, Schmoor C, Storre JH, Windisch W. Noninvasive Ventilation in COPD. Chest 2011; 140:939-945. [DOI: 10.1378/chest.11-0253] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Oscroft NS, Ali M, Gulati A, Davies MG, Quinnell TG, Shneerson JM, Smith IE. A randomised crossover trial comparing volume assured and pressure preset noninvasive ventilation in stable hypercapnic COPD. COPD 2011; 7:398-403. [PMID: 21166627 DOI: 10.3109/15412555.2010.528084] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Recent randomised controlled trials suggest non-invasive ventilation may offer benefit in the long-term management of ventilatory failure in stable COPD. The best mode of ventilation is unknown and newer volume assured modes may offer advantages by optimising ventilation overnight when treatment is delivered. This study compares volume assured with pressure preset non-invasive ventilation. Randomised crossover trial including twenty five subjects previously established on long-term non-invasive ventilation to manage COPD with chronic ventilatory failure. Two 8-week treatment periods of volume assured and pressure preset non-invasive ventilation. The primary outcomes were daytime arterial blood gas tensions and mean nocturnal oxygen saturation. Secondary outcomes included lung function, exercise capacity, mean nocturnal transcutaneous carbon dioxide, health status and compliance. No significant differences were seen in primary or secondary outcomes following 8 weeks of treatment when comparing volume assured and pressure preset ventilation. Primary outcomes assessed: mean (standard deviation) PaO(2) 7.8 (1.2) vs 8.1(1) kPa, PaCO(2) 6.7 (1.1) vs 6.3 (1.2) kPa and mean nocturnal oxygenation 90 (4) vs 91 (3)% volume assured versus pressure preset, respectively. Volume assured and pressure preset non-invasive ventilation appear equally effective in the long-term management of ventilatory failure associated with stable COPD.
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Affiliation(s)
- Nicholas Stephen Oscroft
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK CB23 3RE.
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Funk GC, Breyer MK, Burghuber OC, Kink E, Kirchheiner K, Kohansal R, Schmidt I, Hartl S. Long-term non-invasive ventilation in COPD after acute-on-chronic respiratory failure. Respir Med 2011; 105:427-34. [PMID: 21111590 DOI: 10.1016/j.rmed.2010.09.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 08/06/2010] [Accepted: 09/06/2010] [Indexed: 10/18/2022]
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31
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Tsolaki V, Pastaka C, Kostikas K, Karetsi E, Dimoulis A, Zikiri A, Koutsokera A, Gourgoulianis KI. Noninvasive Ventilation in Chronic Respiratory Failure: Effects on Quality of Life. Respiration 2011; 81:402-10. [DOI: 10.1159/000317138] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 03/30/2010] [Indexed: 11/19/2022] Open
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Affiliation(s)
- R Tamisier
- Pulmonary Function Test and Sleep Laboratory, Department of Rehabilitation and Physiology and HP2 Laboratory, University Hospital, Grenoble, France
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33
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Robert D, Argaud L. Noninvasive positive ventilation in the treatment of sleep-related breathing disorders. HANDBOOK OF CLINICAL NEUROLOGY 2010; 98:459-69. [PMID: 21056205 DOI: 10.1016/b978-0-444-52006-7.00030-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Dominique Robert
- Emergency and Intensive Care Department, Edoward Herriot Hopsital, Lyon, France.
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34
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Ramar K, Kushida CA. CPAP and BPAP Titration. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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35
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Dogan OT, Turkyilmaz S, Berk S, Epozturk K, Akkurt I. Effects of long-term non-invasive home mechanical ventilation on chronic respiratory failure. Curr Med Res Opin 2010; 26:2229-36. [PMID: 20690890 DOI: 10.1185/03007995.2010.508703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Chronic respiratory failure (CRF) is a syndrome defined by certain disturbances in arterial blood gases. Non-invasive mechanical ventilation (NIMV) is an increasingly used treatment modality in respiratory failure. The aim of this study was to investigate the long-term effects of NIMV on pulmonary function and survival of patients with CRF. METHODS The study enrolled 170 CRF patients who it was decided should receive long-term home mechanical ventilation. Patients were stratified into two distinct groups - Group I (patients for whom NIMV was recommended and who had used it) and Group II (patients for whom NIMV was recommended at least 1 year ago but who had not used it for various reasons). Best arterial blood gas and pulmonary function test values in the year before the NIMV recommendation were obtained from patient records. The same tests were performed at least 1 year (1-5 years) after initiation of NIMV therapy in Group I patients and at least 1 year (1-5 years) after prescription of the device in Group II. RESULTS In the assessments performed 1 year after NIMV recommendation, no difference was found between groups in terms of hospital admissions. However, in Group I, intra-group analysis showed a reduction in the number of hospitalizations 1 year after NIMV. A marked reduction in PaCO(2) level was found in Group I patients 1 year after NIMV therapy. Mean survival after NIMV recommendation was 40.27 +/- 3.56 months in Group I, and 27.35 +/- 3.68 months in Group II (log rank = 7.79; p = 0.005). It was found that survival time increased as duration of NIMV usage increased. CONCLUSION NIMV therapy has some important and significant benefits in patients with hypercapnic chronic respiratory failure. This study has some limitations in terms of patient selection, power analysis and survival analysis. To assess the effects of NIMV on mortality and pulmonary functions, the authors believe that there is need for prospective, controlled, multicentre studies with longer follow-up periods, improved adherence and novel ventilator modes and settings.
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OSCROFT NS, QUINNELL TG, SHNEERSON JM, SMITH IE. Long-term non-invasive ventilation to manage persistent ventilatory failure after COPD exacerbation. Respirology 2010; 15:818-22. [DOI: 10.1111/j.1440-1843.2010.01787.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Budweiser S, Jörres RA, Pfeifer M. Treatment of respiratory failure in COPD. Int J Chron Obstruct Pulmon Dis 2009; 3:605-18. [PMID: 19281077 PMCID: PMC2650592 DOI: 10.2147/copd.s3814] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients with advanced COPD and acute or chronic respiratory failure are at high risk for death. Beyond pharmacological treatment, supplemental oxygen and mechanical ventilation are major treatment options. This review describes the physiological concepts underlying respiratory failure and its therapy, as well as important treatment outcomes. The rationale for the controlled supply of oxygen in acute hypoxic respiratory failure is undisputed. There is also a clear survival benefit from long-term oxygen therapy in patients with chronic hypoxia, while in mild, nocturnal, or exercise-induced hypoxemia such long-term benefits appear questionable. Furthermore, much evidence supports the use of non-invasive positive pressure ventilation in acute hypercapnic respiratory failure. It application reduces intubation and mortality rates, and the duration of intensive care unit or hospital stays, particularly in the presence of mild to moderate respiratory acidosis. COPD with chronic hypercapnic respiratory failure became a major indication for domiciliary mechanical ventilation, based on pathophysiological reasoning and on data regarding symptoms and quality of life. Still, however, its relevance for long-term survival has to be substantiated in prospective controlled studies. Such studies might preferentially recruit patients with repeated hypercapnic decompensation or a high risk for death, while ensuring effective ventilation and the patients’ adherence to therapy.
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Nickol AH, Hart N, Hopkinson NS, Hamnegård CH, Moxham J, Simonds A, Polkey MI. Mechanisms of improvement of respiratory failure in patients with COPD treated with NIV. Int J Chron Obstruct Pulmon Dis 2009; 3:453-62. [PMID: 18990974 PMCID: PMC2629992 DOI: 10.2147/copd.s2705] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Noninvasive ventilation (NIV) improves gas-exchange and symptoms in selected chronic obstructive pulmonary disease (COPD) patients with hypercapnic respiratory failure. We hypothesized NIV reverses respiratory failure by one or all of increased ventilatory response to carbon-dioxide, reduced respiratory muscle fatigue, or improved pulmonary mechanics. Methods Nineteen stable COPD patients (forced expiratory volume in one second 35% predicted) were studied at baseline (D0), 5–8 days (D5) and 3 months (3M) after starting NIV. Results Ventilator use was 6.2 (3.7) hours per night at D5 and 3.4 (1.6) at 3M (p = 0.12). Mean (SD) daytime arterial carbon-dioxide tension (PaCO2) was reduced from 7.4 (1.2) kPa to 7.0 (1.1) kPa at D5 and 6.5 (1.1) kPa at 3M (p = 0.001). Total lung capacity decreased from 107 (28) % predicted to 103 (28) at D5 and 103 (27) % predicted at 3M (p = 0.035). At D5 there was an increase in the hypercapnic ventilatory response and some volitional measures of inspiratory and expiratory muscle strength, but not isolated diaphragmatic strength whether assessed by volitional or nonvolitional methods. Conclusion These findings suggest decreased gas trapping and increased ventilatory sensitivity to CO2 are the principal mechanism underlying improvements in gas-exchange in patients with COPD following NIV. Changes in some volitional but not nonvolitional muscle strength measures may reflect improved patient effort.
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Affiliation(s)
- Annabel H Nickol
- Respiratory Muscle Laboratory, Royal Brompton Hospital, London, UK.
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Noninvasive home ventilation for chronic obstructive pulmonary disease: indications, utility and outcome. Curr Opin Pulm Med 2008; 14:128-34. [PMID: 18303422 DOI: 10.1097/mcp.0b013e3282f379fc] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite its widespread use, the role of noninvasive home mechanical ventilation for the management of severe chronic obstructive pulmonary disease and chronic hypercapnic respiratory failure is still controversial. The majority of randomized controlled trials show methodological weaknesses, including issues of patient selection, insufficient pressure support and poor adherence to therapy. Data from short-term trials, while assuring effective ventilation, are encouraging by demonstrating physiological improvements, in line with benefits regarding symptoms and quality of life. The role of home mechanical ventilation for long-term survival is, however, still unclear. RECENT FINDINGS Possible indications of home mechanical ventilation, physiological concepts underlying the effects of noninvasive ventilation and their impact on clinically important long-term outcomes are reported. SUMMARY Due to systemic involvement, the decision to undertake home mechanical ventilation should probably not be based on symptomatic chronic hypercapnia alone, but on a broader spectrum of factors. In particular, patients with repeated hypercapnic decompensation are at high risk for death and obvious candidates for home mechanical ventilation. Beyond restoration of chemosensitivity, changes in breathing pattern and a reduction of mechanical load are likely mechanisms of home mechanical ventilation, inducing symptom relief and improving functional reserve. To fully utilize its potential, high pressure levels are required. Future prospective controlled studies should take into account these experiences.
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Robert D, Argaud L. Clinical review: long-term noninvasive ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:210. [PMID: 17419882 PMCID: PMC2206447 DOI: 10.1186/cc5714] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Noninvasive positive ventilation has undergone a remarkable evolution over the past decades and is assuming an important role in the management of both acute and chronic respiratory failure. Long-term ventilatory support should be considered a standard of care to treat selected patients following an intensive care unit (ICU) stay. In this setting, appropriate use of noninvasive ventilation can be expected to improve patient outcomes, reduce ICU admission, enhance patient comfort, and increase the efficiency of health care resource utilization. Current literature indicates that noninvasive ventilation improves and stabilizes the clinical course of many patients with chronic ventilatory failure. Noninvasive ventilation also permits long-term mechanical ventilation to be an acceptable option for patients who otherwise would not have been treated if tracheostomy were the only alternative. Nevertheless, these results appear to be better in patients with neuromuscular/-parietal disorders than in chronic obstructive pulmonary disease. This clinical review will address the use of noninvasive ventilation (not including continuous positive airway pressure) mainly in diseases responsible for chronic hypoventilation (that is, restrictive disorders, including neuromuscular disease and lung disease) and incidentally in others such as obstructive sleep apnea or problems of central drive.
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Affiliation(s)
- Dominique Robert
- Emergency and Medical Intensive Care Department, Edouard Herriot Hospital, Place d'Arsonval, Lyon, F-69008, France
| | - Laurent Argaud
- Emergency and Medical Intensive Care Department, Edouard Herriot Hospital, Place d'Arsonval, Lyon, F-69008, France
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Díaz-Lobato S, Alises SM, Rodríguez EP. Current status of noninvasive ventilation in stable COPD patients. Int J Chron Obstruct Pulmon Dis 2008; 1:129-35. [PMID: 18046890 PMCID: PMC2706610 DOI: 10.2147/copd.2006.1.2.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Noninvasive ventilation (NIV) has been one of the major advances in respiratory medicine in the last decade. NIV improves quality of life, prolongs survival, and improves gas exchange and sleep quality in restrictive patients, but evidence available now does not allow us to establish clear criteria for prescribing NIV in patients with chronic respiratory failure due to COPD. On the basis of the available studies, NIV should not be used as a treatment of choice for all patients with COPD, even when disease is severe. However, there is more evidence that NIV has an important effect in these patients. In fact, a selected group of patients may well benefit from domiciliary mechanical ventilation, and we need to be able to identify who they are. Moreover, NIV can be a new strategy to improve exercise tolerance in COPD patients.
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Tsolaki V, Pastaka C, Karetsi E, Zygoulis P, Koutsokera A, Gourgoulianis KI, Kostikas K. One-year non-invasive ventilation in chronic hypercapnic COPD: effect on quality of life. Respir Med 2008; 102:904-11. [PMID: 18280131 DOI: 10.1016/j.rmed.2008.01.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 01/02/2008] [Accepted: 01/04/2008] [Indexed: 10/22/2022]
Abstract
The data on long-term application of non-invasive ventilation (NIV) in patients with chronic respiratory failure due to COPD are contradictory. We evaluated the effect of the addition of NIV to optimal treatment for 1 year on the quality of life of stable hypercapnic COPD patients. NIV was offered to 49 of 58 initially enrolled consecutive patients, of whom 22 refused NIV and comprised the standard treatment group whereas 27 received NIV. Quality of life was assessed with the SF-36 questionnaire. Additional measurements included blood gases, pulmonary function tests, dyspnea, daytime sleepiness, exacerbations and hospitalizations. The NIV group showed a significant improvement in quality of life in the third month, both in the Physical (31+/-4 to 38+/-8, p<0.0001) and the Mental Component Summary Score (28+/-7 to 40+/-10, p=0.009), that was maintained until the twelfth month. PaCO2 decreased by the first month in the NIV group (54+/-4.5 to 44.6+/-5.6 mmHg, p<0.0001), and PaO2 rose during the sixth month (58.9+/-5.7 to 64.4+/-6.5 mmHg, p=0.004). Dyspnea and diurnal sleepiness improved significantly. No significant improvements were observed in the control group. Patients on NIV spent less days in the hospital compared to controls. NIV when added to optimal medical treatment has beneficial effects on quality of life in stable hypercapnic COPD patients, with additional improvements in arterial blood gases, dyspnea and daytime sleepiness.
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Affiliation(s)
- Vasiliki Tsolaki
- Respiratory Medicine Department, University Hospital of Larissa, University of Thessaly Medical School, Larissa 41110, Greece
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Marrone O, Salvaggio A, Insalaco G. Respiratory disorders during sleep in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2008; 1:363-72. [PMID: 18044093 PMCID: PMC2707801 DOI: 10.2147/copd.2006.1.4.363] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Patients with COPD may show slow, progressive deteriorations in arterial blood gases during the night, particularly during rapid eye movement (REM) sleep. This is mainly due to hypoventilation, while a deterioration of ventilation/perfusion mismatch plays a minor role. The severity of gas exchanges alterations is proportional to the degree of impairment of diurnal pulmonary function tests, particularly of partial pressure of oxygen (PaO2) and of carbon dioxide (PaCO2) in arterial blood, but correlations between diurnal and nocturnal blood gas levels are rather loose. Subjects with diurnal PaO2 of 60–70 mmHg are distinguished in “desaturators” and “nondesaturators” according to nocturnal oxyhemoglobin saturation behavior. The role of nocturnal hypoxemia as a determinant of alterations in sleep structure observed in COPD is dubious. Effects of the “desaturator” condition on pulmonary hemodynamics, evolution of diurnal blood gases, and life expectancy are also controversial. Conversely, it is generally accepted that occurrence of sleep apneas in COPD is associated with a worse evolution of the disease. Nocturnal polysomnographic monitoring in COPD is usually performed when coexistence of sleep apnea (“overlap syndrome”) is suspected, while in most other cases nocturnal oximetry may be enough. Nocturnal oxygen attenuates sleep desaturations among stable patients, without increases in PaCO2 of clinical concern. Nocturnal treatment with positive pressure ventilators may give benefit to some stable hypercapnic subjects and patients with the overlap syndrome.
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Affiliation(s)
- Oreste Marrone
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy.
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Budweiser S, Hitzl AP, Jörres RA, Heinemann F, Arzt M, Schroll S, Pfeifer M. Impact of noninvasive home ventilation on long-term survival in chronic hypercapnic COPD: a prospective observational study. Int J Clin Pract 2007; 61:1516-22. [PMID: 17686094 DOI: 10.1111/j.1742-1241.2007.01427.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS The long-term benefit from noninvasive ventilation (NIV) in chronic hypercapnic chronic obstructive pulmonary disease (COPD) remains uncertain. METHODS Within a prospective observational design, we compared the long-term survival of 140 patients with severe persistent hypercapnic COPD (FEV(1) 28.7 +/- 8.7% predicted; PaCO(2) 60.1 +/- 9.2 mmHg) with (n = 99) or without (n = 41) NIV. End-point was all-cause mortality, determined up to 4 years by Kaplan-Meier analysis. Additionally, Cox's proportional hazards regression and stratification by risk factors was performed. Patients were characterised by anthropometric and functional parameters, comorbidities and medical therapy. RESULTS Adherence in patients with NIV was high (88.9%), daily ventilator use being 6.4 +/- 2.6 h/day and inspiratory pressures 21.0 +/- 4.0 cmH(2)O. One- and 2-year survival rates were 87.7% and 71.8%, respectively, in patients with NIV vs. 56.7% and 42.0% in patients without NIV. Survival rates were significantly higher in patients with NIV compared to those without this therapy (p = 0.001; hazard ratio 0.380; 95% confidence interval 0.138-0.606). The difference between groups was still significant after adjustment for differences in baseline characteristics. Moreover, stratification by risk factors revealed beneficial effects, particularly in patients with high base excess (BE; > 8.9 mmol/l), low pH (< 7.41), FEV(1) (< 27.5%) haemoglobin (< 13.8 g/dl) or large hyperinflation (residual volume-to-total lung capacity > 189% predicted) upon inclusion (p < 0.05 each). CONCLUSION In patients with severe chronic hypercapnic COPD receiving NIV at high inspiratory pressure levels and showing high adherence to this therapy, long-term survival was significantly higher than in non-ventilated patients. Patients displaying more severe disease according to known risk factors seemed to benefit most from long-term NIV.
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Affiliation(s)
- S Budweiser
- Center for Pneumology, Hospital Donaustauf, Donaustauf, Germany.
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Robert D, Argaud L. Non-invasive positive ventilation in the treatment of sleep-related breathing disorders. Sleep Med 2007; 8:441-52. [PMID: 17470410 DOI: 10.1016/j.sleep.2007.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 03/12/2007] [Indexed: 12/13/2022]
Abstract
This chapter addresses the use of long-term non-invasive positive pressure ventilation (NIPPV) (to the exclusion of continuous positive airway pressure) in the different clinical settings in which it is currently proposed: principally in diseases responsible for hypoventilation characterized by elevated PaCO(2). Nasal masks are predominantly used, followed by nasal pillow and facial masks. Mouthpieces are essentially indicated in case daytime ventilation is needed. Many clinicians currently prefer pressure-preset ventilator in assist mode as the first choice for the majority of the patients with the view of offering better synchronization. Nevertheless, assist-control mode with volume-preset ventilator is also efficient. The settings of the ventilator must insure adequate ventilation assessed by continuous nocturnal records of at least oxygen saturation of haemoglobin-measured by pulse oximetry. The main categories of relevant diseases include different types of neuromuscular disorders, chest-wall deformities and even lung diseases. Depending on the underlying diseases and on individual cases, two schematic situations may be individualized. Either intermittent positive pressure ventilation (IPPV) is continuously mandatory to avoid death in the case of complete or quasi-complete paralysis or is used every day for several hours, typically during sleep, producing enough improvement to allow free time during the daylight in spontaneous breathing while hypoventilation and related symptoms are improved. In case of complete or quasi-complete need of mechanical assistance, a tracheostomy may become an alternative to non-invasive access. In neuromuscular diseases, in kyphosis and in sequela of tuberculosis patients, NIPPV always significantly increases survival. Conversely, no data support a positive effect on survival in chronic obstructive pulmonary disease.
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Affiliation(s)
- Dominique Robert
- University Claude Bernard, Lyon-Nord Medical School, 8, avenue Rockefeller, 69008 Lyon, France.
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Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) has become one of the main indications for domiciliary ventilation, which is usually non-invasive (NIV). This review focuses on the pathophysiology processes and clinical trial data that underlie current guidelines from international societies. STATE OF THE ART To date most published studies about domiciliary ventilation in COPD have been short-term and their message is complicated by the presence of significant methodological problems. The two controlled studies of > or =12 months-duration both found that survival was not improved by long-term NIV. Domiciliary ventilation may be considered when long-term oxygen therapy is unsuccessful and when failed with a progressive deterioration in clinical respiratory status with recurrent episodes of acute hypercapnic respiratory failure. A diurnal PaCO(2) > or =55 mmHg (7.3 kPa) is a necessary but not sufficient condition to consider domiciliary ventilation. CONCLUSION Domiciliary ventilation should only be initiated in selected patients on the basis of clinical symptoms and exacerbation frequency. Until further characterization of patients who are likely to respond, the response to treatment should be assessed regularly.
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Affiliation(s)
- A Cuvelier
- Service de Pneumologie et Unité de Soins Intensifs, UPRES EA 3830-IFR MP23, Centre Hospitalier Universitaire de Rouen, France.
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Budweiser S, Heinemann F, Fischer W, Dobroschke J, Pfeifer M. Long-term reduction of hyperinflation in stable COPD by non-invasive nocturnal home ventilation. Respir Med 2005; 99:976-84. [PMID: 15950138 DOI: 10.1016/j.rmed.2005.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The role of non-invasive positive pressure ventilation (NPPV) in stable COPD with chronic ventilatory failure remains controversial. The impact of long-term home nocturnal NPPV treatment on deflation has not yet been evaluated in detail. METHODS Retrospective explorative study of 46 patients with stable COPD undergoing NPPV treatment. Effects of NPPV on body plethysmographic parameters, blood gas tensions and inspiratory muscle function after 6.2 (+/-1.7) and 12.7 (+/-2.1) months of treatment. Further, evaluation of 1-year survival, compliance and ventilation parameters. RESULTS One-year survival was 89.1%. The effectiveness of ventilation was proven by a significant reduction in nocturnal and daytime PaCO2. We observed a decrease in the ratio of residual volume (RV) to total lung capacity (TLC) on the average of 5.2+/-9.8% (or 15.2+/-29.7% pred.; P<0.01) at six and 3.9+/-9.0% (or 12.9+/-18.6% pred.; P<0.001) at 12 months. As a consequence, we found significant improvements in inspiratory capacity (IC), vital capacity (VC) and forced expiratory volume in one second (FEV1). For patients with the most severe hyperinflation (RV/TLC>75%), we found a significant positive correlation between inspiratory positive airway pressure (IPAP) and reductions in PaCO2 (r=0.56; P<0.05) and RV/TLC (r=0.50; P<0.05). CONCLUSIONS In severe hypercapnic stable COPD long-term nocturnal NPPV can reduce hyperinflation with sustained improved daytime blood gas parameters.
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Windisch W, Kostić S, Dreher M, Virchow JC, Sorichter S. Outcome of Patients With Stable COPD Receiving Controlled Noninvasive Positive Pressure Ventilation Aimed at a Maximal Reduction of Paco2. Chest 2005; 128:657-62. [PMID: 16100151 DOI: 10.1378/chest.128.2.657] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The role of noninvasive positive pressure ventilation (NPPV) has been well established in the treatment of acute hypercapnic respiratory failure due to COPD. However, evidence for a sustained improvement in blood gas levels and survival in patients with stable hypercapnic COPD following NPPV is still lacking. There is concern that this might be due to low inspiratory pressures of < 18 cm H2O used in previous studies, which thereby did not achieve a reduction of Pa(CO2). Therefore, the 2-year survival and changes in lung function and blood gas levels were analyzed in patients with stable hypercapnic COPD in whom controlled pressure-limited NPPV was titrated to achieve a maximal improvement in Pa(CO2). DESIGN Retrospective study between March 1997 and September 2003. SETTING General ward of a university hospital. PATIENTS Thirty-four consecutive patients with stable (mean pH 7.40 +/- 0.03) hypercapnic COPD (mean age, 63.4 +/- 9.7 years [+/- SD]; mean body mass index, 28.3 +/- 7.3 kg/m2). MEASUREMENTS AND RESULTS Daytime Pa(CO2) during spontaneous breathing decreased by 6.9 +/- 8.0 (95% confidence interval, - 9.9 to - 3.9), from 53.3 +/- 4.8 to 46.4 +/- 7.0 mm Hg (p < 0.001); while daytime Pa(O2) increased by 5.8 +/- 9.4 (95% confidence interval, 2.3 to 9.3), from 51.7 +/- 8.8 to 57.5 +/- 9.3 mm Hg (p = 0.002); and FEV1 increased by 0.14 +/- 0.16 (95% confidence interval, 0.08 to 0.20), from 1.03 +/- 0.54 to 1.17 +/- 0.59 L (p < 0.001) after 2 months of NPPV. This was achieved with mean inspiratory pressures of 27.7 +/- 5.9 cm H2O (range, 17 to 40 cm H2O) at a mean respiratory rate of 20.8 +/- 2.5 breaths/min (range, 14 to 24 breaths/min). The 2-year survival rate was 86%. CONCLUSIONS Controlled NPPV using a mean inspiratory pressure of 28 cm H2O is well tolerated over longer periods and can improve blood gas levels and lung function. Prospective, randomized controlled trials of high-intensity NPPV are required to evaluate its role in patients with stable hypercapnic COPD.
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Affiliation(s)
- Wolfram Windisch
- Department of Pneumology, University Hospital Freiburg, Killianstrasse 5, D - 79106 Freiburg, Germany.
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Abstract
A doença pulmonar obstrutiva crônica é uma condição freqüente e é hoje a quarta principal causa de mortes nos Estados Unidos. A prevalência de perturbação respiratória durante o sono, ou síndrome de superposição, como anteriormente denominada, ainda não foi determinada devido à publicação de relatos conflitantes. Esta condição deve continuar sendo investigada devido aos efeitos adversos causados por transtornos respiratórios relacionados ao sono em pacientes com doença pulmonar de base. Neste relato, discutiremos brevemente os mecanismos envolvidos na origem da perturbação respiratória durante o sono em doença pulmonar obstrutiva crônica e auxiliaremos o leitor a distinguir àqueles pacientes que se beneficiariam de uma avaliação do padrão do sono mais detalhada, com a discussão de tópicos de gerenciamento e opções de tratamento.
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Chu CM, Chan VL, Lin AWN, Wong IWY, Leung WS, Lai CKW. Readmission rates and life threatening events in COPD survivors treated with non-invasive ventilation for acute hypercapnic respiratory failure. Thorax 2004; 59:1020-5. [PMID: 15563699 PMCID: PMC1746916 DOI: 10.1136/thx.2004.024307] [Citation(s) in RCA: 158] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Non-invasive ventilation (NIV) has been shown to reduce intubation and in-hospital mortality in patients with chronic obstructive pulmonary disease (COPD) and acute hypercapnic respiratory failure (AHRF). However, little information exists on the outcomes following discharge. A study was undertaken to examine the rates of readmission, recurrent AHRF, and death following discharge and the risk factors associated with them. METHODS A cohort of COPD patients with AHRF who survived after treatment with NIV in a respiratory high dependency unit was prospectively followed from July 2001 to October 2002. The times to readmission, first recurrent AHRF, and death were recorded and analysed against potential risk factors collected during the index admission. RESULTS One hundred and ten patients (87 men) of mean (SD) age 73.2 (7.6) years survived AHRF after NIV during the study period. One year after discharge 79.9% had been readmitted, 63.3% had another life threatening event, and 49.1% had died. Survivors spent a median of 12% of the subsequent year in hospital. The number of days in hospital in the previous year (p = 0.016) and a low Katz score (p = 0.018) predicted early readmission; home oxygen use (p = 0.002), APACHE II score (p = 0.006), and a lower body mass index (p = 0.041) predicted early recurrent AHRF or death; the MRC dyspnoea score (p<0.001) predicted early death. CONCLUSIONS COPD patients with AHRF who survive following treatment with NIV have a high risk of readmission and life threatening events. Further studies are urgently needed to devise strategies to reduce readmission and life threatening events in this group of patients.
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Affiliation(s)
- C M Chu
- Division of Respiratory Medicine, Department of Medicine and Geriatrics, United Christian Hospital, Kowloon, Hong Kong, SAR, China.
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