European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD

Initiation of Chronic Non-invasive Ventilation

Initiation of home non-invasive ventilation (NIV) requires careful consideration of the patient's condition, motivation, expectations, wishes, and social circumstances. The decision to start NIV depends on a combination of factors including patient symptoms and objective evidence of nocturnal hypoventilation. A solid understanding of the underlying pathophysiology is key to a systematic and well-balanced clinical approach to titrating NIV. The location where NIV is initiated is not the most relevant issue, provided that it is a comfortable, safe environment in which adequate monitoring can be assured. The majority of patients prefer their own home for treatment initiation.

Palliative Care and Noninvasive Ventilation

Palliative care is important for many patients who require noninvasive ventilation. The particular needs of patients with neuromuscular disease and chronic obstructive pulmonary disease are explored. Advance care planning is explored with tips for undertaking this important communication task. Brief comments regarding symptom burden, weaning, voluntary assisted dying, and self-care are included.

Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea Overlap Syndrome: An Update on the Epidemiology, Pathophysiology, and Management

This review provides an up-to-date summary of the prevalence, pathophysiology, diagnosis, and treatment of the chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) overlap syndrome (OVS). The presence of OVS is high in patients with COPD and in patients with OSA and is associated with profound nocturnal oxygen desaturation and systemic inflammation. There is a high prevalence of cardiovascular disease among patients with OVS and this likely contributes to increased mortality. Observational studies suggest that positive airway pressure therapy improves survival and reduces COPD exacerbations; however, randomized controlled trials will be required to confirm these findings.

Development of a machine learning model for prediction of the duration of unassisted spontaneous breathing in patients during prolonged weaning from mechanical ventilation

PURPOSE

Treatment of patients undergoing prolonged weaning from mechanical ventilation includes repeated spontaneous breathing trials (SBTs) without respiratory support, whose duration must be balanced critically to prevent over- and underload of respiratory musculature. This study aimed to develop a machine learning model to predict the duration of unassisted spontaneous breathing.

MATERIALS AND METHODS

Structured clinical data of patients from a specialized weaning unit were used to develop (1) a classifier model to qualitatively predict an increase of duration, (2) a regressor model to quantitatively predict the precise duration of SBTs on the next day, and (3) the duration difference between the current and following day. 61 features, known to influence weaning, were included into a Histogram-based gradient boosting model. The models were trained and evaluated using separated data sets.

RESULTS

18.948 patient-days from 1018 individual patients were included. The classifier model yielded an ROC-AUC of 0.713. The regressor models displayed a mean absolute error of 2:50 h for prediction of absolute durations and 2:47 h for day-to-day difference.

CONCLUSIONS

The developed machine learning model showed informed results when predicting the spontaneous breathing capacity of a patient in prolonged weaning, however lacking prognostic quality required for direct translation to clinical use.

Factors associated with noninvasive ventilation usage in patients with hypoventilation disorders

Study Objectives

The objective of this study was to investigate the association between demographic, clinical, and interface factors and noninvasive ventilation (NIV) usage.

Methods

A retrospective cohort analysis of 478 patients prescribed NIV from 2013 to 2021 was performed. Demographic factors, clinical indications for NIV, and interface factors were collected, and linear regression was conducted to evaluate the association between these variables and NIV usage (hour/night).

Results

The average usage of the cohort was 6.5 hour/night ± 4.6, with an average age of 57 years ± 16 and body mass index (BMI) of 40.5kg/m2 ± 14.7. The cohort was mostly male (n = 290, 60.6%). The most common indications for NIV prescription were high-pressure requirement for obstructive sleep apnea (HPR, n = 190, 39.7%), neuromuscular disease (NMD, n = 140, 29.3%), and obesity hypoventilation syndrome (OHS, n = 111, 23.2%). A diagnosis of NMD was a significant predictor of higher NIV usage (8.0 ± 6.1 hour/night) in multivariate analysis (p = .036). The HPR subcohort had the lowest usage of all indications. Age and BMI did not predict usage. A nasal interface (p < .01) and lower expiratory positive airway pressure (EPAP) setting (p < .001) were associated with increased NIV usage.

Conclusions

This study highlights the multifaceted nature of NIV usage. Where demographic factors were not consistent predictors of usage, interface, and clinical indication were associated with usage. These findings highlight that the HPR users are a group at risk of low usage.

Update in Noninvasive Home Mechanical Ventilation: A Narrative Review of Indications, Outcomes, and Monitoring

Hypercapnic respiratory failure arises due to an imbalance in the load-capacity-drive relationship of the respiratory muscle pump, typically arising in patients with chronic obstructive pulmonary disease, obesity-related respiratory failure, and neuromuscular disease. Patients at risk of developing chronic respiratory failure and those with established disease should be referred to a specialist ventilation unit for evaluation and consideration of home noninvasive ventilation (NIV) initiation. Clinical trials demonstrate that, following careful patient selection, home NIV can improve a range of clinical, patient-reported, and physiological outcomes. This narrative review provides an overview of the pathophysiology of chronic respiratory failure, evidence-based applications of home NIV, and monitoring of patients established on home ventilation and describes technological advances in ventilation devices, interfaces, and monitoring to enhance comfort, promote long-term adherence, and optimise gas exchange.

Chronic obstructive pulmonary disease and obstructive sleep apnea overlap: who to treat and how?

INTRODUCTION

The co-existence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), or the overlap syndrome, is common and associated with a distinct pattern of nocturnal hypoxemia and worse clinical outcomes than either disease alone. Consequently, identifying who and how to treat these patients is essential.

AREAS COVERED

Treatment is recommended in all patients with OSA and symptoms or systemic hypertension, but determining symptoms attributable to OSA can be challenging in patients with COPD. Treatment should be considered in asymptomatic patients with moderate to severe OSA and COPD with pulmonary hypertension and comorbid cardiovascular and cerebrovascular disease, especially if marked hypoxic burden. CPAP is effective, but in patients with the overlap syndrome and daytime hypercapnia, high-intensity noninvasive ventilation aiming to lower PaCO2 may have additional benefits. Additionally, in those with severe resting daytime hypoxemia, supplemental oxygen improves survival and should be added to positive airway pressure. The role of alternative non-positive airway pressure therapies in the overlap syndrome needs further study.

EXPERT OPINION

Both COPD and OSA are heterogeneous disorders with a wide range of disease severity and further research is needed to better characterize and prognosticate patients with the overlap syndrome to personalize treatment.

Home non-invasive ventilation: An observational study of aetiology, chronic respiratory failure of multiple aetiologies, survival and treatment adherence

Home non-invasive ventilation (NIV) is used to treat patients with chronic respiratory failure (CRF). However, knowledge on the prevalence and impact of multimorbid aetiology of CRF, patterns of NIV use, and survival of these patients is limited. Our aim was to analyse the multiple aetiologies of CRF, patterns of NIV use and the outcome of those patients. We conducted a retrospective analysis of 1,281 patients treated with home-NIV between 2004 and 2014 in Turku University Hospital, Finland. The patients were divided into nine disease categories: obstructive airways disease (16 %); obesity hypoventilation syndrome (11 %); neuromuscular disease (10 %); chest wall diseases (4 %); sleep apnoea (26 %); interstitial lung diseases (3 %); malignancy (2 %); other (3 %) and acute (8 %), which refers to the patients who did not fulfil criteria of CRF. In addition, multiple aetiologies of CRF were found in 17 %. Mean adherence to home-NIV was 6.0 ± 4.4 h/d and median treatment duration 410 (120-1021) days. Adherence, treatment duration or survival did not significantly differ between patients with either single or multiple causative diseases leading to CRF. Median survival was 4.5 years (95 % CI 3.6 to 5.4). The main reasons for discontinuing NIV were death (56 %) and lack of motivation (19 %). We conclude that home-NIV is used in a variety of diseases. CRF of multiple aetiologies is prevalent and not limited to chronic obstructive lung disease and obstructive sleep apnoea overlap syndrome. However, the adherence to home-NIV or survival did not differ between patients with a single or multiple diseases causing CRF, but the survival of the home-NIV patients differed according to the underlying aetiology of CRF.

'Against Medical Advice' Discharges After Respiratory-Related Hospitalizations: Strategies for Respectful Care

Against medical advice (AMA) discharges are practically and emotionally challenging for both patients and clinicians. Moreover, they are common after admissions for respiratory conditions such as COPD and asthma, and they are associated with poor outcomes. Despite the challenges presented by AMA discharges, clinicians rarely receive formal education and have limited guidance on how to approach these discharges. Often, the approach to AMA discharges prioritizes designating the discharge as "AMA," whereas effective coordination of discharge care receives less attention. Such an approach can lead to stigmatization of patients and low-quality care. Although evidence for best practices in AMA discharges remains lacking, we propose a set of strategies to improve care in AMA discharges by focusing on respect, in which clinicians treat patients as equals and honor differing values. We describe five strategies, including (1) preventing an AMA discharge; (2) conducting a patient-centered and truthful discussion of risk; (3) providing harm-reducing discharge care; (4) minimizing stigma and bias; (5) educating trainees. Through a case of a patient discharging AMA after a COPD exacerbation, we highlight how these strategies can be applied to common issues in respiratory-related hospitalizations, such as prescribing inhalers and managing oxygen requirements. We argue that, by using these strategies, clinicians can deliver respectful and higher-quality care to an often-marginalized population of patients with respiratory disease.

Home Noninvasive Ventilation in COPD

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

Applying Noninvasive Ventilation in Treatment of Acute Exacerbation of COPD Using Evidence-Based Interprofessional Clinical Practice

When administered as first-line intervention to patients admitted with acute hypercapnic respiratory failure secondary to COPD exacerbation in conjunction with guideline-recommended therapies, noninvasive ventilation (NIV) has been shown to reduce mortality and endotracheal intubation. Opportunities to increase uptake of NIV continue to exist despite inclusion of this therapy in clinical guidelines. Identifying patients appropriate for NIV, and subsequently providing close monitoring to determine an improvement in clinical condition involves a team consisting of physician, nurse, and respiratory therapist in institutions that successfully implement NIV. We describe to our knowledge the first known evidence-based algorithm speaking to initiation, titration, monitoring, and weaning of NIV in treatment of acute exacerbation of COPD that incorporates the necessary interprofessional collaboration among physicians, nurses, and respiratory therapists caring for these patients.

Internet of things-based management versus standard management of home noninvasive ventilation in COPD patients with hypercapnic chronic respiratory failure: a multicentre randomized controlled non-inferiority trial

Background

Effective monitoring and management are crucial during long-term home noninvasive positive pressure ventilation (NPPV) in patients with hypercapnic chronic obstructive pulmonary disease (COPD). This study investigated the benefit of Internet of Things (IOT)-based management of home NPPV.

Methods

This multicenter, prospective, parallel-group, randomized controlled non-inferiority trial enrolled patients requiring long-term home NPPV for hypercapnic COPD. Patients were randomly assigned (1:1), via a computer-generated randomization sequence, to standard home management or IOT management based on telemonitoring of clinical and ventilator parameters over 12 months. The intervention was unblinded, but outcome assessment was blinded to management assignment. The primary outcome was the between-group comparison of the change in health-related quality of life, based on severe respiratory insufficiency questionnaire scores with a non-inferiority margin of -5. This study is registered with Chinese Clinical Trials Registry (No. ChiCTR1800019536).

Findings

Overall, 148 patients (age: 72.7 ± 6.8 years; male: 85.8%; forced expiratory volume in 1 s: 0.7 ± 0.3 L; PaCO2: 66.4 ± 12.0 mmHg), recruited from 11 Chinese hospitals between January 24, 2019, and June 28, 2021, were randomly allocated to the intervention group (n = 73) or the control group (n = 75). At 12 months, the mean severe respiratory insufficiency questionnaire score was 56.5 in the intervention group and 50.0 in the control group (adjusted between-group difference: 6.26 [95% CI, 3.71-8.80]; P < 0.001), satisfying the hypothesis of non-inferiority. The 12-month risk of readmission was 34.3% in intervention group compared with 56.0% in the control group, adjusted hazard ratio of 0.56 (95% CI, 0.34-0.92; P = 0.023). No severe adverse events were reported.

Interpretation

Among stable patients with hypercapnic COPD, using IOT-based management for home NPPV improved health-related quality of life and prolonged the time to readmission.

Funding

Air Liquide Healthcare (Beijing) Co., Ltd.

ERS International Congress 2023: highlights from the Respiratory Intensive Care Assembly

Early career members of Assembly 2 (Respiratory Intensive Care) attended the 2023 European Respiratory Society International Congress in Milan, Italy. The conference covered acute and chronic respiratory failure. Sessions of interest to our assembly members and to those interested in respiratory critical care are summarised in this article and include the latest updates in respiratory intensive care, in particular acute respiratory distress syndrome and mechanical ventilation.

Does PaCO2 correction have an impact on survival of patients with chronic respiratory failure and long-term non-invasive ventilation?

Background and objective

Non-invasive ventilation (NIV) improves survival of patients with chronic respiratory failure (CRF). Most often, pressure settings are made to normalize arterial blood gases. However, this objective is not always achieved due to intolerance to increased pressure or poor compliance. Few studies have assessed the effect of persistent hypercapnia on ventilated patients' survival. Data from the Pays de la Loire Respiratory Health Research Institute cohort were analyzed to answer this question.

Study design and methods

NIV-treated adults enrolled between 2009 and 2019 were divided into 5 subgroups: obesity-hypoventilation syndrome (OHS), COPD, obese COPD, neuromuscular disease (NMD) and chest wall disease (CWD). PaCO2 correction was defined as the achievement of a PaCO2 < 6 kPa or a 20% decrease in baseline PaCO₂ in COPD patients. The endpoint was all-cause mortality. Follow-up was censored in case of NIV discontinuation.

Results

Data from 431 patients were analyzed. Median survival was 103 months and 148 patients died. Overall, PaCO2 correction was achieved in 74% of patients. Bivariate analysis did not show any survival difference between patients who achievedPaCO₂ correction and those who remained hypercapnic: overall population: p = 0.74; COPD: p = 0.97; obese COPD: p = 0.28; OHS: p = 0.93; NMD: p = 0.84; CWD: p = 0.28.

Conclusion

Moderate residual hypercapnia under NIV does not negatively impact survival in CRF patients. In individuals with poor tolerance of pressure increases, residual hypercapnia can therefore be tolerated under long-term NIV. Larger studies, especially with a higher number of patients with residual PaCO2 > 7 kPa, are needed to confirm these results.

Effects of non-invasive ventilation on sleep in chronic hypercapnic respiratory failure

Chronic respiratory disease can exacerbate the normal physiological changes in ventilation observed in healthy individuals during sleep, leading to sleep-disordered breathing, nocturnal hypoventilation, sleep disruption and chronic respiratory failure. Therefore, patients with obesity, slowly and rapidly progressive neuromuscular disease and chronic obstructive airways disease report poor sleep quality. Non-invasive ventilation (NIV) is a complex intervention used to treat sleep-disordered breathing and nocturnal hypoventilation with overnight physiological studies demonstrating improvement in sleep-disordered breathing and nocturnal hypoventilation, and clinical trials demonstrating improved outcomes for patients. However, the impact on subjective and objective sleep quality is dependent on the tools used to measure sleep quality and the patient population. As home NIV becomes more commonly used, there is a need to conduct studies focused on sleep quality, and the relationship between sleep quality and health-related quality of life, in all patient groups, in order to allow the clinician to provide clear patient-centred information.

Non-invasive ventilation in the care of patients with chronic obstructive pulmonary disease with palliative care needs: a scoping review

BACKGROUND

Patients with severe chronic obstructive pulmonary disease (COPD) could have palliative care (PC) needs because of unmet needs such as dyspnoea. This may lead to anxiety and may have an impact on patients' ability to perform daily activities of living. PC can be started when patients with COPD have unmet needs and can be provided alongside disease-modifying therapies. Non-invasive ventilation (NIV) could be an important measure to manage dyspnoea in patients with COPD in need of PC. A scoping review was conducted to gain an overview of the existing research and to identify knowledge gaps. The aim of this scoping review was to systematically map published studies on the use of NIV in patients with COPD with PC needs, including the perspectives and experiences of patients, families, and healthcare professionals (HCPs).

METHODS

This review was conducted following the framework of Arksey and O'Malley. The reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The review protocol was published. AMED, CINAHL, Embase, MEDLINE, PEDro, and PsycInfo were searched from inception to November 14, 2022. The included studies had to report the perspectives and experiences of COPD patients, relatives, and HCPs regarding NIV in the care of patients with COPD with PC needs. In pairs, the authors independently assessed studies' eligibility and extracted data. The data were organised thematically. The results were discussed in a consultation exercise.

RESULTS

This review included 33 papers from 32 studies. Four thematic groupings were identified: preferences and attitudes towards the use of NIV; patient participation in the decision-making process of NIV treatment; conflicting results on the perceived benefits and burdens of treatment; and heterogenous clinical outcomes in experimental studies. Patients perceived NIV as a 'life buoy' to keep them alive. Many patients wanted to take part in the decision-making process regarding NIV treatment but expressed varying degrees of inclusion by HCPs in such decision-making. Conflicting findings were identified regarding the perceived benefits and burdens of NIV treatment. Diversity in heterogeneous clinical outcomes were reported in experimental studies.

CONCLUSIONS

There is a need for more studies designed to investigate the effectiveness of NIV as a palliative measure for patients with COPD with PC needs using comprehensive outcomes. It is especially important to gain more knowledge on the experiences of all stakeholders in the use of home-based NIV treatment to these patients.

Hospital-Provider Company Network for Home Non-Invasive Ventilation: A Feasibility Pilot Study

This study assessed the feasibility of implementing a hybrid hospital-provider company (PC) clinical pathway for patients with chronic respiratory failure (CRF) through the adaptation and follow-up of non-invasive ventilation (NIV). Over a 3-month period, a PC physiotherapist case manager oversaw the adaptation process, making adjustments as necessary, using remote monitoring and home visits. Outcome measures, including the number of patients enrolled, serious adverse events, hospitalizations, survival rates, professional time allocation, NIV adherence, nocturnal apnea-hypopnea, and oxygen saturation, Δ arterial carbon dioxide pressure (PaCO2), dyspnea, Short Physical Performance Battery (SPPB), exercise tolerance, quality of life, physical activity, and patient satisfaction, were collected. The recruitment rate was 74% (nineteen patients). Commonly reported adverse events included leakage, discomfort and sleep disturbance. Predominant interventions were four home visits (3; 4) and two NIV adjustments (1; 5). The overall program time commitment averaged 43.97 h per patient (being hospital 40 ± 11% and PC 60 ± 11%). Improvements in PaCO2, dyspnea, SPPB and exercise tolerance were observed by the third month. Adherence to NIV was high, with good or very good satisfaction with its use. This study demonstrates that a hybrid hospital-PC service for NIV adaptation and follow-up is not only feasible but also shows validity, reliability, and acceptability.

Analysis and applications of respiratory surface EMG: report of a round table meeting

Surface electromyography (sEMG) can be used to measure the electrical activity of the respiratory muscles. The possible applications of sEMG span from patients suffering from acute respiratory failure to patients receiving chronic home mechanical ventilation, to evaluate muscle function, titrate ventilatory support and guide treatment. However, sEMG is mainly used as a monitoring tool for research and its use in clinical practice is still limited-in part due to a lack of standardization and transparent reporting. During this round table meeting, recommendations on data acquisition, processing, interpretation, and potential clinical applications of respiratory sEMG were discussed. This paper informs the clinical researcher interested in respiratory muscle monitoring about the current state of the art on sEMG, knowledge gaps and potential future applications for patients with respiratory failure.

Supporting patients with hypercapnia

Hypercapnia is commonly encountered by general and specialist respiratory clinicians. Patients at risk of developing hypercapnic respiratory failure include those with chronic obstructive pulmonary disease (COPD), obesity and neuromuscular disease. Such patients may present to clinicians acutely unwell on the acute medical take or during an inpatient deterioration, or be identified in the stable outpatient setting. In this review, we provide a practical guide to develop clinicians' knowledge, skills and confidence in promptly recognising and managing hypercapnic respiratory failure, and to promote national ventilation quality standards to encourage consistent delivery of high-quality care and optimise outcomes for patients.

A history of home mechanical ventilation: The past, present and future

This state-of-the-art review provides an overview of the history of home mechanical ventilation (HMV), including early descriptions of mechanical ventilation from ancient and Renaissance perspectives and the mass development of ventilators designed for long-term use during the poliomyelitis epidemic. Seminal data from key clinical trials supports the application of HMV in certain patients with chronic obstructive pulmonary disease, neuromuscular disease and obesity-related respiratory failure. Innovative engineering coupled with refined physiological understanding now permits widespread delivery of home mechanical ventilation to a global population, using portable devices with advanced ventilatory modes and telemonitoring capabilities. Exponential growth in digital technology continues, and ongoing research is needed to understand how to harness clinical and physiological data to benefit patients and healthcare services in a clinically- and cost-effective manner.

Home noninvasive ventilation in severe COPD: in whom does it work and how?

Background

Not all hypercapnic COPD patients benefit from home noninvasive ventilation (NIV), and mechanisms through which NIV improves clinical outcomes remain uncertain. We aimed to identify "responders" to home NIV, denoted by a beneficial effect of NIV on arterial partial pressure of carbon dioxide (PaCO2), health-related quality of life (HRQoL) and survival, and investigated whether NIV achieves its beneficial effect through an improved PaCO2.

Methods

We used individual patient data from previous published trials collated for a systematic review. Linear mixed-effect models were conducted to compare the effect of NIV on PaCO2, HRQoL and survival, within subgroups defined by patient and treatment characteristics. Secondly, we conducted a causal mediation analysis to investigate whether the effect of NIV is mediated by a change in PaCO2.

Findings

Data of 1142 participants from 16 studies were used. Participants treated with lower pressure support (<14 versus ≥14 cmH2O) and with lower adherence (<5 versus ≥5 h·day-1) had less improvement in PaCO2 (mean difference (MD) -0.30 kPa, p<0.001 and -0.29 kPa, p<0.001, respectively) and HRQoL (standardised MD 0.10, p=0.002 and 0.11, p=0.02, respectively), but this effect did not persist to survival. PaCO2 improved more in patients with severe dyspnoea (MD -0.30, p=0.02), and HRQoL improved only in participants with fewer than three exacerbations (standardised MD 0.52, p=0.03). The results of the mediation analysis showed that the effect on HRQoL is mediated partially (23%) by a change in PaCO2.

Interpretation

With greater pressure support and better daily NIV usage, a larger improvement in PaCO2 and HRQoL is achieved. Importantly, we demonstrated that the beneficial effect of home NIV on HRQoL is only partially mediated through a reduction in diurnal PaCO2.

Indications and evidence for domiciliary noninvasive ventilation

INTRODUCTION

Home noninvasive ventilation (HNIV) has expanded globally, with a greater evidence base for its use. HNIV improves multiple patient related outcomes in patients with chronic hypercapnic respiratory failure. Obesity hypoventilation syndrome (OHS) is rapidly taking over as the primary indication for HNIV and COPD patients who overlap with obstructive sleep apnea hypoventilation syndromes (OSAHS) and are increasingly recognized but add to the complexity of HNIV prescribing. Optimal settings vary for differing diseases, with higher inspiratory pressures often required in those with OHS and COPD, yet which settings translate into greatest patient benefit remains unknown.

AREAS COVERED

We cover the evidence base underpinning the common indications for HNIV in COPD, OHS, neuromuscular disease (NMD), and chest wall disease (CWD) and highlight common HNIV modes used.

EXPERT OPINION

Active screening for nocturnal hypoventilation in OHS and COPD may be important to guide earlier ventilation. Further research on which HNIV modalities best improve patient related outcomes and the right time for initiation in different patient phenotypes is rapidly needed. Worldwide, clinical research trials should aim to bridge the gap by reporting on patient-related outcomes and cost effectiveness in real-world populations to best understand the true benefit of HNIV amongst heterogenous patient populations.

Home ventilation for patients with end-stage chronic obstructive pulmonary disease

PURPOSE OF THE REVIEW

The number of patients with end-stage chronic obstructive pulmonary disease (COPD) treated with chronic non-invasive ventilation (NIV) has greatly increased. In this review, the authors summarize the evidence for nocturnal NIV and NIV during exercise. The authors discuss the multidisciplinary and advanced care of patients with end-stage COPD treated with NIV.

RECENT FINDINGS

Nocturnal NIV improves gas exchange, health-related quality of life and survival in stable hypercapnic COPD patients. Improvements in care delivery have been achieved by relocating care from the hospital to home based; home initiation of chronic NIV is feasible, non-inferior regarding efficacy and cost-effective compared to in-hospital initiation. However, the effect of NIV on symptoms is variable, and applying optimal NIV for end-stage COPD is complex. While exercise-induced dyspnoea is a prominent complaint in end-stage COPD, nocturnal NIV will not change this. However, NIV applied solely during exercise might improve exercise tolerance and dyspnoea. While chronic NIV is often a long-standing treatment, patient expectations should be discussed early and be managed continuously during the treatment. Further, integration of advance care planning requires a multidisciplinary approach.

SUMMARY

Although chronic NIV is an effective treatment in end-stage COPD with persistent hypercapnia, there are still important questions that need to be answered to improve care of these severely ill patients.

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN

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

RESULTS

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

INTERPRETATION

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

Home NIV treatment quality in patients with chronic respiratory failure having participated to the French nationwide telemonitoring experimental program (The TELVENT study)

BACKGROUND

The ETAPES program is a national telemedicine experiment conducted in France between 2018 and 2023 to investigate whether home non-invasive ventilation (NIV) telemonitoring improves healthcare pathways in patients with chronic respiratory failure (CRF) and impacts healthcare organization. The program provides a combination of therapeutic education and NIV telemonitoring with data processed by an algorithm generating alerts. The TELVENT study objective was to analyze the evolution of ventilation quality in patients included in the ETAPES program.

METHODS

Multicentric cohort study on patients undergoing long-term NIV included in the ETAPES program between September 2018 and December 2020 and who did not refuse the use of their data for this research. Data were obtained from homecare provider databases. The primary endpoint was to attain successful NIV treatment, which was determined by a combination of daily NIV usage for > 4 h per day, low leaks, and a low apnea-hypopnea index (AHI) identified by the NIV device. Respiratory disability was assessed using the DIRECT questionnaire.

RESULTS

329 patients were included in the study of which 145 had COPD and 83 had started NIV and ETAPES within one-month delay. Approximately 25% of patients did not achieve the criteria for successful NIV at ETAPES entry. The proportion of patients with successful NIV treatment increased to 86.8% at six months (p = 0.003, Cochran-Armitage trend test) regardless of NIV history and continued to increase at 12 months in newly equipped NIV patients (93.8%, at month 12, p = 0.0026 for trend test). Over time, a significant increase in NIV use and compliance was observed, while AHI significantly decreased in the overall population. No significant decrease was observed for non-intentional leaks. Approximately 4.9 alerts were generated per patient per 6 months. Their number and type (low NIV use, high AHI or leaks) differed among patients based on their NIV history. Respiratory disability score decreased over time compared with baseline.

CONCLUSION

The TELVENT study highlights the importance of remote NIV monitoring to rapidly identify patients with unsuccessful ventilation. The combination of remote monitoring and therapeutic education may improve the quality of home NIV, especially in the first months of treatment.

Health trajectories before initiation of non-invasive ventilation for chronic obstructive pulmonary disease: a French nationwide database analysis

Background

Chronic obstructive pulmonary disease (COPD) is the most common indication for long-term domiciliary non-invasive ventilation (NIV) but there is uncertainty in data supporting current guidelines. This study described health trajectories before initiation of at-home NIV in people with COPD, and compared mortality outcomes between groups with different pre-NIV health trajectories.

Methods

Data were from the French national health insurance reimbursement system database for individuals with COPD aged ≥40 years and ≥1 reimbursement for NIV between 1 January 2015 and 31 December 2019. Common health trajectories were determined using time sequence analysis through K-clustering (TAK analysis).

Findings

Data from 54,545 individuals were analysed; the population was elderly (median age 70 years) with multiple comorbidities. Four clusters were generated. Cluster 1 (n = 35,975/54,545; 66%) had NIV initiated in ambulatory settings or after the first acute event/exacerbation. Cluster 2 (6653/54,545; 12%) started NIV after ≥2 severe exacerbations in the previous 6 months. Cluster 3 (11,375/54,545; 21%) started NIV after frequent severe COPD-related exacerbations in the previous year. Cluster 4 (652/54,545; 1%) started NIV after many long-lasting severe exacerbations. The four clusters differed in age, sex, comorbidities, pre-NIV investigations, and prescriber/location of NIV initiation. Mortality differed significantly between clusters: highest in Cluster 4 and lowest in Cluster 1.

Interpretation

The significant heterogeneity in clinical initiation of NIV probably reflects the current lack of strong evidence and guideline recommendations. Knowledge about the characteristics and outcomes in different clusters should be used to address inequities and facilitate more consistent and personalised use domiciliary NIV in COPD.

Funding

JLP and SB are supported by the French National Research Agency in the framework of the "Investissements d'avenir" program (ANR-15-IDEX-02) and the "e-health and integrated care and trajectories medicine and MIAI artificial intelligence (ANR-19-P3IA-0003)" Chairs of excellence from the Grenoble Alpes University Foundation. This work was supported by ResMed.

International Survey of the Tools Used for Assessment, Monitoring and Management of Home Mechanical Ventilation Patients

BACKGROUND

There are limited data reporting diagnostic practices, compared to clinical guidelines, for patients with chronic respiratory failure requiring home mechanical ventilation (HMV). There are no data detailing the current use of downloaded physiological monitoring data in day-to-day clinical practice during initiation and follow up of patients on HMV. This survey reports clinicians' practices, with a specific focus on the clinical approaches employed to assess, monitor and manage HMV patients.

METHODS

A web-based international survey was open between 1 January and 31 March 2023.

RESULTS

In total, 114 clinicians responded; 84% of the clinicians downloaded the internal physiological ventilator data when initiating and maintaining HMV patients, and 99% of the clinicians followed up with patients within 3 months. Adherence, leak and the apnea-hypopnea index were the three highest rated items. Oxygen saturation was used to support a diagnosis of nocturnal hypoventilation and was preferred over measurements of carbon dioxide. Furthermore, 78% of the clinicians reviewed data for the assessment of patient ventilator asynchrony (PVA), although the confidence reported in identifying certain PVAs was reported as unconfident or extremely unconfident.

CONCLUSIONS

This survey confirmed that clinical practice varies and often does not follow the current guidelines. Despite PVA being of clinical interest, its clinical relevance was not clear, and further research, education and training are required to improve clinical confidence.

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

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

Advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation: A qualitative study exploring barriers, facilitators and patients' and healthcare professionals' recommendations

BACKGROUND

Although home non-invasive ventilation for patients with chronic obstructive pulmonary disease and persisting hypercapnia prolongs time to hospital readmission and prognosis, they retain a poor long-term prognosis. Requiring non-invasive ventilation in this population should trigger advance care planning, yet only 50% of patients are engaged in such discussions.

AIM

This study aimed to explore the barriers and facilitators to advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation and generate recommendations for improving practice.

STUDY DESIGN

A cross-sectional interview study took place with 10 patients with chronic obstructive pulmonary disease on home non-invasive ventilation and 12 North East Assisted Ventilation Service healthcare professionals from the North East of England.

RESULTS

Three themes ('overlooked', 'disjointed care' and 'awareness and expertise') were identified. Patients with chronic obstructive pulmonary disease are a 'forgotten about' population, exacerbated by prejudice and unpredictable disease trajectories. Recognition as a distinct and underserved population may improve care and advance care planning. All participants recognised a lack of care continuity, including limited collaboration and communication between services, as a significant barrier to advanced care planning. Additionally, lacking understanding of the rationale and positive impacts of advance care planning, exacerbated by a lack of expertise in difficult conversations, was a barrier to advance care planning.

CONCLUSIONS

Patients and healthcare professionals highlighted the need for individualised and ongoing advance care planning, particularly around prognosis and care preferences. Discussions should be initiated by familiar clinicians. Effective communication between services, clear agreements and protocols and upskilling healthcare professionals may ensure continuity of care.

Long-term non-invasive ventilation for COPD patients following an exacerbation with acute hypercapnic respiratory failure: a randomized controlled trial

Introduction

It remains unclear whether long-term non-invasive ventilation (LT-NIV) for patients with chronic obstructive pulmonary disease (COPD) improves survival and reduces admissions as results from randomized trials are inconsistent. We aim to determine whether LT-NIV initiated after an admission with acute hypercapnic respiratory failure (AHRF) can affect survival and admission rate in COPD patients.

Methods

A randomized controlled open-label trial, allocating patients with COPD to LT-NIV or standard of care immediately after an admission with AHRF treated with acute NIV. LT-NIV was aimed to normalize PaCO2 using high-pressure NIV.

Results

The study was discontinued before full sample size due to slow recruitment. 28 patients were randomized to LT-NIV and 27 patients to standard of care. 42% of patients had a history of ≥ 2 admissions with AHRF. Median IPAP was 24 cmH2O (IQR 20-28). The primary outcome, time to readmission with AHRF or death within 12 months, did not reach significance, hazard ratio 0.53 (95% CI 0.25-1.12) p = 0.097. In a competing risk analysis, adjusted for history of AHRF, the odds ratio for AHRF within 12 months was 0.30 (95% CI 0.11-0.87) p = 0.024. The LT-NIV group had less exacerbations (median 1 (0-1) vs 2 (1-4) p = 0.021) and readmissions with AHRF (median 0 (0-1) vs 1 (0-1) p = 0.016).

Conclusion

The risk of the primary outcome, time to readmission with AHRF or death within 12 months was numerically smaller in the LT-NIV group, however, did not reach significance. Nevertheless, several secondary outcome analyses like risk of AHRF, number of episodes of AHRF and exacerbations were all significantly reduced in favour of high-pressure LT-NIV, especially in patients with frequent AHRF.

Expanded central role of the respiratory physiotherapists in the community setting

The development of community hubs through the Slaintecare initiative will rely on respiratory physiotherapists and clinical nurse specialists for the management of chronic respiratory diseases. The role of the respiratory physiotherapist has evolved dramatically over the last decade. We review the increasing scope of practice of the physiotherapist and the evidence base for same. We pay particular attention to the role of the physiotherapist in areas such as pulmonary rehabilitation, sputum clearance, neuromuscular disease, chronic respiratory failure, ambulatory oxygen assessments and dysfunctional breathing. We give an in depth review of sputum clearance techniques. We also address areas of potential future expansion for the role of the physiotherapist such as prescription and initiation of non-invasive ventilation.

A Real-Life Study of Combined Treatment with Long-Term Non-Invasive Ventilation and High Flow Nasal Cannula in Patients with End-Stage Chronic Obstructive Lung Disease

Patients with end-stage chronic obstructive pulmonary disease (COPD) often develop persistent hypoxic or hypercapnic respiratory failure, or a combination of both. Ventilatory support, in terms of a long-term high-flow nasal cannula (LT-HFNC) and long-term non-invasive ventilation (LT-NIV), may be indicated. Often, clinicians choose either one or the other. This paper explores combined treatment with LT-HFNC and LT-NIV in a real-life setting. In total, 33 patients with COPD and persistent respiratory failure were included in this study. Of those, 17 were initiated on LT-HFNC and used it for 595 (374) days and 16 were initiated on LT-NIV and used it for 558 (479) days. On average, patients used respiratory support continuously for 908 (586) days. Baseline characteristics were comparable, apart from PaCO₂ at first ventilatory support initiation (LT-HFNC/LT-NIV 7.1 (1.1) kPa/8.8 (0.9) kPa respectively (p = 0.002)). Both groups experienced a reduction in hospitalizations in the first twelve months after treatment initiation, compared to the twelve months before (LT-HFNC p = 0.022 and LT-NIV p = 0.014). In total, 25% of LT-NIV patients stopped treatment after HFNC initiation due to intolerance and 59% stopped LT-HFNC treatment 126 (36) days after LT-NIV initiation as monotherapy was sufficient. In 44% of these patients, LT-HFNC was re-initiated at the end of life. At the time of analysis, 70% of patients had died. In the last three months of life, patients stopped using LT-NIV, whereas 91% used LT-HFNC. In conclusion, the combined use of LT-NIV and LT-HFNC reduced hospitalizations in patients with COPD and persistent respiratory failure. The study indicates that LT-HFNC is well tolerated, and better tolerated than LT-NIV at the very end stages of COPD.

Quality of life in patients with chronic respiratory failure on home mechanical ventilation

Home mechanical ventilation (HMV) is a treatment for chronic respiratory failure that has shown clinical and cost effectiveness in patients with underlying COPD, obesity-related respiratory failure and neuromuscular disease (NMD). By treating chronic respiratory failure with adequate adherence to HMV, improvement in patient-reported outcomes including health-related quality of life (HRQoL) have been evaluated using general and disease-specific quantitative, semi-qualitative and qualitative methods. However, the treatment response in terms of trajectory of change in HRQoL is not uniform across the restrictive and obstructive disease groups. In this review, the effect of HMV on HRQoL across the domains of symptom perception, physical wellbeing, mental wellbeing, anxiety, depression, self-efficacy and sleep quality in stable and post-acute COPD, rapidly progressive NMD (such as amyotrophic lateral sclerosis), inherited NMD (including Duchenne muscular dystrophy) and obesity-related respiratory failure will be discussed.

Does one size fit all? An update on chronic ventilatory support in different respiratory illnesses

Home noninvasive ventilation (HNIV) improves outcomes in different disease categories. In this article, we discuss indications for when and how to initiate HNIV in COPD, obesity hypoventilation syndrome (OHS) and neuromuscular disorders (NMD). While in COPD, significant diurnal hypercapnia and high-intensity HNIV are essential ingredients for success, in NMD and OHS, early respiratory changes are best detected during sleep through oxy-capnography associated (or not) with respiratory polygraphy. In COPD and OHS, it is crucial to consider the coexistence of obstructive sleep apnoea because treatment with continuous positive airway pressure may be the simplest and most effective treatment that should be proposed even in hypercapnic patients as first-line therapy. In NMD, the need for continuous HNIV and eventual switching to tracheostomy ventilation makes this group's management more challenging. Achieving successful HNIV by improving quality of sleep, quality of life and keeping a good adherence to the therapy is a challenge, above all in COPD patients. In OHS patients, on top of HNIV, initiation of other interventions such as weight loss management is crucial. More resources should be invested in improving all these aspects. Telemonitoring represents a promising method to improve titration and follow-up of HNIV.

Effect of Intensity of Home Noninvasive Ventilation in Individuals With Neuromuscular and Chest Wall Disorders: A Systematic Review and Meta-Analysis of Individual Participant Data

INTRODUCTION

Home noninvasive ventilation (NIV), targeting a reduction of carbon dioxide with a combination of sufficient inspiratory support and backup-rate improves outcomes in patients with chronic obstructive pulmonary disease. The aim of this systematic review with individual participant data (IPD) meta-analysis was to evaluate the effects of intensity of home NIV on respiratory outcomes in individuals with slowly progressive neuromuscular (NMD) or chest-wall disorders (CWD).

METHODS

Controlled, non-controlled and cohort studies indexed between January-2000 and December-2020 were sought from Medline, Embase and the Cochrane Central Register. Outcomes were diurnal PaCO₂, PaO₂, daily NIV usage, and interface type (PROSPERO-CRD 42021245121). NIV intensity was defined according to the Z-score of the product of pressure support (or tidal volume) and backup-rate.

RESULTS

16 eligible studies were identified; we obtained IPD for 7 studies (176 participants: 113-NMD; 63-CWD). The reduction in PaCO₂ was greater with higher baseline PaCO₂. NIV intensity per se was not associated with improved PaCO₂ except in individuals with CWD and the most severe baseline hypercapnia. Similar results were found for PaO₂. Daily NIV usage was associated with improvement in gas exchange but not with NIV intensity. No association between NIV intensity and interface type was found.

CONCLUSION

Following home NIV initiation in NMD or CWD patients, no relationship was observed between NIV intensity and PaCO₂, except in individuals with the most severe CWD. The amount of daily NIV usage, rather than intensity, is key to improving hypoventilation in this population during the first few months after introduction of therapy.

COPD Exacerbation: Why It Is Important to Avoid ICU Admission

Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD causing acute respiratory failure (ARF) often requires admission to an intensive care unit (ICU) with endotracheal intubation and invasive mechanical ventilation. AECOPD also acts as comorbidity in critically ill patients; this condition is associated with poorer prognoses. The prevalence reported in the literature on ICU admission rates ranges from 2 to 19% for AECOPD requiring hospitalization, with an in-hospital mortality rate of 20-40% and a re-hospitalization rate for a new severe event being 18% of the AECOPD cases admitted to ICUs. The prevalence of AECOPD in ICUs is not properly known due to an underestimation of COPD diagnoses and COPD misclassifications in administrative data. Non-invasive ventilation in acute and chronic respiratory failure may prevent AECOPD, reducing ICU admissions and disease mortality, especially when associated with a life-threating episode of hypercapnic ARF. In this review, we report on up to date evidence from the literature, showing how improving the knowledge and management of AECOPD is still a current research issue and clinical need.

Getting It Right in Obstructive Lung Disease

Chronic hypercapnic respiratory failure in obstructive lung diseases may benefit from nocturnal Home non-invasive ventilation (HNIV). It has been shown that in patients with persistence of hypercapnia after an acute episode of chronic obstructive pulmonary disease (COPD) exacerbation requiring mechanical ventilation, HNIV may improve the risk for new admission and survival. The ability to reach these aims depends on the correct timing of enrolling patients, as well as a correct definition of ventilatory needing and setting of the ventilator. This review tries to define a possible home treatment path of hypercapnic respiratory failure in COPD by analyzing the main studies published in recent years.

Acute COPD exacerbation treatment with noninvasive ventilation

The establishment of a guideline for long-term noninvasive ventilation treatment (LTH-NIV) of acute hypercapnic exacerbations of chronic obstructive pulmonary disease (AECOPD) requiring acute ventilation has proven elusive. Most studies thus far have shown no mortality benefit of long-term noninvasive ventilation treatment. Using retrospective analysis of the data of our patients (n = 143) recruited from 2012 to 2019, we aimed to compare patients discharged with and without long-term noninvasive ventilation. The follow-up results showed no significant difference (p = 0.233) between the groups [LTH-NIV (n = 83); non-NIV (n = 60)] regarding readmission due to clinical worsening. However, the first- and second-year survival rates were 82% and 72%, respectively, in the LTH-NIV group and significantly different (p = 0.023) from 67 and 55% in the non-NIV group. The statistical models showed a significant mortality risk for the non-NIV group, with a hazard ratio (HR) of 2.82 (1.31; 6.03). To the best of our knowledge, this is the first study to demonstrate the mortality benefit of long-term NIV therapy for patients with AECOPD under real-world conditions.

Moving from Inpatient to Outpatient or Home Initiation of Non-Invasive Home Mechanical Ventilation

Home mechanical ventilation (HMV) is an effective treatment for patients with chronic hypercapnic respiratory failure caused by restrictive or obstructive pulmonary disorders. Traditionally, HMV is initiated in the hospital, nowadays usually on a pulmonary ward. The success of HMV, and especially non-invasive home mechanical ventilation (NIV), has led to a steep and ongoing increase in the incidence and prevalence of HMV, in particular for patients with COPD or obesity hypoventilation syndrome. Consequently, the number of available hospital beds to accommodate these patients has become insufficient, and models of care that minimize the use of (acute) hospital beds need to be developed. At present, the practices for initiation of NIV vary widely, reflecting the limited research on which to base model-of-care decisions, local health system features, funding models, and historical practices. Hence, the opportunity to establish outpatient and home initiation may differ between countries, regions, and even HMV centres. In this narrative review, we will describe the evidence regarding the feasibility, effectiveness, safety, and cost savings of outpatient and home initiation of NIV. In addition, the benefits and challenges of both initiation strategies will be discussed. Finally, patient selection and execution of both approaches will be examined.

Ventilators, Settings, Autotitration Algorithms

The choice of a ventilator model for a single patient is usually based on parameters such as size (portability), presence or absence of battery and ventilatory modes. However, there are many details within each ventilator model about triggering, pressurisation or autotitration algorithms that may go unnoticed, but may be important or may justify some drawbacks that may occur during their use in individual patients. This review is intended to emphasize these differences. Guidance is also provided on the operation of autotitration algorithms, in which the ventilator is able to take decisions based on a measured or estimated parameter. It is important to know how they work and their potential sources of error. Current evidence on their use is also provided.

What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation

Most of the published reviews about non-invasive home ventilation mainly reflect the technical aspects of ventilators. There is much less information about the consumables most used at home. However, the choice of a good interface or tubing system can lead to physiological changes in the patient–ventilator interaction that the clinician should be aware of. These physiological changes may affect the performance of the ventilator itself, the reliability of monitoring and, of course, the comfort of the patient. The use of different circuits, masks or filters is therefore related to the concepts of rebreathing, compressible volume, instrumental dead space or leak estimation and tidal volume. Through certain bench experiments, it is possible to determine the implications that each of these elements may have in clinical practice.

Supplemental oxygen and noninvasive ventilation

The respiratory system attempts to maintain normal levels of oxygen and carbon dioxide. However, airflow limitation, parenchymal abnormalities and dysfunction of the respiratory pump may be compromised in individuals with advanced COPD, eventually leading to respiratory failure, with reduced arterial oxygen tension (hypoxaemia) and/or increased arterial carbon dioxide tension (P aCO2 ; hypercapnia). Hypoxaemia may persist in individuals with severe COPD despite smoking cessation and optimisation of pharmacotherapy. Long-term oxygen therapy (LTOT) can improve survival in those with severe daytime hypoxaemia, whereas those with less severe hypoxaemia may only have improved exercise capacity and dyspnoea. Changes in respiratory physiology that occur during sleep further predispose to hypoxaemia, particularly in individuals with COPD. However, the major cause of hypoxaemia is hypoventilation. Noninvasive ventilation (NIV) may reduce mortality and need for intubation in individuals with COPD and acute hypercapnic respiratory failure. However, NIV may also improve survival and quality of life in individuals with stable, chronic hypercapnia and is now suggested for those with prolonged hypercapnia (e.g. P aCO2 >55 mmHg 2-6 weeks after hospital discharge) when clinically stable and after optimisation of medical therapy including LTOT if indicated. Many questions remain about the optimal mode, settings and goal of NIV therapy.

The Danish respiratory society guideline for long-term high flow nasal cannula treatment, with or without supplementary oxygen

Introduction

Long-term High Flow Nasal Cannula (LT-HFNC), defined as High Flow Nasal Cannula treatment provided to patients with chronic pulmonary conditions during stable phases, has emerged as a home treatment in different categories of patients with chronic lung diseases in recent years.

Methods

This paper summarizes the physiological effects of LT-HFNC and evaluates the clinical knowledge to date about treatment in patients with chronic obstructive lung disease, interstitial lung disease and bronchiectasis. The guideline is translated and summarized in this paper and presented unabridged as an appendix to the paper.

Results

The paper describes the working process behind the Danish Respiratory Society's National guideline for treatment of stable disease, which has been written to support clinicians in both evidence-based decision making and practical issues concerning the treatment.

How do I wean a patient with acute hypercapnic respiratory failure from noninvasive ventilation?

Noninvasive ventilation (NIV) has been increasingly used for the management of different etiologies of acute hypercapnic respiratory failure (AHRF). Although NIV implementation has been framed well by the guidelines, limited number of studies evaluated the NIV weaning strategies, including a gradual decrease in the level of ventilator support and/or duration of NIV as well as abrupt discontinuation, once respiratory acidosis and distress have resolved. None of the methods have yet been established to be superior to the other in terms of the success rate of weaning and duration of NIV; as well as mortality, length of stay (LOS) in hospital, respiratory ICU (RICU), and ICU.  Patient-derived factors, such as etiology of AHRF, disease severity, history of prior NIV use, and clinical status can help to predict NIV weaning outcome and eventually choose the best method for each individual. In this paper, we have described the strategies for weaning a patient with AHRF from NIV and provided a quick guide for implementation of these data into daily practice based on our experience in and the current scientific evidence.

Caring for patients with advanced COPD: beyond the inhalers…

COPD affects millions of people worldwide. Patients with advanced COPD have a high symptom burden. Breathlessness, cough and fatigue are frequent daily symptoms. Guidelines often focus on pharmacological treatment, especially inhaler therapy, but other approaches in combination with medications offer symptomatic benefit. In this review, we take a multidisciplinary approach with contributions from pulmonary physicians, cardiothoracic surgeons and a physiotherapist. The following areas are addressed: oxygen therapy and noninvasive ventilation (NIV), dyspnoea management, surgical and bronchoscopic options, lung transplantation and palliative care. Oxygen therapy prescribed within guidelines improves mortality in patients with COPD. NIV guidelines offer only low-certainty instruction on the use of this therapy on the basis of the limited available evidence. Dyspnoea management can take place through pulmonary rehabilitation. Specific criteria aid decisions on referral for lung volume reduction treatments through surgical or bronchoscopic approaches. Lung transplantation requires precise disease severity assessment to determine which patients have the most urgent need for lung transplantation and are likely to have the longest survival. The palliative approach runs in parallel with these other treatments, focusing on symptoms and aiming to improve the quality of life of patients and their families facing the problems associated with life-threatening illness. In combination with appropriate medication and an individual approach to symptom management, patients' experiences can be optimised.

Educational aims

To understand the multidisciplinary approach to management of patients with advanced COPD.To recognise the parallel approaches to oxygen, NIV and dyspnoea management with consideration of more interventional options with lung volume reduction therapy or lung transplantation.To understand the high level of symptomatology present in advanced COPD and the relevance of palliative care alongside optimal medical management.

Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the ICU: An Observational Study From the OUTCOMEREA Database, 1997-2018

OBJECTIVES

Our aim was to describe changes in the management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) by ICUs and patient outcomes.

DESIGN

We extracted data from the OutcomeRea database concerning patients admitted for AECOPD between 1997 and 2018. We analyzed trends in the use of ventilatory support, corticosteroid therapy, antibiotic therapy, and patient survival.

SETTING

ICUs at 32 French sites.

PATIENTS

One thousand eight hundred sixteen patients in the database had a diagnosis of AECOPD.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Over time, there was a reduction in the prescription of corticosteroids and antibiotics. In a time-series analysis, these changes in practice were not linked with ICU mortality. The proportion of patients treated with invasive mechanical ventilation (IMV) also gradually declined (from 51% between 1997 and 2002 to 35% between 2013 and 2018) with an association between decrease in IMV use and reduction in ICU mortality in a time series analysis. Rates of noninvasive ventilation (NIV) failure decreased with an increase in NIV use to support weaning from IMV. There was a reduction in the median ICU length of stay (from 8 d in 1997-2002 to 4 d in 2013-2018) and in the median total duration of hospitalization (from 23 d in 1997-2002 to 14 d in 2013-2018). We observed an improvement in prognosis, with decreases in overall hospital mortality (from 24% between 1997 and 2002 to 15% between 2013 and 2018), ICU mortality (from 14% between 1997 and 2002 to 10% between 2013 and 2018), and 90-day mortality (from 41% between 1997 and 2002 to 22% between 2013 and 2018).

CONCLUSIONS

The length of stay and mortality of patients with AECOPD admitted to ICUs has decreased over the last 20 years, with a wider use of NIV and a reduction in antibiotic and corticosteroid prescriptions.

COPD: Providing the right treatment for the right patient at the right time

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.