Long-term non-invasive ventilation reduces readmissions in COPD patients with two or more episodes of acute hypercapnic respiratory failure

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.

Predictors of early hospital readmission in patients receiving home mechanical ventilation

BACKGROUND

Although the proportion of patients with chronic respiratory failure requiring home mechanical ventilation (HMV) is increasing, hospital readmissions in these patients are also increasing.

OBJECTIVE

We investigated the factors for early readmission in patients receiving HMV.

METHODS

We retrospectively analyzed the data of adult patients readmitted to the hospital within a year who first received HMV and were discharged from the Asan Medical Center between March 2014 and February 2019. We compared the clinical characteristics at discharge before readmission between the early (readmission within 30 days) and late readmission groups (readmission between day 31 and 1 year) and investigated the clinical characteristics and outcomes at readmission.

RESULTS

Of the 116 patients identified, 36.2% had been readmitted early. The patients who received invasive HMV had a higher rate of early readmission than those who received non-invasive HMV. Pneumonia was the most common reason of readmission in the two groups. The rate of aspiration was significantly higher in the early readmission group (28.6% vs. 8.1%; P = .003). In multivariate logistic regression analysis, nasogastric tube feeding, sequelae of pneumonia or acute respiratory distress syndrome, and central nervous system disorders as causes for HMV were significantly associated with early readmission.

CONCLUSION

Feeding methods and causes for HMV were associated with early readmission. Educating caregivers on respiratory care (suction and feeding methods) is important for preventing early readmission.

Greek Guidelines for the Management of COPD, a Proposal of a Holistic Approach Based on the needs of the Greek Community

Despite that COPD remains one of the most common respiratory diseases worldwide, it can be managed effectively with certain treatments and, more importantly, be prevented by the early implementation of various measures. The pathology and pathophysiology of this disease continue to be studied, with new pharmacological and invasive therapies emerging. In this consensus paper, the Working Group of the Hellenic Thoracic Society aimed to consolidate the up-to-date information and new advances in the treatment of COPD. Local and international data on its prevalence are presented, with revised strategies on the diagnostic approach and the evaluation of risk assessment and disease severity classification. Emphasis is placed on the management and therapy of patients with COPD, covering both common principles, specialized modalities, and algorithms to distinguish between home care and the need for hospitalization. Although pharmacological treatment is commonly recognized in COPD, an integrative approach of pulmonary rehabilitation, physical activity, patient education, and self-assessment should be encountered for a comprehensive treatment, prevention of exacerbations, and increased quality of life in patients.

High-pressure NIV for acute hypercapnic respiratory failure in COPD: improved survival in a retrospective cohort study

Introduction

Updated treatment guidelines for acute hypercapnic respiratory failure (AHRF) in chronic obstructive pulmonary disease (COPD) with non-invasive ventilation (NIV) in 2016 recommended a rapid increase in inspiratory positive airway pressure (IPAP) to 20 cm H₂O with possible further increase for patients not responding. Previous guidelines from 2006 suggested a more conservative algorithm and maximum IPAP of 20 cm H₂O.

Aim

To determine whether updated guidelines recommending higher IPAP during NIV were related with improved outcome in patients with COPD admitted with AHRF, compared with NIV with lower IPAP.

Methods

A retrospective cohort study comparing patients with COPD admitted with AHRF requiring NIV in 2012–2013 and 2017–2018.

Results

101 patients were included in the 2012–2013 cohort with low IPAP regime and 80 patients in the 2017–2018 cohort with high IPAP regime. Baseline characteristics, including age, forced expiratory volume in 1 s (FEV₁), pH and PaCO₂ at initiation of NIV, were comparable. Median IPAP in the 2012–2013 cohort was 12 cm H₂O (IQR 10–14) and 20 cm H₂O (IQR 18-24) in the 2017–2018 cohort (p<0.001). In-hospital mortality was 40.5% in the 2012–2013 cohort and 13.8% in the 2017–2018 cohort (p<0.001). The 30-days and 1-year mortality were significantly lower in the 2017–2018 cohort. With a Cox model 1 year survival analysis, adjusted for age, sex, FEV₁ and pH at NIV initiation, the HR was 0.45 (95% CI 0.27 to 0.74, p=0.002).

Conclusion

Short-term and long-term survival rates were substantially higher in the cohort treated with higher IPAP. Our data support the current strategy of rapid increase and higher pressure.

The Effects of Low Pressure Domiciliary Non-Invasive Ventilation on Clinical Outcomes in Patients with Severe COPD Regardless Having Hypercapnia

Background

The effectiveness of non-invasive home ventilation in patients with severe chronic obstructive pulmonary disease (COPD) is lacking. Non-invasive home ventilation might be more effective when high ventilator settings are used. However, high ventilator settings might reduce patient adherence. We have developed a multidisciplinary approach (ventilation practitioners, 24 hours support of respiratory nurses, physicians) to non-invasive ventilation aimed at optimizing patient adherence using low ventilator settings in severe COPD patients with high disease burden irrespectively having hypercapnia.

Methods

We included in a proof of concept, prospective interventional study, 48 GOLD stage III-IV COPD patients with a high disease burden (≥2 exacerbations in a year, and Medical Research Council dyspnea scores ≥3). Outcome measures included hospital admissions, capillary pCO_2, Medical Research Council dyspnea scores (MRC), Clinical COPD Questionnaire scores (CCQ) and Hospital Anxiety and Depression Scale (HADS).

Results

After 1 year 32 patients could be evaluated. Hospital admissions decreased by 1.0 admission (mean difference ± SD: 1.0 ± 1.48; p = 0.001). In-hospital days decreased by 10.0 days (10.0 ± 15.48; p = 0.001). Capillary pCO₂ decreased by 0.33 kPa (0.33 ± 0.81: p = 0.03). The MRC dyspnea score decreased by 0.66 (0.66 ± 1.35; p = 0.02). The CCQ score decreased by 0.59 (0.59 ± 1.39; p = 0.03). The HADS anxiety score decreased by 1.64 (1.64 ± 3.12; p = 0.01). The HADS depression score decreased by 1.64 (1.64 ± 3.91; p = 0.04).

Conclusion

A proof of concept multidisciplinary approach, using low pressure domiciliary non-invasive ventilation, aimed at optimizing patient adherence in severe COPD patients regardless having hypercapnia, reduced hospital admissions and improved symptoms and quality of life measures. This may imply that severe COPD patients with high disease burden, irrespective being hypercapnic, are candidates to be treated with low pressure domiciliary non-invasive ventilation.

Improvement in hypercapnia does not predict survival in COPD patients on chronic noninvasive ventilation

Purpose

It has recently been shown that chronic noninvasive ventilation (NIV) improves a number of outcomes including survival, in patients with stable hypercapnic COPD. However, the mechanisms responsible for these improved outcomes are still unknown. The aim of the present study was to identify parameters associated with: 1) an improved arterial partial pressure of carbon dioxide (PaCO₂) and 2) survival, in a cohort of hypercapnic COPD patients treated with chronic NIV.

Patients and methods

Data from 240 COPD patients treated with chronic NIV were analyzed. Predictors for the change in PaCO₂ and survival were investigated using multivariate linear and Cox regression models, respectively.

Results

A higher level of bicarbonate before NIV initiation, the use of higher inspiratory ventilator pressures, the presence of anxiety symptoms, and NIV initiated following an exacerbation compared to NIV initiated in stable disease were associated with a larger reduction in PaCO₂. A higher body mass index, a higher FEV₁, a lower bicarbonate before NIV initiation, and younger age and NIV initiation in stable condition were independently associated with better survival. The change in PaCO₂ was not associated with survival, neither in a subgroup of patients with a PaCO₂ >7.0 kPa before the initiation of NIV.

Conclusion

Patients with anxiety symptoms and a high bicarbonate level at NIV initiation are potentially good responders in terms of an improvement in hypercapnia. Also, higher inspiratory ventilator pressures are associated with a larger reduction in PaCO₂. However, the improvement in hypercapnia does not seem to be associated with an improved survival and emphasizes the need to look beyond PaCO₂ when considering NIV initiation.

Hypercapnic COPD patients and NIV at home: is there any benefit? Using the CAT and BODE index in an effort to prove benefits of NIV in these patients

Introduction

The benefits of long-term noninvasive ventilation (NIV) in stable COPD with chronic hypercapnic respiratory failure (CHRF) have been debated for many years due to the conflicting results observed in these patients.

Materials and methods

We investigated the effects of domiciliary NIV in stable hypercapnic COPD patients for a period of 1 year using COPD Assessment Test (CAT), BODE Index, and the number of acute exacerbations. NIV was administered in 57 stable COPD patients with CHRF in the spontaneous/timed mode. Spirometry, 6 minute walk test, Medical Research Council dyspnea scale, arterial blood gases, number of acute exacerbations, BODE Index, and CAT were assessed. Study participants were reassessed in the 1st, 6th, and 12th months after the initial evaluation.

Results

There was a significant improvement in COPD exacerbations (p<0.001), CAT (p<0.001), PO₂ (p<0.001), PCO₂ (p<0.001), and Medical Research Council dyspnea scale (p<0.001) in 1 year of follow-up. BODE Index was improved in the first 6 months (5.8±2.2 vs 4.8±2.4, p<0.001), but the improvement was not maintained.

Conclusion

In conclusion, domiciliary NIV in stable COPD patients with CHRF has beneficial effect on CAT, arterial blood gases, and number of acute exacerbations in a year of NIV use at home. A significant improvement in BODE Index from baseline to 12 months was found in patients aged >70 years, while for those aged <70, the improvement was not maintained after the sixth month.

COPD is independently associated with 6-month survival in patients who have life support withheld in intensive care

BACKGROUND

In-hospital outcomes following decisions of withholding or withdrawing in Intensive Care Unit (ICU) patients have been previously assessed, little is known about outcomes after ICU and hospital discharge. Our objective was to report the 6-month outcomes of discharged patients who had treatment limitations in a general ICU and to identify prognostic factors of survival.

METHODS

We retrospectively collected the data of patients discharged from the ICU for whom life support was withheld from 2009 to 2011. We assessed the survival status of all patients at 6 months post-discharge and their duration of survival. Survivors and non-survivors were compared using univariate and multivariate analyses by Cox's proportional hazard model.

RESULTS

One hundred fourteen patients were included. The survival rate at 6 months was 58.8%. Survival was associated with acute respiratory failure (48% vs 19%, P = .006), a history of COPD (40% vs 21%, P = .03) and a lower SAPS II score (44 vs 49, P = .006). We identified a history of COPD as a prognostic factor for survival in the multivariate analysis (HR = 2.1; IC 95% 1.02-4.36, P = .04).

CONCLUSION

A total of 58.8% of patients for whom life-sustaining therapies were withheld in the ICU survived for at least 6 months after discharge. Patients with COPD appeared to have a significantly higher survival rate. The decision to withhold life support in patients should not lead to a cessation of post-ICU care and to non-readmission of COPD patients.

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

Background:

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

Objective:

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

Materials and Methods:

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

Results:

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

Conclusion:

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