High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD

[S3 Guideline: Treating Chronic Respiratory Failure with Non-invasive Ventilation]

The S3 guideline on non-invasive ventilation as a treatment for chronic respiratory failure was published on the website of the Association of the Scientific Medical Societies in Germany (AWMF) in July 2024. It offers comprehensive recommendations for the treatment of chronic respiratory failure in various underlying conditions, such as COPD, thoraco-restrictive diseases, obesity-hypoventilation syndrome, and neuromuscular diseases. An important innovation is the separation of the previous S2k guideline dating back to 2017, which included both invasive and non-invasive ventilation therapy. Due to increased scientific evidence and a significant rise in the number of affected patients, these distinct forms of therapy are now addressed separately in two different guidelines.The aim of the guideline is to improve the treatment of patients with chronic respiratory insufficiency using non-invasive ventilation and to make the indications and therapy recommendations accessible to all involved in the treatment process. It is based on the latest scientific evidence and replaces the previous guideline. This revised guideline provides detailed recommendations on the application of non-invasive ventilation, ventilation settings, and the subsequent follow-up of treatment.In addition to the updated evidence, important new features of this S3 guideline include new recommendations on patient care and numerous detailed treatment pathways that make the guideline more user-friendly. Furthermore, a completely revised section is dedicated to ethical issues and offers recommendations for end-of-life care. This guideline is an important tool for physicians and other healthcare professionals to optimize the care of patients with chronic respiratory failure. This version of the guideline is valid for three years, until July 2027.

Effect of High-Intensity vs Low-Intensity Noninvasive Positive Pressure Ventilation on the Need for Endotracheal Intubation in Patients With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: The HAPPEN Randomized Clinical Trial

Importance

The effect of high-intensity noninvasive positive pressure ventilation (NPPV) on the need for endotracheal intubation in patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD) is unknown.

Objective

To determine whether the use of high-intensity NPPV vs low-intensity NPPV reduces the need for endotracheal intubation in patients with an acute exacerbation of COPD and hypercapnia.

Design, Setting, and Participants

Randomized clinical trial conducted at 30 general respiratory non-intensive care unit wards of Chinese hospitals from January 3, 2019, to January 31, 2022; the last 90-day follow-up was on April 22, 2022. The included patients had an acute exacerbation of COPD and a Paco2 level greater than 45 mm Hg after receiving 6 hours of low-intensity NPPV.

Interventions

Patients were randomized 1:1 to receive high-intensity NPPV with inspiratory positive airway pressure that was adjusted to obtain a tidal volume 10 mL/kg to 15 mL/kg of predicted body weight (n = 147) or to continue receiving low-intensity NPPV with inspiratory positive airway pressure that was adjusted to obtain a tidal volume of 6 mL/kg to 10 mL/kg of predicted body weight (n = 153). Patients in the low-intensity NPPV group who met the prespecified criteria for the need for endotracheal intubation were allowed to crossover to high-intensity NPPV.

Main Outcomes and Measures

The primary outcome was the need for endotracheal intubation during hospitalization, which was defined by prespecified criteria. There were 15 prespecified secondary outcomes, including endotracheal intubation.

Results

The trial was terminated by the data and safety monitoring board and the trial steering committee after an interim analysis of the first 300 patients. Among the 300 patients who completed the trial (mean age, 73 years [SD, 10 years]; 68% were men), all were included in the analysis. The primary outcome of meeting prespecified criteria for the need for endotracheal intubation occurred in 7 of 147 patients (4.8%) in the high-intensity NPPV group vs 21 of 153 (13.7%) in the low-intensity NPPV group (absolute difference, -9.0% [95% CI, -15.4% to -2.5%], 1-sided P = .004). However, rates of endotracheal intubation did not significantly differ between groups (3.4% [5/147] in the high-intensity NPPV group vs 3.9% [6/153] in the low-intensity NPPV group; absolute difference, -0.5% [95% CI, -4.8% to 3.7%], P = .81). Abdominal distension occurred more frequently in the high-intensity NPPV group (37.4% [55/147]) compared with the low-intensity NPPV group (25.5% [39/153]).

Conclusions and Relevance

Patients with COPD and persistent hypercapnia in the high-intensity NPPV group (vs patients in the low-intensity NPPV group) were significantly less likely to meet criteria for the need for endotracheal intubation; however, patients in the low-intensity NPPV group were allowed to crossover to high-intensity NPPV, and the between-group rate of endotracheal intubation was not significantly different.

Trial Registration

ClinicalTrials.gov Identifier: NCT02985918.

Interfaces for Home Noninvasive Ventilation

The choice of interface used to deliver noninvasive ventilation (NIV) is a critical element in successfully and safely establishing home NIV in people with sleep hypoventilation syndromes. Both patient-related and equipment-related factors need to be considered when selecting an interface. Recognizing specific issues that can occur with a particular style of mask is important when troubleshooting NIV problems and attempting to minimize side effects. Access to a range of mask styles and designs to use on a rotational basis is especially important for patients using NIV on a more continuous basis, those at risk of developing pressure areas, and children.

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.

Clinical efficacy of HI-NPPV in the treatment of AECOPD combined with severe type II respiratory failure

OBJECTIVES

Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) combined with severe type II respiratory failure have a high probability of ventilation failure using conventional non-invasive positive pressure ventilation (NPPV). This study aims to investigate the clinical efficacy of high intensity NPPV (HI-NPPV) for the treatment of AECOPD combined with severe type II respiratory failure.

METHODS

The data of patients with AECOPD combined with severe type II respiratory failure (blood gas analysis pH≤7.25) treated with NPPV in the Second Affiliated Hospital of Chongqing Medical University from July 2013 to July 2023 were collected to conduct a retrospective case-control study. The patients were divided into 2 groups according to the inspired positive airway pressure (IPAP) used during the NPPV treatment: a NPPV group (IPAP<20 cmH2O, 1 cmH2O=0.098 kPa) and a HI-NPPV group (20 cmH2O≤IPAP< 30 cmH2O). Ninety-nine and 95 patients were included in the NPPV group and the HI-NPPV group, respectively. A total of 86 pairs of data were matched using propensity score matching (PSM) for data matching. The primary outcome indexes (mortality and tracheal intubation rate) and secondary outcome indexes [blood gas analysis pH, arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2), adverse reaction rate, and length of hospitalization] were compared between the 2 groups.

RESULTS

The tracheal intubation rates of the NPPV group and the HI-NPPV group were 6.98% and 1.16%, respectively, and the difference between the 2 groups was statistically significant (χ2=4.32, P<0.05); the mortality of the NPPV group and the HI-NPPV group was 23.26% and 9.30%, respectively, and the difference between the 2 groups was statistically significant (χ2=11.64, P<0.01). The PaO2 at 24 h and 48 h after treatment of the HI-NPPV group was higher than that of the NPPV group, and the PaCO2 of the HI-NPPV group was lower than that of the NPPV group, and the differences were statistically significant (all P<0.05). The differences of pH at 24 h and 48 h after treatment between the 2 groups were not statistically significant (both P>0.05). The differences between the 2 groups in adverse reaction rate and hospitalization length were not statistically significant (both P>0.05).

CONCLUSIONS

HI-NPPV can reduce mortality and tracheal intubation rates by rapidly improving the ventilation of patients with AECOPD combined with severe type II respiratory failure. This study provides a new idea for the treatment of patients with AECOPD combined with severe type II respiratory failure.

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.

Noninvasive positive pressure in acute exacerbations of chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Noninvasive positive pressure ventilation (NIV) is standard of care for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We review the most current evidence and highlight areas of uncertainty and ongoing research. We highlight key concepts for the clinician caring for patients with AECOPD which require NIV.

RECENT FINDINGS

Implementation of NIV in AECOPD is not uniform in spite of the evidence and guidelines. Initiation of NIV should be done early and following protocols. Low-intensity NIV remains the standard of care, although research and guidelines are evaluating higher intensity NIV. Scores to predict NIV failure continue to be refined to allow early identification and interventions. Several areas of uncertainty remain, among them are interventions to improve tolerance, length of support and titration and nutritional support during NIV.

SUMMARY

The use of NIV in AECOPD is the standard of care as it has demonstrated benefits in several patient-centered outcomes. Current developments and research is related to the implementation and adjustment of NIV.

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.

The Impact of Non-Invasive Ventilation on Sleep Quality in COPD Patients

Background: Non-invasive ventilation (NIV) has been shown to be the most appropriate therapy for COPD patients with chronic respiratory failure. While physiological parameters and long-term outcome frequently serve as primary outcomes, very few studies have primarily addressed the impact of NIV initiation on sleep quality in COPD. Methods: This single-center prospective cohort study comprised NIV-naïve patients with COPD. All patients underwent polysomnographic evaluation both at baseline and at 3 months follow-up, accompanied by the assessment of health-related quality of life (HRQL) using the Severe Respiratory Insufficiency Questionnaire (SRI) and the Epworth Sleepiness Scale (ESS). A subgroup evaluation was performed to address the impact of comorbid obstructive sleep apnea syndrome (OSAS). Results: Forty-six patients were enrolled and twenty-five patients completed the follow-up period (66.7 ± 7.4 years). NIV resulted in an increase in slow-wave sleep (+2% (−3.5/7.5), p = 0.465) and rapid eye movement sleep (+2.2% (−1.0/5.4), p = 0.174), although no statistical significance could be detected. ESS (−1.7(−3.6/0.1), p = 0.066) also showed a positive trend. Significant improvements in the Respiratory Disturbance Index (RDI) (−12.6(−23.7/−1.5), p = 0.027), lung function parameters, transcutaneous PCO₂ and the SRI summary scale (4.5(0.9/8), p = 0.016) were observed. Conclusion: NIV therapy does not decrease sleep quality and is even capable of improving HRQL, transcutaneous PaCO₂, daytime sleepiness and RDI, and the latter especially holds true for patients with comorbid OSAS.

The right interface for the right patient in noninvasive ventilation: a systematic review

INTRODUCTION

Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy.

AREAS COVERED

This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here.

EXPERT OPINION

The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.

Home Non-Invasive Positive Pressure Ventilation in Chronic Obstructive Pulmonary Disease: Why, Who, and How?

Advanced chronic obstructive pulmonary disease (COPD) might result in chronic hypercapnic ventilatory failure. Similar to neuromuscular and restrictive chest wall diseases, long-term non-invasive positive pressure ventilation (NPPV) is increasingly used in chronic hypercapnic COPD. This review describes the methods, patient selection, ventilatory strategies, and therapeutic effects of long-term Home-NPPV based on randomized controlled clinical trials published since 1985 in English language retrieved from the databases PubMed and Scopus. Long-term NPPV is feasible and effective in stable, non-exacerbated COPD patients with daytime hypercapnia with arterial pressure of carbon dioxide (PaCO2) levels ≥50 mm Hg (6.6 kPa), if the applied ventilatory pressures and application times improve baseline hypercapnia by at least 20%. Patients who survived an acute hypercapnic exacerbation might benefit from long-term NPPV if hypercapnia persists 2-4 weeks after resolution of the exacerbation. Pressure-controlled ventilation or pressure-support ventilation with adequate minimum backup breathing frequencies, in combination with nasal masks or oronasal masks have been successfully used in all larger clinical trials. Ventilatory strategies with mean inspiratory pressures of up to 28 cm H2O are well-tolerated by patients, but limitations exist in patients with impaired cardiac performance. Home-NPPV with a PaCO2-reductive approach might be considered as an additional treatment option in patients with stable chronic hypercapnic COPD.

Hypercapnia in COPD: Causes, Consequences, and Therapy

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder that may lead to gas exchange abnormalities, including hypercapnia. Chronic hypercapnia is an independent risk factor of mortality in COPD, leading to epithelial dysfunction and impaired lung immunity. Moreover, chronic hypercapnia affects the cardiovascular physiology, increases the risk of cardiovascular morbidity and mortality, and promotes muscle wasting and musculoskeletal abnormalities. Noninvasive ventilation is a widely used technique to remove carbon dioxide, and several studies have investigated its role in COPD. In the present review, we aim to summarize the causes and effects of chronic hypercapnia in COPD. Furthermore, we discuss the use of domiciliary noninvasive ventilation as a treatment option for hypercapnia while highlighting the controversies within the evidence. Finally, we provide some insightful clinical recommendations and draw attention to possible future research areas.

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.

Toward a digital decision- and workflow-support system for initiation and control of long-term non-invasive ventilation in stable hypercapnic COPD patients

Introduction

Due to an increasing demand for the initiation and control of non-invasive ventilation (NIV), digital algorithms are suggested to support therapeutic decisions and workflows in an ambulatory setting. The DIGIVENT project established and implemented such algorithms for patients with chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease (COPD) by a predefined process.

Methods

Based on long-term clinical experience and guideline recommendations as provided by the German Respiratory Society, detailed graphical descriptions of how to perform NIV in stable COPD patients were created. Subsequently, these clinical workflows were implemented in the Business Process Model and Notation (BPMN) as one tool to formalize these workflows serving as input for an executable digital implementation.

Results

We succeeded in creating an executable digital implementation that reflects clinical decision-making and workflows in digital algorithms. Furthermore, we built a user-friendly graphical interface that allows easy interaction with the DIGIVENT support algorithms.

Conclusion

The DIGIVENT project established digital treatment algorithms and implemented a decision- and workflow-support system for NIV whose validation in a clinical cohort is planned.

Physiological effects of high-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease: a randomised controlled trial

Background

High-intensity noninvasive positive pressure ventilation (NPPV) is a novel ventilatory approach to maximally decreasing elevated arterial carbon dioxide tension (PaCO₂) toward normocapnia with stepwise up-titration of pressure support. We tested whether high-intensity NPPV is more effective than low-intensity NPPV at decreasing PaCO₂, reducing inspiratory effort, alleviating dyspnoea, improving consciousness, and improving NPPV tolerance in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

In this physiological, randomised controlled trial, we assigned 24 AECOPD patients to undergo either high-intensity NPPV (n = 12) or low-intensity NPPV (n = 12). The primary outcome was PaCO₂ 24 h after randomisation. Secondary outcomes included gas exchange other than PaCO₂ 24 h after randomisation, inspiratory effort, dyspnoea, consciousness, NPPV tolerance, patient–ventilator asynchrony, cardiac function, ventilator-induced lung injury (VILI), and NPPV-related adverse events.

Results

Inspiratory positive airway pressure 24 h after randomisation was significantly higher (28.0 [26.0–28.0] vs. 15.5 [15.0–17.5] cmH₂O; p = 0.000) and NPPV duration within the first 24 h was significantly longer (21.8 ± 2.1 vs. 15.3 ± 4.7 h; p = 0.001) in the high-intensity NPPV group. PaCO₂ 24 h after randomisation decreased to 54.0 ± 11.6 mmHg in the high-intensity NPPV group but only decreased to 67.4 ± 10.6 mmHg in the low-intensity NPPV group (p = 0.008). Inspiratory oesophageal pressure swing, oesophageal pressure–time product (PTPes)/breath, PTPes/min, and PTPes/L were significantly lower in the high-intensity group. Accessory muscle use and dyspnoea score 24 h after randomisation were also significantly lower in that group. No significant between-groups differences were observed in consciousness, NPPV tolerance, patient–ventilator asynchrony, cardiac function, VILI, or NPPV-related adverse events.

Conclusions

High-intensity NPPV is more effective than low-intensity NPPV at decreasing elevated PaCO₂, reducing inspiratory effort, and alleviating dyspnoea in AECOPD patients.

Trial registration: ClinicalTrials.gov (NCT04044625; registered 5 August 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01018-4.

Baseline Level and Reduction in PaCO2 are Associated with the Treatment Effect of Long-Term Home Noninvasive Positive Pressure Ventilation in Stable Hypercapnic Patients with COPD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose

Patients and Methods

Results

Conclusion

An Investigation of the Factors Affecting Compliance When Using Home Non-Invasive Ventilation Therapy

Abstract:

Home non-invasive ventilation has become a well-established form of therapy over the last few decades. Many conditions benefit from home NIV, for instance, patients with motor neurone disease (MND) and chest wall deformities that lead to respiratory complications. Home NIV has been shown to increase survival and improve quality of life in many chest wall diseases and MND. There is also substantial evidence to indicate that NIV can palliate symptoms of Obesity Hypoventilation Syndrome (OHS). Also, Home NIV is a valuable tool in the management of patients with severe COPD and has been shown to reduce mortality and morbidity in patients with chronic respiratory failure. However, the usefulness of home NIV varies according to compliance. This review investigates the factors affecting compliance with home NIV. Compliance remains to be an incredibly complex matter. Yet, due to the importance of compliance and its effect on outcomes, investigating influencing variables is a priority.

Long-Term Effect of Noninvasive Ventilation on Diaphragm in Chronic Respiratory Failure

Purpose

Home non-invasive ventilation (NIV) is recommended in patients with COPD and hypercapnic chronic respiratory failure (HCRF). The mechanism by it can improve alveolar ventilation during spontaneous breathing is not yet completely explained. Our aim is to evaluate the impact of on diaphragm muscle function in a series of patients with HCRF.

Patients and Methods

Observational, longitudinal, prospective study of a series of patients with very severe chronic obstruction to airflow treated with home high imntensity NIV (HINIV). Patients underwent a baseline and after 12 months assessment including adherence to treatment, quality of life, respiratory function tests and diaphragmatic ultrasound. SPSS v.26 software was used for statistical analysis.

Results

We studied 30 patients, 63% male, the mean age was 60.8 (±6.4) years old. Patients had a severe obstructive ventilatory pattern [FEV1 21.8 (±6.1)%] and hypercapnia [pCO2 56.4 (±7.2) mmHg]. After 12 months of HINIV, we observed significant increases in FVC of 9.2% (p = 0.002), FEV1 of 3.5% (p = 0.04), MIP of 9.4% (p = 0.006), and 6-minute-walking test (6MWT) of 31.9 m (p = 0.001), as well as decreases in paCO2 of 12.5 mmHg (p = 0.001), HCO3 of 4.7 mmol/L (p = 0.001) and BODE index from 7 to 6. Diaphragmatic ultrasound demonstrated an increase in the thickening fraction of 14% (p = 0.002). Respiratory symptoms (p = 0.04), physical function (p = 0.03), and sleep (p = 0.04) also improved.

Conclusion

In patients with HCRF due to very severe chronic obstruction to airflow, long-term HINIV can improve respiratory performance by improving the function of the diaphragmatic musculature. Larger multicenter clinical trials are needed to confirm the results suggested in this study.

A review of therapies for the overlap syndrome of obstructive sleep apnea and chronic obstructive pulmonary disease

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are common chronic diseases. These two noncommunicable diseases (NCDs) are prevalent among approximately 10% of the general population. Approximately 1% of the population is affected by the co-existence of both conditions, known as the overlap syndrome (OS). OS patients suffer from greater degrees of nocturnal oxygen desaturation and cardiovascular consequences than those with either condition in isolation. Besides OS, patients with COPD may suffer from a spectrum of sleep-related breathing disorders, including hypoventilation and central sleep apnea. The article provides an overview of the pathogenesis, associated risk factors, prevalence, and management of sleep-related breathing disorders in COPD. It examines respiratory changes during sleep caused by COPD and OSA. It elaborates upon the factors that link the two conditions together to lead to OS. It also discusses the clinical evaluation and diagnosis of these patients. Subsequently, it reviews the pathophysiological basis and the current evidence for three potential therapies: positive airway pressure therapy [including continuous positive airway pressure (CPAP) and bilevel positive airway pressure], oxygen therapy, and pharmacological therapy. It also proposes a phenotypic approach toward the diagnosis and treatment of OS and the entire spectrum of sleep-related breathing disorders in COPD. It concludes with the current evidence gaps and future areas of research in the management of OS.

Chronic non-invasive ventilation for chronic obstructive pulmonary disease

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.

Long-term home non-invasive ventilation in chronic hypercapnic chronic obstructive pulmonary disease patients: Real-world impact on lung function, acute exacerbations and survival

INTRODUCTION

Although long-term home non-invasive ventilation (H-NIV) has been used among chronic hypercapnic COPD patients, its clinical benefit is still on debate. We aim to assess the impact of H-NIV in chronic hypercapnic COPD patients.

METHODS

COPD patients who initiated H-NIV between January 2010 and December 2017 were included. Patients with concomitant respiratory disorders were excluded. Acute exacerbation (AE) before and 2 years after H-NIV initiation was assessed as main outcome. Secondary outcomes included lung function and gas exchange parameters. Survival since H-NIV initiation was determined, and factors related with survival were explored.

RESULTS

Seventy-two patients were enrolled. A decrease in partial pressure of carbon dioxide (PaCO₂ ) in arterial blood (p < 0.001) and an improvement of partial pressure of oxygen (PaO₂ ) (p < 0.001) were achieved using a high-intensity H-NIV. Regarding lung function, residual volume (RV) reduced (p = 0.010) and forced-expiratory volume in 1 s (FEV₁ ) improved (p = 0.043) after H-NIV initiation. No significant differences in 6-min walking test (6MWT) were found. Compared with the year before H-NIV initiation, the number of AE diminished in the first and in the second years of follow-up (p < 0.001). The median survival was 79.0 months (95% confidence interval [CI], 52.9-105.1), and the covered distance in 6MWT predicted survival (hazard ratio [HR] = 0.026, p = 0.003) in the multivariate analysis.

CONCLUSIONS

High-intensity H-NIV significantly improved FEV1 and hyperinflation, decreased frequency of AEs and led to a remarkable median survival, which was independently predicted by the walking distance in 6MWT.

Long-Term Domiciliary Noninvasive Ventilation for COPD

COPD can lead to abnormalities in oxygenation as well as ventilation. Thanks to pioneering work by Dr Thomas Petty, supplemental oxygen therapy has been shown to improve morbidity and mortality for individuals with COPD and severe daytime hypoxemia. However, efforts to augment ventilation have been less uniformly successful. Recent studies employing a so-called high-intensity noninvasive ventilation strategy, which used high inspiratory pressures and backup breathing frequency to reduce arterial carbon dioxide levels, have shown improved quality of life and reduced mortality. Thus, efforts are underway to better identify and treat patients with COPD who might benefit from noninvasive ventilation, though many practical questions remain.

Oronasal versus Nasal Masks for Non-Invasive Ventilation in COPD: A Randomized Crossover Trial

Purpose

The impact of oronasal and nasal masks on the quality of nocturnal non-invasive ventilation (NIV) needs to be clarified. This trial was designed to compare the impact of oronasal and nasal masks on the objective quality and subjective acceptance of nocturnal NIV in COPD-patients.

Patients and Methods

In a randomized crossover trial, 30 COPD-patients with well-established high-intensity NIV (mean inspiratory/expiratory positive airway pressure 26±3/5±1 cmH₂O, mean respiratory back-up rate 17±1/min) were ventilated for two consecutive nights on oronasal and nasal masks, respectively.

Results

Full polysomnography, nocturnal blood gas measurements, and subjective assessments were performed. There was a tendency towards improved sleep efficiency (primary outcome) when an oronasal mask was worn (+9.9%; 95% CI:-0.2%-20.0%; P=0.054). Sleep stages 3/4 were favored by the oronasal mask (+12.7%; 95% CI: 6.0%-19.3%; P=<0.001). Subjective assessments were comparable with the exception of items related to leakage (P<0.05 in favor of nasal masks). The mean transcutaneous PCO₂ value for oronasal masks (47.7±7.4 mmHg) was comparable to that of nasal masks (48.9±6.6 mmHg) (P=0.11). There was considerable diversity amongst individual patients in terms of sleep quality and gas exchange following mask exchange. Subjective mask preference was not associated with sleep quality, but with nocturnal dyspnea. Over 40% of patients subsequently switched to the mask that they were not previously accustomed to.

Conclusion

In general, oronasal and nasal masks are each similarly capable of successfully delivering NIV in COPD-patients. However, the individual response to different interfaces is extremely heterogeneous, while subjective mask preference is independent from objective measures, but associated with dyspnea.

Trial Registration

German Clinical Trials Registry (DRKS00007741).

Long-term noninvasive ventilation in COPD: current evidence and future directions

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 P_aCO₂ 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.

Chronic obstructive pulmonary disease - diagnosis and management of stable disease; a personalized approach to care, using the treatable traits concept based on clinical phenotypes. Position paper of the Czech Pneumological and Phthisiological Society

This position paper has been drafted by experts from the Czech national board of diseases with bronchial obstruction, of the Czech Pneumological and Phthisiological Society. The statements and recommendations are based on both the results of randomized controlled trials and data from cross-sectional and prospective real-life studies to ensure they are as close as possible to the context of daily clinical practice and the current health care system of the Czech Republic. Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable heterogeneous syndrome with a number of pulmonary and extrapulmonary clinical features and concomitant chronic diseases. The disease is associated with significant mortality, morbidity and reduced quality of life. The main characteristics include persistent respiratory symptoms and only partially reversible airflow obstruction developing due to an abnormal inflammatory response of the lungs to noxious particles and gases. Oxidative stress, protease-antiprotease imbalance and increased numbers of pro-inflammatory cells (mainly neutrophils) are the main drivers of primarily non-infectious inflammation in COPD. Besides smoking, household air pollution, occupational exposure, low birth weight, frequent respiratory infections during childhood and also genetic factors are important risk factors of COPD development. Progressive airflow limitation and airway remodelling leads to air trapping, static and dynamic hyperinflation, gas exchange abnormalities and decreased exercise capacity. Various features of the disease are expressed unequally in individual patients, resulting in various types of disease presentation, emerging as the "clinical phenotypes" (for specific clinical characteristics) and "treatable traits" (for treatable characteristics) concept. The estimated prevalence of COPD in Czechia is around 6.7% with 3,200-3,500 deaths reported annually. The elementary requirements for diagnosis of COPD are spirometric confirmation of post-bronchodilator airflow obstruction (post-BD FEV₁/VCmax <70%) and respiratory symptoms assessement (dyspnoea, exercise limitation, cough and/or sputum production. In order to establish definite COPD diagnosis, a five-step evaluation should be performed, including: 1/ inhalation risk assessment, 2/ symptoms evaluation, 3/ lung function tests, 4/ laboratory tests and 5/ imaging. At the same time, all alternative diagnoses should be excluded. For disease classification, this position paper uses both GOLD stages (1 to 4), GOLD groups (A to D) and evaluation of clinical phenotype(s). Prognosis assessment should be done in each patient. For this purpose, we recommend the use of the BODE or the CADOT index. Six elementary clinical phenotypes are recognized, including chronic bronchitis, frequent exacerbator, emphysematous, asthma/COPD overlap (ACO), bronchiectases with COPD overlap (BCO) and pulmonary cachexia. In our concept, all of these clinical phenotypes are also considered independent treatable traits. For each treatable trait, specific pharmacological and non-pharmacological therapies are defined in this document. The coincidence of two or more clinical phenotypes (i.e., treatable traits) may occur in a single individual, giving the opportunity of fully individualized, phenotype-specific treatment. Treatment of COPD should reflect the complexity and heterogeneity of the disease and be tailored to individual patients. Major goals of COPD treatment are symptom reduction and decreased exacerbation risk. Treatment strategy is divided into five strata: risk elimination, basic treatment, phenotype-specific treatment, treatment of respiratory failure and palliative care, and treatment of comorbidities. Risk elimination includes interventions against tobacco smoking and environmental/occupational exposures. Basic treatment is based on bronchodilator therapy, pulmonary rehabilitation, vaccination, care for appropriate nutrition, inhalation training, education and psychosocial support. Adequate phenotype-specific treatment varies phenotype by phenotype, including more than ten different pharmacological and non-pharmacological strategies. If more than one clinical phenotype is present, treatment strategy should follow the expression of each phenotypic label separately. In such patients, multicomponental therapeutic regimens are needed, resulting in fully individualized care. In the future, stronger measures against smoking, improvements in occupational and environmental health, early diagnosis strategies, as well as biomarker identification for patients responsive to specific treatments are warranted. New classes of treatment (inhaled PDE3/4 inhibitors, single molecule dual bronchodilators, anti-inflammatory drugs, gene editing molecules or new bronchoscopic procedures) are expected to enter the clinical practice in a very few years.

Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology

Long-term mechanical ventilation is a well-established treatment for chronic hypercapnic respiratory failure (CHRF). It is aimed at improving CHRF-related symptoms, health-related quality of life, survival, and decreasing hospital admissions. In Switzerland, long-term mechanical ventilation has been increasingly used since the 1980s in hospital and home care settings. Over the years, its application has considerably expanded with accumulating evidence of beneficial effects in a broad range of conditions associated with CHRF. Most frequent indications for long-term mechanical ventilation are chronic obstructive pulmonary disease, obesity hypoventilation syndrome, neuromuscular and chest wall diseases. In the current consensus document, the Special Interest Group of the Swiss Society of Pulmonology reviews the most recent scientific literature on long-term mechanical ventilation and provides recommendations adapted to the particular setting of the Swiss healthcare system with a focus on the practice of non-invasive and invasive home ventilation in adults.

Long-Term Noninvasive Ventilation in Chronic Stable Hypercapnic Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: Noninvasive ventilation (NIV) is used for patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnia. However, evidence for clinical efficacy and optimal management of therapy is limited.

Target Audience: Patients with COPD, clinicians who care for them, and policy makers.

Methods: We summarized evidence addressing five PICO (patients, intervention, comparator, and outcome) questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to evaluate the certainty in evidence and generate actionable recommendations. Recommendations were formulated by a panel of pulmonary and sleep physicians, respiratory therapists, and methodologists using the Evidence-to-Decision framework.

Recommendations:1) We suggest the use of nocturnal NIV in addition to usual care for patients with chronic stable hypercapnic COPD (conditional recommendation, moderate certainty); 2) we suggest that patients with chronic stable hypercapnic COPD undergo screening for obstructive sleep apnea before initiation of long-term NIV (conditional recommendation, very low certainty); 3) we suggest not initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure, favoring instead reassessment for NIV at 2–4 weeks after resolution (conditional recommendation, low certainty); 4) we suggest not using an in-laboratory overnight polysomnogram to titrate NIV in patients with chronic stable hypercapnic COPD who are initiating NIV (conditional recommendation, very low certainty); and 5) we suggest NIV with targeted normalization of Pa_CO2 in patients with hypercapnic COPD on long-term NIV (conditional recommendation, low certainty).

Conclusions: This expert panel provides evidence-based recommendations addressing the use of NIV in patients with COPD and chronic stable hypercapnic respiratory failure.

[Non-invasive home ventilation in patients with severe hypercapnic chronic obstructive pulmonary disease: The SOMNOVENT' study]

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, especially in cases of chronic hypercapnic respiratory failure. Following a prolonged debate, the indication and benefits of noninvasive ventilation (NIV) have been recently established. Although improved ventilation and reduction in hyperinflation appear to underlie the positive effect on NIV in COPD, only a few studies have focused on specific ventilatory algorithms for improving PaCO2.

METHODS

The main objective of this study is to analyze the impact of Löwenstein's ventilatory algorithms, supposed to allow a better management of hyperinflation and its consequences on alveolar ventilation and blood gas parameters. This is an interventional study in routine care, prospective, single blind, randomized with cross over. The primary endpoint will be the transcutaneous partial pressure of nocturnal carbon dioxide. Secondary endpoints will be: abnormal respiratory events occurring during nocturnal NIV; the objective quality of sleep via polysomnography; the tolerance of ventilation and the subjective quality of sleep evaluated by auto questionnaires.

EXPECTED RESULTS

The results of this study will clarify whether is it necessary to explore more the impact of the ventilatory modes developed by Löwenstein, dedicated to hypercapnic COPD patients, requiring a long-term NIV.

Extubating to Noninvasive Ventilation: Noninvasive Ventilation from Intensive Care Unit to Home

Weaning to noninvasive ventilation in intensive care unit and bridging the patients to home with respiratory support is evolving as the technology of noninvasive ventilation is improving. In patients with chronic obstructive pulmonary disease exacerbation, timing of initiation of noninvasive ventilation is the key, as persistently hypercapnic patients show benefits. High-intensity pressure support seems to do better in comparison to low-intensity pressure support. In patients with obesity and hypercapnia, obesity hypoventilation cannot be ruled out especially in an inpatient setting, and it is crucial that these patients are discharged with noninvasive ventilation.

Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease

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

Long-term survival following initiation of home non-invasive ventilation: a European study

INTRODUCTION

Although home non-invasive ventilation (NIV) is increasingly used to manage patients with chronic ventilatory failure, there are limited data on the long-term outcome of these patients. Our aim was to report on home NIV populations and the long-term outcome from two European centres.

METHODS

Cohort analysis including all patients established on home NIV from two European centres between 2008 and 2014.

RESULTS

Home NIV was initiated in 1746 patients to treat chronic ventilatory failure caused by (1) obesity hypoventilation syndrome±obstructive sleep apnoea (OHS±OSA) (29.5%); (2) neuromuscular disease (NMD) (22.7%); and (3) obstructive airway diseases (OAD) (19.1%). Overall cohort median survival following NIV initiation was 6.6 years. Median survival varied by underlying aetiology of respiratory failure: rapidly progressive NMD 1.1 years, OAD 2.7 years, OHS±OSA >7 years and slowly progressive NMD >7 years. Multivariate analysis demonstrated higher mortality in patients with rapidly progressive NMD (HR 4.78, 95% CI 3.38 to 6.75), COPD (HR 2.25, 95% CI 1.64 to 3.10), age >60 years at initiation of home NIV (HR 2.41, 95% CI 1.92 to 3.02) and NIV initiation following an acute admission (HR 1.38, 95% CI 1.13 to 1.68). Factors associated with lower mortality were NIV adherence >4 hours per day (HR 0.64, 95% CI 0.51 to 0.79), OSA (HR 0.51, 95% CI 0.31 to 0.84) and female gender (HR 0.79, 95% CI 0.65 to 0.96).

CONCLUSION

The mortality rate following initiation of home NIV is high but varies significantly according to underlying aetiology of respiratory failure. In patients with chronic respiratory failure, initiation of home NIV following an acute admission and low levels of NIV adherence are poor prognostic features and may be amenable to intervention.

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

Background

While the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients.

Materials and methods

The European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients.

Results

The task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode.

Conclusions

Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.

Long-term non-invasive ventilation for stable chronic hypercapnic COPD

Introduction: Long-term non-invasive ventilation (LTNIV) for the stable hypercapnic chronic obstructive pulmonary disease (COPD)-patients have been a subject of much debate in the last two decades. The aim of this study was to compile the current knowledge on LTNIV in order to evaluate the effects on mortality and hypercapnia. Methods: Literature search in Pubmed, Ovid, and Embase for RCTs in Humans from January 2000 through January 2019 in written English. Results: Six studies with a total of 861 patients were included. LTNIV in stable hypercapnic COPD patients significantly reduced PaCO₂ but only one study found significant reduction in mortality. Conclusion: Our meta-analyses demonstrate that LTNIV significantly reduced PaCO₂ in stable patients with chronic hypercapnic respiratory failure compared to standard care alone, and subgroup analyses on studies with a predefined plan for ventilation, showed a considerable trend towards significant reduction in mortality. The take home messages on LTNIV in stable hypercapnic COPD are: It is essential that the patients have stable chronic hypercapnia.The degree of stability can best be assessed after a minimum of 2 weeks following an acute hypercapnic respiratory failure (AHRF).It is important to ventilate the patient with the goal to reduce PaCO₂ by at least 20% or below 6.5 kPa.

High-intensity non-invasive ventilation in stable hypercapnic COPD: Evidence of efficacy and practical advice

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.

High-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (HAPPEN): study protocol for a multicenter randomized controlled trial

BACKGROUND

Despite the positive outcomes of the use of noninvasive positive pressure ventilation (NPPV) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), NPPV fails in approximately 15% of patients with AECOPD, possibly because the inspiratory pressure delivered by conventional low-intensity NPPV is insufficient to improve ventilatory status for these patients. High-intensity NPPV, a novel form that delivers high inspiratory pressure, is believed to more efficiently augment alveolar ventilation than low-intensity NPPV, and it has been shown to improve ventilatory status more than low-intensity NPPV in stable AECOPD patients. Whether the application of high-intensity NPPV has therapeutic advantages over low-intensity NPPV in patients with AECOPD remains to be determined. The high-intensity versus low-intensity NPPV in patients with AECOPD (HAPPEN) study will examine whether high-intensity NPPV is more effective for correcting hypercapnia than low-intensity NPPV, hence reducing the need for intubation and improving survival.

METHODS/DESIGN

The HAPPEN study is a multicenter, two-arm, single-blind, prospective, randomized controlled trial. In total, 600 AECOPD patients with low to moderate hypercapnic respiratory failure will be included and randomized to receive high-intensity or low-intensity NPPV, with randomization stratified by study center. The primary endpoint is NPPV failure rate, defined as the need for endotracheal intubation and invasive ventilation. Secondary endpoints include the decrement of arterial carbon dioxide tension from baseline to 2 h after randomization, in-hospital and 28-day mortality, and 90-day survival. Patients will be followed up for 90 days after randomization.

DISCUSSION

The HAPPEN study will be the first randomized controlled study to investigate whether high-intensity NPPV better corrects hypercapnia and reduces the need for intubation and mortality in AECOPD patients than low-intensity NPPV. The results will help critical care physicians decide the intensity of NPPV delivery to patients with AECOPD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02985918 . Registered on 7 December 2016.

Prospective cross-sectional multicenter study on domiciliary noninvasive ventilation in stable hypercapnic COPD patients

Background

Domiciliary noninvasive ventilation (NIV) use in stable hypercarbic COPD is becoming increasingly widespread. However, treatment compliance criteria and factors related to compliance remain to be defined.

Methods

This research was designed as a prospective, cross-sectional, multicenter real-life study. Chronic hypercapnic COPD patients who were using domiciliary NIV for at least 1 year and being followed up in 19 centers across Turkey were included in the study. The patients who used NIV regularly, night or daytime and ≥5 hours/d, were classified as “high-compliance group,” and patients who used NIV irregularly and <5 hours/d as “low-compliance group.”

Results

Two hundred and sixty-six patients with a mean age of 64.5±10.3 years were enrolled, of whom 75.2% were males. They were using domiciliary NIV for 2.8±2 years. Spontaneous time mode (p<0.001) and night use (p<0.001) were more frequent in the high-compliance group (n=163). Also, mean inspiratory positive airway pressure values of the high-compliance group were significantly higher than the low-compliance group (n=103; p<0.001). Cardiac failure (p=0.049) and obesity (p=0.01) were significantly more frequent in the high-compliance group. There were no difference between 2 groups regarding hospitalization, emergency department and intensive care unit admissions within the last year, as well as modified Medical Research Council dyspnea and COPD Assessment Test scores. With regard to NIV-related side effects, only conjunctivitis was observed more frequently in the high-compliance group (p=0.002).

Conclusion

Determination of the patients who have better compliance to domiciliary NIV in COPD may increase the success and effectiveness of treatment. This highly comprehensive study on this topic possesses importance as it suggests that patient and ventilator characteristics may be related to treatment compliance.

Impact of home mechanical ventilation on sleep quality

PURPOSE OF REVIEW

The number of patients receiving home mechanical ventilation (HMV) has dramatically increased in recent years. Although physiological parameters, health-related quality of life and long-term outcomes frequently serve as primary outcomes, only a few studies have primarily addressed sleep quality in patients undergoing HMV. Therefore, this review article summarizes the current knowledge on sleep quality in patients receiving HMV.

RECENT FINDINGS

HMV can be performed noninvasively via face masks or invasively via tracheal cannulas. Studies in patients receiving invasive HMV therapy are clearly lacking. Most studies in this field have focused on invasively ventilated patients in the ICU, but the findings are not necessarily applicable to patients undergoing invasive HMV. On the other hand, there are several trials showing that noninvasive ventilation (NIV) has the potential to improve sleep quality in patients with severe sleep disturbances associated with chronic hypercapnic respiratory failure. To this end, both subjectively and objectively assessed sleep qualities by polysomnography are reported to improve after long-term NIV is initiated.

SUMMARY

Although HMV has the potential to improve sleep quality in patients with chronic hypercapnic respiratory failure, it can also have a negative impact on sleep quality, particularly in cases of patient-ventilator asynchrony or leakage. Therefore, both subjective and objective polysomnographic assessments of sleep quality should become an integral part of managing patients who receive HMV therapy.

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

BACKGROUND

Home noninvasive ventilation (NIV) has been increasingly used in stable chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure (CHRF). However its effectiveness remains debatable.

AIM

To describe a follow-up of COPD patients under home NIV.

METHODS

Retrospective descriptive study based on a prospective 3-year database that included COPD patients under home NIV between August 2011 and July 2014.

RESULTS

Within the 334 patients initially screened, 109 (32.6%) had COPD with a mean±SD post-bronchodilator FEV1 of 38.6±14.9% predicted; age of 65.6±9.6 years. The mean±SD duration of ventilation was 63.4±51.1 months. Heterogeneous comorbidities that can contribute to CHRF were not excluded: obstructive sleep apnea and obesity were the most prevalent. Sixty-two (56.9%) patients started NIV during admission with acute respiratory failure. During follow-up there was a significant increase in mean inspiratory positive airway pressure (IPAP) and respiratory rate (19.5±4.4 vs. 23.6±5.3cmH₂O and 10.7±5.2 vs. 15.2±1.4 breaths/min, respectively, p<0.0001), with a significant improvement in hypercapnia (PaCO₂: 52.9±7.7 vs. 49.5±7.5mmHg, p<0.0001), with 93.3% of patients compliant to NIV. Admissions and days spent in hospital for respiratory illness significantly decreased after institution of NIV (respectively, 1.2±1.1 vs. 0.7±1.8 and 15.0±16.8 vs. 8.8±19.4, p<0.001). At final evaluation, patients with severe hypercapnia (n=47; PaCO₂ ≥50mmHg) performing NIV at higher pressures (n=30; IPAP ≥25cmH₂O) were more compliant (10.1±3.3 vs. 6.1±3.6h/day). Three-year mortality was 24.8% (27 of 109 patients).

CONCLUSIONS

This is a real-life retrospective study in COPD patients with CHRF which results suggest benefit from home NIV. For most, NIV was effective and tolerable even at high pressures.

Home noninvasive ventilatory support for patients with chronic obstructive pulmonary disease: patient selection and perspectives

Long-term or home mechanical noninvasive ventilation (Home-NIV) has become a well-established form of therapy over the last few decades for chronic hypercapnic COPD patients in European countries. However, meta-analyses and clinical guidelines do not recommend Home-NIV for COPD patients on a routine basis. In particular, there is ongoing debate about Home-NIV in chronic hypercapnic COPD regarding the overall effects, the most favorable treatment strategy, the selection of eligible patients, and the time point at which it is prescribed. The current review focuses on specific aspects of patient selection and discusses the various scientific as well as clinical-guided perspectives on Home-NIV in patients suffering from chronic hypercapnic COPD. In addition, special attention will be given to the topic of ventilator settings and interfaces.

High-pressure versus low-pressure home non-invasive positive pressure ventilation with built-in software in patients with stable hypercapnic COPD: a pilot study

High-pressure non-invasive positive pressure ventilation (NPPV) is a new strategy targeted at maximally reducing arterial carbon dioxide. However, high inspiratory positive airway pressure (IPAP) might cause respiratory adverse events likely to diminish the benefit of NPPV. In the setting of ventilatory support, monitoring NPPV efficacy and resolving problems promptly are critical. This study assessed the treatment effect of high and low-pressure NPPV in chronic hypercapnic COPD using home ventilator with built-in software. In this pilot study, we investigated 34 patients using NPPV for 3 months. 13 patients used high-pressure ventilation and 21 patients used low-pressure ventilation. The primary outcome was daytime partial pressure of arterial blood carbon dioxide (P_aCO₂). There were no between-group differences in daytime P_aCO₂ and FEV₁, but a trend favouring high-pressure NPPV was observed. Significant between-group differences were found in the transition dyspnoea index (TDI) (high-pressure, 1.69 ± 1.75, versus low-pressure, -0.04 ± 2.71, p = 0.044). No differences were found in usage time, leakage, health-related quality of life, spirometry, or 6-minute walk test. High-pressure NPPV with built-in software monitoring in patients with chronic hypercapnic COPD is associated with improvement in TDI scores and a positive trend in favour of high-pressure NPPV for improving P_aCO₂ is observed.

Non invasive ventilation in patients with chronic obstructive pulmonary disease in a hospital and at home

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.