Noninvasive ventilation for COPD patients
Noninvasive ventilation for COPD patients
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Noninvasive ventilation for COPD patients

Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of death worldwide, and a major economic burden on healthcare systems. Treatment of COPD with noninvasive ventilation (NIV) has been shown to be effective in treating acute exacerbations of COPD, assisting pulmonary rehabilitation in COPD patients, and providing benefits in managing chronic hypercapnic COPD patients.

NIV in management of acute exacerbation of COPD

There is strong evidence recommending NIV in the management of acute respiratory failure associated with COPD exacerbations. The 2011 GOLD guidelines1 state that NIV improves respiratory acidosis, and decreases respiratory rate, severity of breathlessness including complications such as ventilator associated pneumonia, and length of hospital stay are reduced, more importantly reduces mortality and intubation rate.

In a Chochrane systematic review of studies which have compared NIV with standard care, NIV was associated with lower mortality, reduced need for intubation, and greater improvements in pH, PaCO2, and respiratory rate after 1 hour. NIV also resulted in fewer complications and reduced hospital stay2.

Continued use of NIV after hospitalisation due to COPD exacerbations has also been shown to reduce the risk of recurrent exacerbations and clinical worsening3,4. A recent review found that using NIV post COPD acute exacerbation led improved event-free survival rates and reduced hospital admissions5.

NIV in Pulmonary Rehabilitation

The GOLD Guidelines stated that all COPD patients could benefit from pulmonary rehabilitation and maintenance of physical activity1. NIV during pulmonary rehabilitation can:

  • Improve oxygenation and gas exchange6,8
  • Increase exercise intensity and duration6,7
  • Decrease dyspnoea6
  • Improve several measures of health-related quality of life8

NIV in the management of stable COPD

Recent evidence indicates that treatment with home NIV has benefits for COPD patients with chronic stable hypercapnia. Studies show that home NIV with sufficient pressure to decrease pCO2 can significantly improve survival and quality of life9 and reduce the risk of hospital readmission or death.10

The HOT-HMV study10

The HOT-HMV study showed a 51% reduction in the risk of hospital readmission or death within 12 months when treating with home oxygen therapy (HOT) and home mechanical ventilation (HMV).The study population included severe hypoxic and hypercapnic COPD patients who had been hospitalised for acute decompensated hypercapnic exacerbation of COPD requiring NIV.

The randomised controlled trial showed that patients receiving both home oxygen therapy  and home mechanical ventilation  had a median 

admission-free survival of 4.3 months versus 1.4 months for those receiving HOT alone. This translates to an increase of over 90 days in the median time to first event for the HOT-HMV arm

The Köhnlein study9

Mortality risk reduction of 76% over 1 year with NIV

This randomised, controlled trial showed a significant improvement in survival for stable hypercapnic COPD patients who were effectively treated with NIV.

The 1-year mortality rate was 11.8% in patients treated with NIV targeted to reduce hypercapnia compared with 33% for patients in the control group, which received optimised standard treatment without NIV (p=0.0004).




Improved quality of life

Using the St George’s Respiratory Questionnaire, the study also showed that patients treated with NIV reported an improved quality of life (5.8 points higher than patients treated without NIV (p=0.0289)).

Evolving guidelines

Accumulating evidence of the beneficial effects of long-term NIV in hypercapnic COPD patients is being incorporated into the GOLD guidelines to further strengthen the recommendation for the use of NIV to reduce hospital readmissions.

“NPPV  (Non-invasive Positive-Pressure Ventilation) may improve hospitalisation-free survival in selected patients after recent hospitalisation, particularly those with pronounced daytime persistent hypercapnia (PaCO2 ≥ 52 mmHg, Level Evidence = B).”5

References
  1. Ram F, Picot J, Lightowler J, Wedzicha J. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2004; CD004104. 
  2. Funk GC, Breyer MK, Burghuber OC, Kink E, Kirchheiner K, Kohansal R, Schmidt I, Hartl S. Long-term non-invasive ventilation in COPD after acute-on-chronic respiratory failure Respir Med 2011; 105(3):427-34. 
  3. Cheung AP, Chan VL, Liong JT, Lam JY, Leung WS, Lin A, Chu CM. A pilot trial of non-invasive home ventilation after acidotic respiratory failure in chronic obstructive pulmonary disease. Int J Tuberc Lung Dis 2010; 14(5):642-9. 
  4. Galli JA, et al., Home non-invasive ventilation use following acute hypercapnic respiratory failure in COPD, Respiratory Medicine (2014). 
  5. Vogelmeier, Criner et al., Global Strategy for Diagnosis, Management, and Prevention of COPD. Am J Respir Crit Care Med. 2017 Mar 1;195(5):557-582. doi: 10.1164/rccm.201701-0218PP. https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf (accessed October 22, 2018) 
  6. Dreher M, Storre JH, Windisch W . Noninvasive ventilation during walking in patients with severe COPD: a randomised cross-over trial. Eur Respir J 2007; 29(5):930-6. 
  7. Corner E, Garrod R. Does the addition of non-invasive ventilation during pulmonary rehabilitation in patients with chronic obstructive pulmonary disease augment patient outcome in exercise tolerance? A literature review. Physiother Res Int 2010; 15(1):5-15. 
  8. Duiverman ML, Wempe JB, Bladder G, Jansen DF, Kerstjens HA, Zijlstra JG, Wijkstra PJ. Nocturnal non-invasive ventilation in addition to rehabilitation in hypercapnic patients with COPD. Thorax 2008; 63(12):1052-7. 
  9. Kohnlein T, Windisch W, Kohler D, et al. Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. Lancet Respir Med 2014; 2(9): 698-705. 
  10. Murphy P, et al. Effect of Home Noninvasive Ventilation With Oxygen Therapy vs Oxygen Therapy Alone on Hospital Readmission or Death After an Acute COPD Exacerbation. A Randomized Clinical Trial, JAMA. Published online May 21, 2017. doi:10.1001/jama.2017.4451.