Written by Umur Hatipoğlu, MD, MBA
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Noninvasive ventilation (NIV) has become an indispensable tool for the treatment of acute hypercapnic respiratory failure related to COPD. Patients who receive NIV as the initial ventilatory assistance modality for acute ventilatory failure have less need for invasive mechanical ventilation, reduced hospital stay and improved mortality.1 Recent studies suggest that there could be a role for the use of NIV for stable COPD patients with chronic hypercapnic respiratory failure.2 For instance, in the HOT-HMV study from the United Kingdom,3 116 patients who were on home oxygen and had persistent hypercapnia (PaCO2 >53 mmHg) two to four weeks following hospitalization for COPD-related acute respiratory failure were randomized to receive NIV and home oxygen versus home oxygen alone.3 After one year of follow-up, the time to readmission or death was significantly improved in the intervention group (63.4% versus 80.4%).
HOT-HMV and other studies that report successful outcomes utilize high-intensity NIV defined as a combination of high inspiratory airway pressures with backup rate during nocturnal ventilation with the goal of achieving near or complete normocapnia. In these studies, high-intensity NIV settings were titrated over a few days in the hospital. However, hospitalization for the purpose of NIV titration may be challenging in the current US healthcare environment.4 Improving telemedicine capabilities could provide a solution to this problem of initiating and managing NIV in the ambulatory setting.
Recently, Duiverman and colleagues from the Netherlands reported feasibility and noninferiority of a home NIV initiation program compared to in-hospital initiation.5 The home program included nurse visits to install the equipment and provide education, close monitoring with transcutaneous PCO2 monitoring and remote ventilator setting changes. While the home program took longer to titrate NIV to goal, it achieved significant cost savings compared to in-hospital initiation.
A new program
Considering the financial and logistic challenges posed for in-hospital and laboratory titration NIV for COPD patients, the Respiratory Institute is has begun trial of an ambulatory NIV titration program. Accordingly, a two-hour visit is arranged for patients during which NIV settings are titrated to achieve a 20% reduction in arterial carbon dioxide tension, using transcutaneous PCO2 monitoring as a surrogate in between adjustments. Close attention is paid to additional physiological variables (e.g., tidal volume, blood pressure, pulse rate, respiratory effort and auto PEEP) and patient comfort.
Additional visits are arranged to achieve high-intensity NIV if normocapnia is not accomplished during the first visit. Patients receive frequent calls to ensure adherence and troubleshooting. Downloads for adherence are reviewed by clinicians aiming for six hours of NIV treatment on a daily basis. Patients have arterial blood gases evaluated during follow-up visits after four to six weeks on the prescribed regimen.
A group effort
The members of the NIV treatment team include respiratory therapists, nurse, COPD coordinator, advanced practice providers and pulmonologists. The program recruits COPD patients who have chronic hypercapnic respiratory failure. Since a quarter of the patients with acute hypercapnic respiratory failure may achieve normocapnia after hospitalization, four weeks are allowed between discharge and assessment of candidacy for the program. An arterial blood gas is obtained to ensure hypercapnia is persistent. Clinical assessment and questionnaires are used to exclude other conditions that may result in chronic hypercapnic respiratory failure such as obesity hypoventilation syndrome and neuromuscular disease. Early experience is encouraging for feasibility and the program has been well received by patients.
- Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jul 13;7(7):CD004104. doi: 10.1002/14651858.CD004104.pub4. PMID: 28702957; PMCID: PMC6483555.
- Chronic hypercapnic respiratory failure and non-invasive ventilation in people with chronic obstructive pulmonary disease Hatipoğlu U, Aboussouan LS. BMJMED 2022;1:e000146. doi:10.1136/ bmjmed-2022-000146
- Murphy PB, Rehal S, Arbane G, Bourke S, Calverley PMA, Crook AM, Dowson L, Duffy N, Gibson GJ, Hughes PD, Hurst JR, Lewis KE, Mukherjee R, Nickol A, Oscroft N, Patout M, Pepperell J, Smith I, Stradling JR, Wedzicha JA, Polkey MI, Elliott MW, Hart N. 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. 2017 Jun 6;317(21):2177-2186. doi: 10.1001/jama.2017.4451. PMID: 28528348; PMCID: PMC5710342.
- Weir M, Marchetti N, Czysz A, Hill N, Sciurba F, Strollo P, Criner GJ. High Intensity Non-Invasive Positive Pressure Ventilation (HINPPV) for Stable Hypercapnic Chronic Obstructive Pulmonary Disease (COPD) Patients. Chronic Obstr Pulm Dis. 2015 Oct 6;2(4):313-320. doi: 10.15326/jcopdf.2.4.2015.0145. PMID: 28848853; PMCID: PMC5556827.
- Duiverman ML, Vonk JM, Bladder G, van Melle JP, Nieuwenhuis J, Hazenberg A, Kerstjens HAM, van Boven JFM, Wijkstra PJ. Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial. Thorax. 2020 Mar;75(3):244-252. doi: 10.1136/thoraxjnl-2019-213303. Epub 2019 Sep 4. PMID: 31484786; PMCID: PMC7063397.