Evidence supports routine application of chronic noninvasive ventilation in people with severe but stable COPD

Wednesday 15 September 2021

Vanessa Jordan

PEARLS No.

684

Clinical question

How effective is the use of chronic non-invasive ventilation at home via face mask in people with chronic obstructive pulmonary disease?

Bottom line

The results provide sufficient evidence for the routine application of chronic NIV in people with severe COPD who have chronic hypercapnic respiratory failure, while benefits of its use are uncertain for people who remain hypercapnic shortly after a severe COPD exacerbation.

The benefits and goals of chronic NIV seem to differ between different COPD populations. For people initiated in a stable clinical state, significant and relevant improvements in diurnal hypercapnia can be achieved, accompanied by possible improvements in oxygenation, health‐related quality of life and all‐cause mortality.

In contrast, people who remain hypercapnic after a severe COPD exacerbation seem to benefit mostly in terms of a reduction in hypercapnia, and a prolonged time to readmission or death, but without relevant improvements in HRQL.

Evidence also suggests that the effect of NIV on gas exchange is largest when the NIV is applied with sufficiently high pressure for at least 5 hours per night.

Caveat

The vast majority of studies included participants with chronic hypercapnia; only 61 participants (8%) without hypercapnia were included. Therefore, the results apply primarily to people with COPD who experience chronic hypercapnia.

Most of the studies were conducted in Europe, especially the larger studies and those with positive outcomes. This could limit the generalisability.

The quality of the evidence was reduced due to the unblinded nature of most trials, but outcomes were influenced to differing extents. For example, blood gases, hospitalisations and mortality are unlikely to be affected by the unblinded nature of the trials, while participant‐reported outcomes are likely affected to a larger extent.

Context

NIV is currently applied as evidence‐ based therapy for COPD patients admitted to hospital with acute hypercapnic respiratory failure due to an exacerbation. In this situation, NIV reduces the likelihood of endotracheal intubation, complications associated with treatment, duration of hospital stay, and in‐hospital mortality. There has been much discussion about the need for chronic NIV in stable COPD, mainly because earlier trials published conflicting results.

Cochrane Systematic Review

Raveling T, et al. Chronic non‐invasive ventilation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2021;8:CD002878. This review contains 21 trials with a total of 1429 participants.

PEARLS archive

How to Treat

Prostate cancer

Prostate cancer consultations are common in primary care and there is no one approach to testing and treatment that fits all patients. Urologist Simon van Rij discusses the key considerations and options for personalised care, appropriate investigation and treatment

Wednesday 11 September 2024, 12:45 AM