NOTICIAS DIARIAS

Effects of Noninvasive Ventilation and Oxygen in Acute Exacerbation of COPD

Anaesthesiology

Noninvasive Ventilation is the standard of care for treating patients hospitalized for COPD exacerbation. Some research suggests that home-based NIV added to usual care following hospitalization may also benefit some patients, but results are conflicting, and it is unclear whether or not benefits may be most apparent in specific groups. A recent trial assessed home-based NIV following hospitalization for acute decompensated hypercapnic exacerbation of COPD that required NIV in the hospital. This trial demonstrated that the addition of home-based NIV to oxygen therapy might reduce the risk of the composite outcome of hospital readmission or death within 12 months among adults recently hospitalized for COPD exacerbation who had persistent hypercapnia and hypoxemia.

Several patients with COPD have an acute hypercapnic respiratory failure and require treatment with noninvasive ventilation ( NIV ). The prolonged hospital stay consumes substantial resources. Besides, they have a high-risk for short-term hospital readmission; 20% -30% were readmitted within 90 days. Thus, from the US perspective, this area is a significant target for quality improvement. The Centers for Medicare and Medicaid Services are looking at about reimbursement issues.

A randomized controlled trial at high-risk COPD patients and the use of nocturnal NIV is published in JAMA . Murphy and colleagues presented the study at The American Thoracic Society's annual meeting. The researchers looked at improving outcomes compared with supplemental oxygen alone.  

In the study, all participants suffered from COPD and had a persistent hypercapnic respiratory failure while they were admitted and required supplemental oxygen. On stabilization of the condition (after 2-4 weeks), they were randomized to either continue on supplemental oxygen alone or to initiate NIV in addition to supplemental oxygen.

Based on arterial blood gas measurement, it was found that participants had persistent but no longer had hypercarbia. They had to demonstrate at pH> 7.3 on arterial blood gas sample. Further, these patients were randomized to receive nocturnal NIV with supplemental oxygen or supplemental oxygen alone.

A follow-up study was done for one year, where exacerbations, mortality, and quality of life ( QOL ) related to COPD was looked at. The researchers found that the conditions were aggravated when the patients were treated with NIV and supplemental oxygen compared to supplemental oxygen alone.

The patients who were obese had preexisting sleep apnea or had other conditions requiring nocturnal ventilation were excluded from the study. Thus, several patients were excluded from the study.

In a cohort study, 116 patients showed a substantial reduction in time to the first exacerbation or mortality. The number of exacerbations per years for patients receiving NIV was reduced from four to three. The duration and expense associated with these hospitalizations were found substantially. 

When time to first exacerbation or times of death were considered, the researchers found that there was no impact on mortality during the follow-up study.

The mortality rate in 116 patients over I year was about 30%. The pulmonologists are seeking for the end-of-life care, palliative care for the patients with COPD who have had exacerbations and FEV 1 s of around 600 cc.

All participants in the study had to undergo nocturnal titration studies and required high levels of driving pressure. While patients with less hypercapnia were included in the earlier, the patients had severe hypercapnia; thus the trials were challenging.

The findings suggest that the super-high risk group of patients was benefited, although the quality of life was not improved in the patients associated with NIV. The nocturnal NIV in addition to supplemental oxygen might neutralize the benefit of being cured.

Although there was no substantial improvement in QOL , the role of NIV in patients with severe hypercapnia, recent COPD exacerbations, and hospitalization was explored.