Treatment of Chronic Respiratory Failure in COPD Patients With Non-invasive Ventilation: Starting at Home and Selecting the Right Patient

COPD is a chronic disease with high mortality and morbidity worldwide. Patients with end-stage COPD frequently develop CHRF associated with end-of-life. In that stage of disease, treatment options are limited.

Long-term nocturnal NIV has been applied in patients with chronic alveolar hypoventilation for decades. While there is no doubt that applying chronic nocturnal NIV improves outcomes in patients with restrictive and neuromuscular diseases, the evidence in COPD patients has long been controversial. At the HMV centre Groningen, the majority of patients treated with NIV therefore still concerns patients with neuromuscular diseases.

Initial trials investigating chronic NIV in COPD showed no relevant benefits, neither in terms of improvement in gas exchange nor in improvements in patient-centred outcomes as HRQoL.However, most of these trials used low inspiratory pressures so that improvement of alveolar hypoventilation was not or only partially achieved. Consequently, little improvement in clinical outcomes could be expected.

More than 10 years ago, the concept of high-intensity NIV in COPD was introduced. By applying higher inspiratory pressures and breathing frequencies aimed at a more controlled form of ventilation and improvement in gas exchange, clinically relevant improvements in HRQoL and lung function were observed, without undue loss of patient comfort. Recently, a German group conclusively showed that high-intensity NIV improves survival in severe COPD patients with CHRF. These positive results with high-intensity NIV have changed our view towards the use of chronic NIV in stable COPD. Nowadays, the investigators believe that the evidence for long-term nocturnal NIV is convincing and justifies the application of this therapy in patients with severe stable COPD patients with CHRF. Nevertheless, for a broader implementation of this treatment in a potentially large group of severe COPD patients, important issues have to be solved.

First, the current inpatient NIV initiation process has to be reconsidered, which despite tight titration based on arterial blood gases, does not always lead to good patient compliance, is inconvenient for patients and is expensive. While it might be thought that high-intensity NIV necessitates inpatient titration to gain adequate reversal of hypoventilation, different in hospital set ups of NIV initiation (on a general ward, medium care unit or on an intensive care unit), with different ways of titration (guided by transcutaneous carbon dioxide (PtCO2) or arterial blood gases (PaCO2)), have not resulted in different outcomes or a different compliance at the long-term. Also, these inpatient options are expensive as initiation of NIV in COPD routinely requires 5-14 days. Recently, our group of the HMV centre Groningen has shown that, in patients with neuromuscular and restrictive thoracic diseases, initiation of NIV can safely be performed at home. Initiation of NIV at home was preferred by the patients, was equally effective and saved costs compared to inpatient initiation. Importantly, COPD patients have been excluded in this randomised controlled trial (RCT), as at the start of that study chronic NIV in COPD was not considered a regular standard treatment option in the Netherlands. Furthermore, initiation of NIV in COPD patients at that time was thought to be probably too difficult to be performed at home, because high-intensity NIV is needed in this patient group to improve outcomes.