Abstract
The most recent British Thoracic Society/Intensive Care Society (BTS/ICS) guidelines on the use of noninvasive ventilation (NIV) in acute hypercapnic respiratory failure (AHRF) suggest to maximize NIV use in the first 24 hours and to perform a slow tapering. However, a limited number of studies evaluated the phase of NIV weaning. The aim of this study is to describe the NIV weaning protocol used in AHRF due to acute exacerbation of chronic obstructive pulmonary disease (AE-COPD), patients' characteristics, clinical course, and outcomes in a real-life intermediate respiratory care unit (IRCU) setting. We performed a retrospective study on adult patients hospitalized at the IRCU of San Gerardo Hospital, Monza, Italy, from January 2015 to April 2017 with a diagnosis of AHRF due to COPD exacerbation. The NIV weaning protocol used in our institution consists of the interruption of one of the three daily NIV sessions at the time, starting from the morning session and finishing with the night session. The 51 patients who started weaning were divided into three groups: 20 (39%) patients (median age 80 yrs, 65% males) who completed the protocol and were discharged home without NIV (Completed Group), 20 (39%) did not complete it because they were adapted to domiciliary ventilation (Chronic NIV Group), and 11 (22%) interrupted weaning ex abrupto mainly due to NIV intolerance (Failed Group). Completed Group patients were older, had a higher burden of comorbidities, but a lower severity of COPD compared to Chronic NIV Group. Failed Group patients experienced higher frequency of delirium after NIV discontinuation. None of the patients who completed weaning had AHRF relapse during hospitalization. While other NIV weaning methods have been previously described, our study is the first to describe a protocol that implies the interruption of a ventilation session at the time. The application of a weaning protocol may prevent AHRF relapse in the early stages of NIV interruption and in elderly frail patients.
Highlights
Bilevel noninvasive ventilation (NIV) is a milestone in the treatment of acute hypercapnic respiratory failure (AHRF) in patients with acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) [1, 2]
Among the 94 patients hospitalized in the intermediate respiratory care unit (IRCU) with a diagnosis of COPD exacerbation during the study period, we focused on 51 patients who were started on NIV weaning after an episode of AHRF (Figure 2)
Clinical conditions for which Failed Group did not complete weaning included NIV intolerance, high risk of pneumothorax due to severe bullous emphysema, and NIV weaning failure, as defined in Section 2, which required an 94 patients admitted to the IRCU with a diagnosis of AE-COPD
Summary
Bilevel noninvasive ventilation (NIV) is a milestone in the treatment of acute hypercapnic respiratory failure (AHRF) in patients with acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) [1, 2]. A recently published randomized controlled trial (RCT) questioned the utility of the weaning phase [5] In this RCT, Sellares et al compared the prolongation of NIV for three nights after recovery from an AHRF episode to direct NIV. As in all RCTs, very elderly patients, not fully cooperative and with several comorbidities, have rarely been included, they often represent a consistent part of the COPD population with AHRF admitted to IRCUs [5]. In such a frail group, many factors may play a role in AHRF relapse after NIV discontinuation, including other respiratory comorbidities, delirium, and sarcopenia [7]
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