The Non-Invasive Ventilation Outcomes (NIVO) score in patients requiring NIV for COPD exacerbation without prior evidence of airflow obstruction

Abstract

Exacerbation of Chronic Obstructive Pulmonary disease (COPD) complicated by respiratory acidaemia is the commonest indication for non-invasive ventilation (NIV). The NIV Outcomes (NIVO) score offers the best estimate of survival for those ventilated. Unfortunately 2/3 cases of COPD are unrecognised, and patients may present without COPD having been confirmed by spirometry. In the 10-centre NIVO validation study there was no pre-admission spirometry in 111 of 844 consecutive patients (termed “clinical diagnosis” patients). We compared the performance of the NIVO, DECAF and CURB-65 scores for in-hospital mortality in the clinical diagnosis cohort. Usual clinical practice was not influenced, but confirmation of COPD in the year following discharge was captured. In the clinical diagnosis cohort, in-hospital mortality was 19.8%, and rose incrementally across the NIVO risk categories, consistent with the NIVO validation cohort. NIVO showed good discrimination in the clinical diagnosis cohort: area under the receiver operating curve 0.724,versus0.79 in the NIVO validation cohort. At one year post discharge, 41 of 89 clinical diagnosis patients had undertaken diagnostic spirometry; 33/41 had confirmation of airflow obstruction (FEV1/[F]VC <0.7), meaning the diagnosis of COPD was incorrect in 19.5% of cases. These data support use of the NIVO score in patients with a “clinical diagnosis” of COPD. NIVO can help guide shared decision making, assess risk-adjusted outcomes by centre and challenge prognostic pessimism. Accurate diagnosis is critical to ensure acute and long-term treatment is optimised; this study highlights failings in follow up of such patients.