Home Non-invasive Ventilation Research Articles

A comparison of two weaning strategies for non-invasive ventilation in chronic obstructive pulmonary disease patients with acute respiratory failure.

Non-Invasive Ventilation (NIV) is a crucial therapy for managing acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) with hypercapnic respiratory failure. Research has shown that NIV can decrease the rate of endotracheal intubation, length of hospital and Intensive Care Unit stays, and mortality. There are three main strategies for weaning patients off NIV: gradual reduction of NIV duration, gradual reduction of NIV pressure support, and immediate cessation of NIV. To compare the rate of successful withdrawal of COPD patients with acute hypercapnic respiratory failure, one group will use a stepwise reduction of duration of NIV, while the other group will use a stepwise reduction of pressure support. This study was a prospective observational study conducted at the Department of Pulmonary Medicine, Institute of Chest Diseases, Government Medical College, Kozhikode, over a period of 15months. The study population consisted of all COPD patients admitted to the Pulmonary Medicine ward or ICU with acute hypercapnic respiratory failure who were managed with non-invasive ventilation (NIV) without the need for invasive mechanical ventilation. Exclusions included patients requiring NIV for respiratory diseases other than COPD, those with significant comorbiditieslike acute left ventricular failure or fluid overload states as in chronic kidney disease, COVID-19 positive patients, patients on home NIV, patients who needed intubation early in treatment, and patients unwilling to participate in the study. The sample size was 140. Initial NIV settings and other management decisions prior to enrolment in the study were made by the treating physician according to standard protocols. Once weaning criteria were met (i.e., arterial pH > 7.35, SpO2 ≥ 90% at an FiO2 ≤ 50%, respiratory rate ≤ 25 breaths per minute, heart rate ≤ 120 beats per minute, systolic BP > 90mm Hg, and no signs of respiratory distress), patients were assigned to either group 1 or group 2 by purposive sampling. Group 1: stepwise reduction of duration of NIV use, with a reduction to 16h per day on day 1 of enrolment, 12h on day 2 (including 6-8h of nocturnal NIV), 6-8h on day 3, and NIV withdrawal on day 4. Group 2: stepwise reduction of pressure support, with pressure support reduced by 2-4cm every 4-6h until Inspiratory Positive Airway Pressure is < 8cm H2O and Expiratory Positive Airway Pressure is < 4cm H2O, followed by NIV withdrawal. The clinical outcome was classified as either improved or weaning failure. Improved was defined as an objective or subjective sense of improvement. Weaning failure was defined as the presence of any of the following: respiratory rate ≥ 25/minute or increase of ≥ 50% from baseline, heart rate ≥ 140/minute or increase of ≥ 20% from baseline, SpO2 ≤ 90% on FiO2 ≥ 50%, arterial pH ≤ 7.35, or respiratory distress. Data was collected using a pro forma that included demographic details, smoking status, GOLD COPD category, comorbidities, and vital signs. ABG parameters, NIV settings at the time of hospital admission, at the time of study enrolment, and 48h after weaning were also recorded. Independent sample t-test was used to test the statistical significance of the difference between means of variables between the two groups. Pearson Chi square test and Fisher's exact test were used to compare categorical variables between the groups. A p-value of < 0.05 was considered statistically significant. NIV was successfully withdrawn in 56/70 (80%) and 50/70 (71.4%) patients in Groups 1 and 2, respectively. This difference was not statistically significant. The length of hospital stay was longer in the stepwise reduction of duration group (Group 1), but this was not statistically significant. On comparison of two methods of NIV withdrawal, it was found that neither method is superior to the other in terms of weaning failure, intubation rates, and average length of hospital stay.

A nomogram-based prediction model for dysphagia in patients with chronic obstructive pulmonary disease: A cross-sectional study.

To investigate the prevalence of dysphagia in patients with COPD, identify the risk factors for dysphagia, develop a visual clinical prediction model and quantitatively predict the probability of developing dysphagia. Patients with COPD are at high risk of dysphagia, which is strongly linked to the acute exacerbation of their condition. The use of effective tools to predict its risk may contribute to the early identification and treatment of dysphagia in patients with COPD. A cross-sectional design. From July 2021 to April 2023, we enrolled 405 patients with COPD for this study. The clinical prediction model was constructed according to the results of a univariate analysis and a logistic regression analysis, evaluated by discrimination, calibration and decision curve analysis and visualized by a nomogram. This study was reported using the TRIPOD checklist. In total, 405 patients with COPD experienced dysphagia with a prevalence of 59.01%. A visual prediction model was constructed based on age, whether combined with cerebrovascular disease, chronic pulmonary heart disease, acute exacerbation of COPD, home noninvasive positive pressure ventilation, dyspnoea level and xerostomia level. The model exhibited excellent discrimination at an AUC of .879. Calibration curve analysis indicated a good agreement between experimental and predicted values, and the decision curve analysis showed a high clinical utility. The model we devised may be used in clinical settings to predict the occurrence of dysphagia in patients with COPD at an early stage. The model can help nursing staff to calculate the risk probability of dysphagia in patients with COPD, formulate personalized preventive care measures for high-risk groups as soon as possible to achieve early prevention or delay of dysphagia and its related complications and improve the prognosis. No patient or public contribution.

Long-term outcomes in patients with COPD treated with non-invasive ventilation for acute hypercapnic respiratory failure.

Chronic Obstructive Lung Disease (COPD) remains a major cause of morbidity and mortality across the world. We evaluated survival over 9years in a cohort of patients with COPD requiring acute inpatient non-invasive ventilation (NIV). We analyzed prognostic indices to evaluate if they were associated with mortality. We performed a retrospective chart review of all patients who were admitted to St. James's Hospital respiratory ward with COPD and acute hypercapnic respiratory failure who required NIV over a 12-month period and followed their outcomes over 9years. We investigated the association between survival and potential prognostic variables using univariate analysis and multivariate Cox proportional hazards model. We evaluated the association between survival and the following parameters: age, gender, multiple admissions requiring NIV (> 1 admission in within 12months of index presentation), home NIV use preadmission, initial arterial blood gas pH, days spent on NIV, serum albumin and serum albumin to serum CRP ratio at admission. Ninety-nine patients with COPD and acute hypercapnic respiratory failure were identified over a 12-month period from January to December 2011. Survival at 1, 2, 5 and 9years was 65% (n = 64), 42% (n = 42), 25% (n = 25) and 21% (n = 21), respectively. Increasing age (p value < 0.001) and a lower serum albumin (p value < 0.005) were associated with a higher mortality. There was a trend towards improved survival in the group who were treated with home NIV prior to admission compared to no NIV therapy at home but this did not reach statistical significance (Fig.3, p value = 0.088). This study highlights the long-term mortality in patients with COPD admitted with hypercapnic respiratory failure requiring NIV and correlates with prior studies. Increasing age and lower serum albumin were associated with increased mortality.Home NIV may have a protective long-term survival benefit in patients with COPD who have been admitted for acute NIV.

Home respiratory strategies in COPD patients with chronic hypercapnic respiratory failure: a systematic review and network meta-analysis.

Background: Home non-invasive positive pressure ventilation (NPPV) may improve chronic hypercarbia in COPD and patient important outcomes. The efficacy of home high flow nasal cannula (HFNC) as an alternative is unclear.Methods: We searched MEDLINE, EMBASE, Cochrane CENTRAL, SCOPUS, and Clinicaltrials.gov for randomized trials of patients from inception to March 31st and updated the search on July 14, 2023. We performed a frequentist network meta-analysis and assessed the certainty of the evidence using the GRADE approach. We analyzed randomized trials (RCTs) comparing NPPV, HFNC, or standard care in adult COPD patients with chronic hypercapnic respiratory failure. Outcomes included mortality, COPD exacerbations, hospitalizations, and quality of life (SGRQ).Results: We analyzed twenty-four RCTs (1850 patients). We found that NPPV may reduce death risk compared to standard care (relative risk [RR] 0.82 [95% CI 0.66 to 1.00]) and probably reduces acute exacerbations (RR 0.71 [95% CI 0.58 to 0.87]). HFNC probably reduces acute exacerbations compared to standard care (RR 0.77 [0.68 to 0.88]) but its effect on mortality is uncertain (RR 1.20 [95% CI 0.63 to 2.28]). HFNC probably improves SGRQ scores (mean difference [MD] -7.01 [95% CI -12.27 to -1.77]) and may reduce hospitalizations (RR 0.87 [0.69 to 1.09]) compared to standard care. No significant difference was observed between HFNC and NPPV in reducing exacerbations.Conclusion: Both NPPV and HFNC reduce exacerbation risks in COPD patients compared to standard care. HFNC may offer advantages in improving quality of life.

Mask interfaces and devices for home noninvasive ventilation in children.

Home noninvasive ventilation (NIV), including continuous (CPAP) and bilevel (BPAP) positive airway pressure, is increasingly used in children worldwide. In this narrative review, we present a comprehensive summary of the equipment available for home NIV in pediatrics, excluding neonates. NIV may be challenging in young children, as the majority of the equipment has been developed for adults. Regarding the interfaces, only a few masks have been specifically developed for young children in recent years, while older children may benefit from a large variety of interfaces. Even though much progress has been made, skin injuries are still present, and need to be managed rapidly. Several studies addressed the management of the side effects, but recent studies are lacking regarding orofacial anomalies. No recent study reported the available interfaces for young children and the strategies for an optimal mask fit. Regarding the devices, an adapted NIV device to pediatrics that allows an adequate patient's breathing detection should guarantee optimal ventilatory efficiency and monitoring of NIV. A close follow-up and regular monitoring should be mandatory to rule out the potential issues, optimize NIV therapy and ascertain the efficacy of NIV. However, studies are lacking to guide the choice of devices in young children and the optimal management of home NIV in pediatrics. We summarized the characteristics of the different interfaces available for young children and the limitations of NIV devices. We finally addressed potential areas for future research on long-term home NIV in children.

Internet of things-based management versus standard management of home noninvasive ventilation in COPD patients with hypercapnic chronic respiratory failure: a multicentre randomized controlled non-inferiority trial

Effective monitoring and management are crucial during long-term home noninvasive positive pressure ventilation (NPPV) in patients with hypercapnic chronic obstructive pulmonary disease (COPD). This study investigated the benefit of Internet of Things (IOT)-based management of home NPPV. This multicenter, prospective, parallel-group, randomized controlled non-inferiority trial enrolled patients requiring long-term home NPPV for hypercapnic COPD. Patients were randomly assigned (1:1), via a computer-generated randomization sequence, to standard home management or IOT management based on telemonitoring of clinical and ventilator parameters over 12 months. The intervention was unblinded, but outcome assessment was blinded to management assignment. The primary outcome was the between-group comparison of the change in health-related quality of life, based on severe respiratory insufficiency questionnaire scores with a non-inferiority margin of-5. This study is registered with Chinese Clinical Trials Registry (No. ChiCTR1800019536). Overall, 148 patients (age: 72.7±6.8 years; male: 85.8%; forced expiratory volume in 1s: 0.7±0.3L; PaCO2: 66.4±12.0mmHg), recruited from 11 Chinese hospitals between January 24, 2019, and June 28, 2021, were randomly allocated to the intervention group (n=73) or the control group (n=75). At 12 months, the mean severe respiratory insufficiency questionnaire score was 56.5 in the intervention group and 50.0 in the control group (adjusted between-group difference: 6.26 [95% CI, 3.71-8.80]; P<0.001), satisfying the hypothesis of non-inferiority. The 12-month risk of readmission was 34.3% in intervention group compared with 56.0% in the control group, adjusted hazard ratio of 0.56 (95% CI, 0.34-0.92; P=0.023). No severe adverse events were reported. Among stable patients with hypercapnic COPD, using IOT-based management for home NPPV improved health-related quality of life and prolonged the time to readmission. Air Liquide Healthcare (Beijing) Co., Ltd.

Hospital–Provider Company Network for Home Non-Invasive Ventilation: A Feasibility Pilot Study

This study assessed the feasibility of implementing a hybrid hospital–provider company (PC) clinical pathway for patients with chronic respiratory failure (CRF) through the adaptation and follow-up of non-invasive ventilation (NIV). Over a 3-month period, a PC physiotherapist case manager oversaw the adaptation process, making adjustments as necessary, using remote monitoring and home visits. Outcome measures, including the number of patients enrolled, serious adverse events, hospitalizations, survival rates, professional time allocation, NIV adherence, nocturnal apnea–hypopnea, and oxygen saturation, Δ arterial carbon dioxide pressure (PaCO2), dyspnea, Short Physical Performance Battery (SPPB), exercise tolerance, quality of life, physical activity, and patient satisfaction, were collected. The recruitment rate was 74% (nineteen patients). Commonly reported adverse events included leakage, discomfort and sleep disturbance. Predominant interventions were four home visits (3; 4) and two NIV adjustments (1; 5). The overall program time commitment averaged 43.97 h per patient (being hospital 40 ± 11% and PC 60 ± 11%). Improvements in PaCO2, dyspnea, SPPB and exercise tolerance were observed by the third month. Adherence to NIV was high, with good or very good satisfaction with its use. This study demonstrates that a hybrid hospital–PC service for NIV adaptation and follow-up is not only feasible but also shows validity, reliability, and acceptability.

Impact of COVID-19 pandemic in children using non-invasive ventilation: a thematic analysis of caregivers answers to a survey study

PurposeThe COVID-19 pandemic has resulted in drastic changes in people's lives, more so in individuals with chronic conditions, such as children with chronic respiratory disorders requiring home non-invasive ventilation. Our research question was: How has the COVID-19 pandemic affected the daily lives of children using home NIV and their families and their NIV adherence?MethodsAn anonymous online survey was administered to caregivers of pediatric patients using home NIV followed at the Stollery's Pediatric NIV Program in Alberta, Canada, between September 2020 and September 2021. Thematic analysis was conducted for the identification of emerging themes.Results/findingsFour themes were identified: (1) positive effects, (2) negative effects, (3) neutral effects, and (4) impact on NIV adherence. Effects of COVID-19 on children and families were reported by 55 respondents (57% response rate). Positive effects included a slower lifestyle, more family time, and less recurrent acute respiratory illness. Negative effects included increased parental anxiety, prolonged social isolation beyond imposed restrictions, and limited access to health supplies. Despite these negative effects, 90% of respondents reported adequate maintenance or even increases in their child's NIV use. A general sense of benefit in the virtual specialized care model was also highlighted.ConclusionCOVID-19 resulted in varying levels of impact on the lives of children using NIV, not unlike the general population. Negative effects, however, appeared to intensify in these technology-dependent children. NIV adherence, however, was prioritized by families and even increased during COVID-19. Further research is needed to analyse the potential benefits of virtual models of specialized care.

Home noninvasive ventilation in severe COPD: in whom does it work and how?

Not all hypercapnic COPD patients benefit from home noninvasive ventilation (NIV), and mechanisms through which NIV improves clinical outcomes remain uncertain. We aimed to identify "responders" to home NIV, denoted by a beneficial effect of NIV on arterial partial pressure of carbon dioxide (PaCO2), health-related quality of life (HRQoL) and survival, and investigated whether NIV achieves its beneficial effect through an improved PaCO2. We used individual patient data from previous published trials collated for a systematic review. Linear mixed-effect models were conducted to compare the effect of NIV on PaCO2, HRQoL and survival, within subgroups defined by patient and treatment characteristics. Secondly, we conducted a causal mediation analysis to investigate whether the effect of NIV is mediated by a change in PaCO2. Data of 1142 participants from 16 studies were used. Participants treated with lower pressure support (<14 versus ≥14 cmH2O) and with lower adherence (<5 versus ≥5 h·day-1) had less improvement in PaCO2 (mean difference (MD) -0.30 kPa, p<0.001 and -0.29 kPa, p<0.001, respectively) and HRQoL (standardised MD 0.10, p=0.002 and 0.11, p=0.02, respectively), but this effect did not persist to survival. PaCO2 improved more in patients with severe dyspnoea (MD -0.30, p=0.02), and HRQoL improved only in participants with fewer than three exacerbations (standardised MD 0.52, p=0.03). The results of the mediation analysis showed that the effect on HRQoL is mediated partially (23%) by a change in PaCO2. With greater pressure support and better daily NIV usage, a larger improvement in PaCO2 and HRQoL is achieved. Importantly, we demonstrated that the beneficial effect of home NIV on HRQoL is only partially mediated through a reduction in diurnal PaCO2.

Home Noninvasive Ventilation in Myasthenia Gravis.

Noninvasive ventilation (NIV) plays an important role in avoiding endotracheal intubation during myasthenic crisis, yet there are few published data concerning long-term home NIV in stable out-patients with myasthenia gravis (MG). The aim of this study was to describe the prevalence of NIV in a cohort of subjects with stable MG and to analyze contributing factors that could predict the need of NIV. We performed a cross-sectional study that included subjects diagnosed with MG managed in the respiratory care unit over the previous year. Subjects underwent clinical analysis including demographic, clinical, and functional respiratory data. Of the 50 subjects included, 35 (70%) were positive for nicotinic acetylcholine receptor antibodies, and 68% had a diagnosis of generalized MG. Bulbar symptoms developed in 16 (32%), and 10 (20%) subjects needed long-term home NIV. The only variable predicting the need for long-term NIV was MG severity measured with Myasthenia Gravis Foundation of America (MGFA), mainly grades IIB (odds ratio 0.14 [95% CI 0.02-0.85], P = .03) and IIIB (odds ratio 0.02 [95% CI 0.01-0.34], P = .01). Home NIV was needed in a substantial percentage of medically stable subjects with MG, mainly in those with generalized type and with oropharyngeal and/or respiratory muscle involvement (MGFA grades IIB and IIIB).

O056 Is Obstruction Obstructing Survival? Long-term Mortality in Patients with Chronic Obstructive Pulmonary Disease (COPD) requiring Acute Non-invasive Ventilation (NIV) with and without Obstructive sleep apnoea (OSA).

Abstract Introduction COPD/OSA overlap syndrome (OVS) is associated with poor outcomes in studies conducted in ambulatory settings. However, little is known about the prognosis of patients hospitalised with acute hypercapnic respiratory failure (ARF) requiring NIV. The aim of this study was to compare the long-term prognosis of OVS patients compared to patients with COPD. Methods In this retrospective cohort study, 129 patients with COPD and 52 OVS patients were treated with NIV for ARF and followed up for a median of 1.8 years (IQR 3.8). We compared patient characteristics and overall survival. Results Compared to patients with COPD alone, OVS patients had higher prevalence of hypertension and type-2 diabetes mellitus. There was no difference in arterial pH, PaCO2 or serum bicarbonate at hospital presentation. Mortality was lower in OVS (HR 0.57, 95% CI 0.38-0.85) and remained lower after adjustment for age, gender, BMI, FEV1%predicted and comorbid cardiovascular disease. Median survival in OVS patients discharged home on NIV was significantly higher compared to OVS not discharged on therapy, as well as COPD patients, irrespective of home therapy prescription (p&amp;lt;0.01). Discussion OVS patients discharged on NIV had lower mortality compared to OVS patients not discharged on NIV. Patients with COPD and ARF requiring NIV have overall higher mortality rates compared to OVS patients. These findings suggest that following hospital admission with ARF, OVS patients may benefit from ongoing home NIV.

Contribution of Transcutaneous PCO2 in Obesity Hypoventilation Syndrome.

More and more patients have obesity-hypoventilation syndrome (OHS) because of the increasing prevalence of obesity. The accuracy of transcutaneous PCO2 (PtcCO2 ) has recently been validated. However, no study evaluated the interest of measuring systematically nocturnal PtcCO2 in the follow-up of patients with OHS and home mechanical ventilation to detect residual nocturnal hypoventilation. We aimed to evaluate the contribution of nocturnal PtcCO2 to assess nocturnal hypoventilation compared with current routine examinations, that is, daytime arterial blood gases and nocturnal pulse oximetry. A prospective monocentric pilot study was conducted from August 2018 to November 2019. Patients with stable OHS and who were treated with home noninvasive ventilation for at least 6 months were eligible to participate. After oral consent, we performed both diurnal arterial blood gases and combined home oximetry and capnography. The primary end point was the presence of residual nocturnal hypoventilation, defined as PaCO2 > 45 mm Hg or bicarbonate ≥ 27 mmol/L, SpO2 < 90% for ≥ 10% of the night, or PtcCO2 > 49 mm Hg for ≥ 10% of the night. A total of 32 subjects were included. Twenty-nine subjects with nocturnal PtcCO2 were analyzed. Eighteen of the 29 subjects showed residual nocturnal hypoventilation. The association of diurnal arterial blood gases and nocturnal pulse oximetry revealed nocturnal hypoventilation in only 9 subjects. Among the 19 subjects with both normal blood gases and normal nocturnal pulse oximetry, 11 had nocturnal hypoventilation with transcutaneous capnography. Only one subject presented with hypoventilation symptoms (asthenia). The assessment of PtcCO2 in comparison with nocturnal pulse oximetry and arterial blood gases provides important information for the diagnosis of residual nocturnal hypoventilation in the subjects with OHS who were ventilated at home.

Sonographic assessment of mean pulmonary artery pressure and diaphragmatic excursion in chronic respiratory failure patient after using home non-invasive positive pressure ventilation

BackgroundNon-invasive positive pressure ventilation (NIPPV) has emerged as a recognized and effective long-term therapeutic approach for individuals suffering from chronic respiratory insufficiency resulting from various diverse disorders. Nevertheless, providing home non-invasive positive pressure ventilation encounters several challenges, including compliance, training inadequacies, and limited resources. Therefore, the objective of this study was to observe the impact of home non-invasive positive pressure ventilation on patients with chronic respiratory failure, specifically focusing on its effects on the mean pulmonary artery pressure, diaphragmatic excursion, and associated complications.ResultsThe study included a total of 48 patients, consisting of 26 males (54.1%) and 22 females (45.9%). The baseline mean pulmonary artery pressure (PAP) was found to be 39.79 ± 7.51. Additionally, the baseline diaphragmatic excursion in quiet breathing was measured to be 1.80 ± 0.38 cm, while the baseline diaphragmatic excursion in deep breathing was recorded as 4.35 ± 0.99 cm. Following the implementation of home non-invasive ventilation, specifically bilevel-positive airway pressure or continuous positive airway pressure, significant improvements were observed in the aforementioned parameters. The most commonly reported complications among the patients included skin ulcers and aerophagia. Furthermore, mortality rate of 6.3% was observed.ConclusionsThe use of home non-invasive positive pressure ventilation has been shown to be a successful and sustainable therapeutic approach for persons suffering from chronic respiratory failure. This therapy method has significantly improved PAP, diaphragm force, and overall mortality rates. The use of ultrasonography to evaluate pulmonary pressure or diaphragmatic excursion is considered a beneficial and straightforward approach for the follow-up of subjects with chronic respiratory failure.

Noninvasive Home Mechanical Ventilation for Stable Hypercapnic COPD: A Clinical Respiratory Review from Canadian Perspectives.

Acute short-term noninvasive ventilation (NIV) for hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD) has well-established benefits; however, the role of long-term home NIV remains controversial. In the past decade, studies utilizing aggressive NIV settings to maximally reduce carbon dioxide levels (PaCO2) have resulted in several positive clinical trials and led to updated guidelines on home NIV for stable hypercapnic COPD patients. This clinical respiratory review discusses the high-intensity NIV approach, summarizes recent key trials and guidelines pertaining to home NIV in COPD, and considers key clinical questions for future research and application in the Canadian context. With recent evidence and Canadian Thoracic Society (CTS) guidelines supporting the use of NIV in carefully selected COPD patients with persistent daytime hypercapnia, we believe it is time to reconsider our approach.

Advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation: A qualitative study exploring barriers, facilitators and patients' and healthcare professionals' recommendations.

Although home non-invasive ventilation for patients with chronic obstructive pulmonary disease and persisting hypercapnia prolongs time to hospital readmission and prognosis, they retain a poor long-term prognosis. Requiring non-invasive ventilation in this population should trigger advance care planning, yet only 50% of patients are engaged in such discussions. This study aimed to explore the barriers and facilitators to advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation and generate recommendations for improving practice. A cross-sectional interview study took place with 10 patients with chronic obstructive pulmonary disease on home non-invasive ventilation and 12 North East Assisted Ventilation Service healthcare professionals from the North East of England. Three themes ('overlooked', 'disjointed care' and 'awareness and expertise') were identified. Patients with chronic obstructive pulmonary disease are a 'forgotten about' population, exacerbated by prejudice and unpredictable disease trajectories. Recognition as a distinct and underserved population may improve care and advance care planning. All participants recognised a lack of care continuity, including limited collaboration and communication between services, as a significant barrier to advanced care planning. Additionally, lacking understanding of the rationale and positive impacts of advance care planning, exacerbated by a lack of expertise in difficult conversations, was a barrier to advance care planning. Patients and healthcare professionals highlighted the need for individualised and ongoing advance care planning, particularly around prognosis and care preferences. Discussions should be initiated by familiar clinicians. Effective communication between services, clear agreements and protocols and upskilling healthcare professionals may ensure continuity of care.

Effectiveness of long-term noninvasive ventilation measured by remote monitoring in neuromuscular disease.

Patients with neuromuscular disease are often treated with home noninvasive ventilation (NIV) with devices capable of remote patient monitoring. We sought to determine whether long-term NIV data could provide insight into the effectiveness of ventilation over time. We abstracted available longitudinal data for adults with neuromuscular disease in monthly increments from first available to most recent. Generalised linear mixed-effects modelling with subject-level random effects was used to evaluate trajectories over time. 1799 months of data across 85 individuals (median age 61, interquartile range (IQR) 46-71 years; 44% female; 49% amyotrophic lateral sclerosis (ALS)) were analysed, with a median (IQR) of 17 (8-35) months per individual. Over time, tidal volume increased and respiratory rate decreased. Dynamic respiratory system compliance decreased, accompanied by increased pressure support. Compared to volume-assured mode, fixed-pressure modes were associated with lower initial tidal volume, higher respiratory rate and lower pressures, which did not fully equalise with volume-assured mode over time. Compared with non-ALS patients, those with ALS had lower initial pressure support, but faster increases in pressure support over time, and ALS was associated wtih a more robust increase in respiratory rate in response to low tidal volume. Nonsurvivors did not differ from survivors in ventilatory trajectories over time, but did exhibit decreasing NIV use prior to death, in contrast with stable use in survivors. NIV keeps breathing patterns stable over time, but support needs are dynamic and influenced by diagnosis and ventilation mode. Mortality is preceded by decreased NIV use rather than inadequate support during use.

Mortality in individuals with COPD on long-term home non-invasive ventilation

BackgroundReal-world evidence regarding survival of patients with chronic obstructive pulmonary disease (COPD) using chronic non-invasive ventilation (NIV) is scarce. Research questionHow do obesity and other factors relate to mortality in patients with COPD on chronic NIV? Study designand Methods: We retrospectively analyzed data from COPD patients enrolled in a home ventilation program between 2014 and 2018. Survival was compared between obese and non-obese groups using the Kaplan-Meier method. Factors associated with mortality were identified using multivariable Cox proportional regression analyses with Least Absolute Selection and Shrinkage Operator (LASSO) regularization. Univariable analyses were also done stratified by obesity. ResultsMedian survival was 80.0 (95% CI: 71.0-NA) months among obese (n = 205) and 30.0 (95%CI: 19.0–42.0) months in non-obese (n = 61) patients. NIV adherence was high in both groups. Mortality was associated with male gender [HR 1.44], chronic opioids or benzodiazepines use [HR 1.07], home oxygen use [HR 1.82], fixed pressure mode of ventilation [HR 1.55], NIV inspiratory pressure [HR 1.05], and thoracic cancer [HR 1.27]; obesity [HR: 0.43], age [HR 0.99] and NIV expiratory pressure [HR 0.94] were associated with decreased mortality. In the obese, univariable analyses revealed that chest wall disease, thoracic cancer, home oxygen use, FEV1% predicted, and ventilation parameters were associated with mortality. In the non-obese, male gender and respiratory comorbidities were related to mortality. InterpretationObesity is associated with improved survival in COPD patients highly adherent to NIV. Other factors associated with mortality reflect disease severity and ventilator parameters, with differences between obese and non-obese patients.

Relationship between nighttime symptoms and clinical features in COPD patients: A cross-sectional multicenter study in China

BackgroundChronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that causes breathing difficulties, coughing, and other symptoms. Nighttime symptoms, such as coughing, wheezing, and shortness of breath, can significantly impact the quality of life for people with COPD. ObjectiveTo investigate the relationship between nighttime symptoms and other clinical features in patients with COPD, and identify potential risk factors associated with nighttime symptoms. MethodsThis cross-sectional study was conducted from October 1, 2022 to November 30, 2022 in 24 hospital outpatient departments in different cities of Hunan Province, China. The COPD Nighttime Symptom Instrument (NiSCI) was used to measure the severity of night time symptoms in COPD patients. Descriptive and inferential statistics were used to express patient socio-demographics and factors influencing nighttime symptoms. ResultsThe study included 2219 COPD patients. The results showed that nighttime symptom scores differed significantly based on gender, whether the patient had experienced acute exacerbation in the past year, mMRC and CAT scores, the duration of home oxygen therapy and home non-invasive ventilation (all P < 0.0001). Multiple linear regression analysis revealed that CAT score (P < 0.0001) was significantly associated with nighttime symptom scores. ConclusionNighttime symptoms are prevalent in Chinese COPD patients and correlate with disease severity. The assessment and management of nighttime symptoms in COPD patients must take into account gender, CAT and mMRC scores, history of acute exacerbations, and duration of home oxygen therapy and home non-invasive ventilation to enable tailoring of treatment strategies to individual needs.

Home noninvasive ventilation use in patients hospitalized with COPD.

The study objective was to estimate the prevalence of chronic hypercapnic respiratory failure (CHRF) and home noninvasive ventilation (NIV) use in a high-risk population, individuals with a history of at least one COPD-related hospitalizations. We retrospectively analyzed electronic medical record data of patients with at least one COPD-related hospitalization between October 1, 2011, and September 30, 2017, to the Iowa City VA Medical Center. We excluded individuals with no obstructive ventilatory defect. Of 186 patients, the overall prevalence of compensated hypercapnic respiratory failure (CompHRF), defined as PaCO2 > 45 mmHg with a pH =7.35-7.45, was 52.7%, while the overall prevalence of home NIV was 4.3%. The prevalence of CompHRF was 43.6% and home NIV was 1.8% in those with one COPD-related hospitalization. Among those with ≥4 COPD-related hospitalizations, the prevalence of CompHRF was 77.8% (14 of 18), and home NIV was 11.1% (2 of 18). Approximately half of individuals with at least one COPD-related hospitalization have CompHRF, but only 8.2% of those use home NIV. Future studies should estimate CHRF rates and the degree of underutilization of home NIV in larger multicenter samples.

Home Noninvasive Ventilation for COPD.

Patients with hypercapnic COPD appear to represent a phenotype driven by specific physiology including air trapping and mechanical disadvantage, sleep hypoventilation, and sleep apnea. Such individuals appear to be at high risk for adverse health outcomes. Home noninvasive ventilation (NIV) has been shown to have the potential to help compensate for physiological issues underlying hypercapnia. In contrast to older literature, contemporary clinical trials of home NIV have been shown to improve patient-oriented outcomes including quality of life, hospitalizations, and mortality. Advancements in the use of NIV, including the use of higher inspiratory pressures, may account for recent success. Successful practical application of home NIV thus requires an adequate understanding of patient selection, devices and modes, and strategies for titration. The emergence of telemonitoring holds promise for further improvements in patient care by facilitating titration, promoting adherence, troubleshooting issues, and possibly predicting exacerbations. Given the complexity of home NIV, clinicians and health systems might consider establishment of dedicated home ventilation programs to provide such care. In addition, incorporation of respiratory therapist expertise is likely to improve success. Traditional fee-for-service structures have been a challenge for financing such programs, but ongoing changes toward value-based care are likely to make home NIV programs more feasible.