New guidance on long-term noninvasive ventilation in chronic stable hypercapnic COPD

A new clinical practice guideline addresses limited evidence and provides new recommendations for management of noninvasive ventilation in patients with COPD and chronic hypercapnia.

“This guideline is needed because patients with severe COPD are very sick and have few therapies that have been shown to improve outcomes,” Robert L. Owens, MD, guidance chair and associate professor in the division of pulmonary, critical care and sleep medicine at the University of California, San Diego, said in a press release issued by the American Thoracic Society. “Clinicians who care for these patients need information about whether to consider noninvasive ventilation and some practical advice on how to set up patients with noninvasive ventilation.”

The guideline was issued by the Assembly in Sleep and Respiratory Neurobiology, a subcommittee of the ATS.

Limited evidence to date

While noninvasive ventilation is used for patients with COPD and chronic hypercapnia, up to this point, evidence for clinical efficacy and optimal management of therapy have been limited.

The new guideline, published in the American Journal of Respiratory and Critical Care Medicine, lists recommendations for clinicians treating patients with COPD and chronic hypercapnia.

The guideline panel reviewed results from various randomized controlled trials to assess health equity, availability of pulmonary and critical care specialists in underserved areas, and patient compliance likelihood.

“The purpose of this clinical practice guideline is to summarize the available evidence and provide actionable recommendations addressing patients with COPD, especially potential subgroups who might benefit from noninvasive ventilation therapy, the ideal timing and location for noninvasive ventilation initiations and the identification of optimal modes and setting for chronic noninvasive ventilation therapy,” the authors wrote.

Recommendations for clinicians

The main recommendations for clinicians for optimal management of patients with COPD and chronic hypercapnia are:

• use nocturnal noninvasive ventilation in addition to usual care in patients with chronic stable hypercapnic COPD;
• screen patients with COPD and chronic hypercapnia for obstructive sleep apnea before initiation of long-term noninvasive ventilation;
• avoid initiating long-term noninvasive ventilation during admission for acute-on-chronic respiratory failure and, instead, reassess for noninvasive ventilation 2 to 4 weeks following resolution;
• avoid use of in-laboratory overnight polysomnogram to titrate noninvasive ventilation in patients with COPD and chronic hypercapnia initiating management; and
• use noninvasive ventilation with targeted normalization of the partial pressure of carbon dioxide in patients with COPD and chronic hypercapnia on long-term noninvasive ventilation.

The full list of recommendations and details are published in the guideline document.

“On the basis of evidence to date, we suggest long-term nocturnal noninvasive ventilation for chronic stable hypercapnic COPD,” the authors wrote. “Research is needed to better determine the benefits and optimal management of such patients. Barriers to implementation will require attention from physicians as well as payors and other stakeholders.”

References:

Press Release.