Home noninvasive ventilation delays readmission for COPD
At 12 months, the time to hospital readmission or death was significantly delayed in the home oxygen + NIV group (combined therapy) compared with the home oxygen alone group (median, 4.3 vs 1.4 months, adjusted hazard ratio [HR], 0.49; p=0.002). The estimated 1-year risk of readmission or death was 63.4 percent with combined therapy vs 80.4 percent with home oxygen alone, which translates to an absolute risk reduction of 17.0 percent. [JAMA 2017;317:2177-2186]
“These data support the screening of patients with COPD after receiving acute NIV to identify persistent hypercapnia and introduce home NIV,” said the researchers.
The multicentre, open-label, phase III trial included 116 patients (mean age 67 years, 53 percent female) with persistent hypercapnia (Paco2 >53 mm Hg) following an acute COPD exacerbation. Within 2–4 weeks after resolution of decompensated respiratory acidosis, they were randomized 1:1 to receive home oxygen alone (median oxygen flow rate, 1.0 L/min) or home oxygen + home NIV (median oxygen flow rate, 1.0 L/min).
The secondary outcome of all-cause mortality at 1 year did not differ significantly between the two groups (28 percent vs 32 percent, HR, 0.67; p=0.23), with most cases attributed to respiratory causes.
In addition, a reduced rate of COPD exacerbation (median, 3.8 vs 5.1 per year; p=0.03) and improved quality of life at 3 months (SGRQ* mean score, 62.9 vs 66.0; p=0.02) were observed with home oxygen + NIV vs with home oxygen alone, although there was no significant improvement in SGRQ score thereafter.
“The results … suggest that home NIV added to home oxygen therapy in this population improved the overall clinical outcome without adding to the health burden of the patient,” said the researchers.
“Conceivably, prevention of greater hypoventilation at night could improve sleep quality, which has been shown to be poor in those with severe COPD, as well as oxygenation. These improvements could also lead to better quality of life,” suggested Drs Nicolas Hill and Aylin Ugurlu from the Tufts Medical Center in Boston, Massachusetts, US and Baskent University in Istanbul, Turkey, respectively in an accompanying editorial. [JAMA 2017;317:2167-2169]
“[S]election of patients and ventilator settings that are likely to favour benefit with long-term home [positive pressure NIV include] … more severe hypercapnia (>52 mm Hg per nearly 20-year-old Medicare guidelines) … The overlap syndrome of COPD with obstructive sleep apnoea is likely another predictor of NIV benefit, and a patient’s motivation and ability to comprehend the reasons for and application of therapy are other important factors along with sufficient inspiratory pressure,” they added.
Future studies were required to confirmed the findings and “to better define patient characteristics (including presence of sleep-disordered breathing)” in order to optimize the success rate of home NIV in patients with COPD, according to Hill and Ugurlu.