Long-term noninvasive ventilation in COPD: current evidence and future directions

ABSTRACT

Introduction: Long-term noninvasive ventilation (NIV) is an established treatment for end-stage COPD patients suffering from chronic hypercapnic respiratory failure. This is reflected by its prominent position in national and international medical guidelines.

Areas covered: In recent years, novel developments in technology such as auto-titrating machines and hybrid modes have emerged, and when combined with advances in information and communication technologies, these developments have served to improve the level of NIV-based care. Such progress has largely been instigated by the fact that healthcare systems are now confronted with an increase in the number of patients, which has led to the need for a change in current infrastructures. This article discusses the current practices and recent trends, and offers a glimpse into the future possibilities and requirements associated with this form of ventilation therapy.

Expert opinion: Noninvasive ventilation is an established and increasingly used treatment option for patients with chronic hypercapnic COPD and those with persistent hypercapnia following acute hypercapnic lung failure. The main target is to augment alveolar hypoventilation by reducing P_aCO₂ to relieve symptoms. Nevertheless, when dealing with severely impaired patients, it appears necessary to switch the focus to patient-related outcomes such as health-related quality of life.

KEYWORDS:

• COPD
• long-term noninvasive ventilation
• respiratory failure
• telemedicine
• outpatient setting
• quality of life
• lung function

Article highlights

• Long-term NIV therapy has critical significance both in COPD patients suffering from symptomatic chronic respiratory failure, and in those with persisting hypercapnia after acute hypercapnic respiratory failure.

• The overall goal is to augment alveolar hypoventilation witnessed by a reduction in P_aCO₂ in order to reduce symptoms such as severe dyspnea, sleep-disordered breathing, and further hypercapnia-related symptoms.

• In COPD patients, long-term NIV should be carried out by High-intensity NIV strategy capable of augmenting ventilation and thereby normalizing P_aCO₂ for at least 5 h per day. Individual titration is essential and it should be aimed for normocapnia.

• The rise in the number of patients who require long-term NIV could lead to so-called bottlenecks in health care expertly arranged outpatient settings and the use of telemonitoring are promising solutions that are simultaneously capable of promoting an improvement in the quality of care.

• Numerous technological developments have taken place in the past decades, thus improving the means of NIV application. However, when dealing with a severely impaired patient collective, it appears necessary to switch the focus to patient-related outcomes and search for solutions that ultimately improve HRQoL

Acknowledgments

We thank Dr Sandra Dieni for helpful comments on the manuscript prior to submission.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Declaration of interest

D. Majorski has previously received open research grants from Philips Respironics Murrysville, Pennsylvania, USA. W. Windisch has previously received open research grants from Weinmann, Germany; Vivisol, Germany; VitalAire, Germany; Philips Respironics Murrysville, Pennsylvania, USA; and from Breas Medical Sweden. M. Duvierman has received funding from the Dutch Lung Foundation (Junior investigator grant number: 5.2.15.057JO); and Philips Respironics Murrysville, Pennsylvania, USA in relation to this work and has previously received personal fees from Vivisol Bristol B.V. and Philips Respironics AND grants from Vivisol Bristol B.V. and FIsher Paykel ltd. S. Schwarz has received non-financial support from Vital Aire and personal fees from Sentec. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

Additional information

Funding

This paper was not funded.