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Nocturnal non-invasive ventilation in addition to rehabilitation in hypercapnic patients with COPD

Background: Long-term non-invasive positive pressure ventilation (NIPPV) might improve the outcomes of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) with chronic respiratory failure. A study was undertaken to investigate whether nocturnal NIPPV in addition to pulmonary rehabilitation improves health-related quality of life, functional status and gas exchange compared with pulmonary rehabilitation alone in patients with COPD with chronic hypercapnic respiratory failure. Methods: 72 patients with COPD were randomly assigned to nocturnal NIPPV in addition to rehabilitation (n = 37) or rehabilitation alone (n = 35). Outcome measures were assessed before and after the 3-month intervention period. Results: The Chronic Respiratory Questionnaire total score improved 15.1 points with NIPPV + rehabilitation compared with 8.7 points with rehabilitation alone. The difference of 7.5 points was not significant (p = 0.08). However, compared with rehabilitation alone, the difference in the fatigue domain was greater with NIPPV + rehabilitation (mean difference 3.3 points, p<0.01), as was the improvement in the Maugeri Respiratory Failure questionnaire total score (mean difference −10%, p<0.03) and its cognition domain (mean difference −22%, p<0.01). Furthermore, the addition of NIPPV improved daytime arterial carbon dioxide pressure (mean difference −0.3 kPa; p<0.01) and daily step count (mean difference 1269 steps/day, p<0.01). This was accompanied by an increased daytime minute ventilation (mean difference 1.4 l; p<0.001). Conclusion: Non-invasive ventilation augments the benefits of pulmonary rehabilitation in patients with COPD with chronic hypercapnic respiratory failure as it improves several measures of health-related quality of life, functional status and gas exchange. Trial registration number: NCT00135538.

Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure: a randomised, controlled, parallel-group study

Introduction The effectiveness of non-invasive positive pressure ventilation (NIV) in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure (ARF) remains unclear. We investigated if nocturnal NIV in these patients prolongs the time to readmission for respiratory causes or death (primary endpoint) in the following 12 months. Methods 201 COPD patients admitted to hospital with ARF and prolonged hypercapnia >48 h after termination of ventilatory support were randomised to NIV or standard treatment. Secondary outcomes were daytime arterial blood gasses, transcutaneous PCO2 during the night, lung function, health-related quality-of-life (HRQL), mood state, daily activities and dyspnoea. Results 1 year after discharge, 65% versus 64% of patients (NIV vs standard treatment) were readmitted to hospital for respiratory causes or had died; time to event was not different (p=0.85). Daytime PaCO2 was significantly improved in NIV versus standard treatment (PaCO2 0.5 kPa (95% CI 0.04 to 0.90, p=0.03)) as was transcutaneous PCO2 during the night. HRQL showed a trend (p=0.054, Severe Respiratory Insufficiency questionnaire) in favour of NIV. Number of exacerbations, lung function, mood state, daily activity levels or dyspnoea was not significantly different. Discussions We could not demonstrate an improvement in time to readmission or death by adding NIV for 1 year in patients with prolonged hypercapnia after an episode of NIV for ARF. There is no reason to believe the NIV was not effective since daytime PaCO2 and night-time PCO2 improved. The trend for improvement in HRQL favouring NIV we believe nevertheless should be explored further. Trial registration number NTR1100.

Two-year home-based nocturnal noninvasive ventilation added to rehabilitation in chronic obstructive pulmonary disease patients: A randomized controlled trial

BackgroundThe use of noninvasive intermittent positive pressure ventilation (NIPPV) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure remains controversial as long-term data are almost lacking.The aim was to compare the outcome of 2-year home-based nocturnal NIPPV in addition to rehabilitation (NIPPV + PR) with rehabilitation alone (PR) in COPD patients with chronic hypercapnic respiratory failure.MethodsSixty-six patients could be analyzed for the two-year home-based follow-up period. Differences in change between the NIPPV + PR and PR group were assessed by a linear mixed effects model with a random effect on the intercept, and adjustment for baseline values. The primary outcome was health-related quality of life (HRQoL); secondary outcomes were mood state, dyspnea, gas exchange, functional status, pulmonary function, and exacerbation frequency.ResultsAlthough the addition of NIPPV did not significantly improve the Chronic Respiratory Questionnaire compared to rehabilitation alone (mean difference in change between groups -1.3 points (95% CI: -9.7 to 7.4)), the addition of NIPPV did improve HRQoL assessed with the Maugeri Respiratory Failure questionnaire (-13.4% (-22.7 to -4.2; p = 0.005)), mood state (Hospital Anxiety and Depression scale -4.0 points (-7.8 to 0.0; p = 0.05)), dyspnea (Medical Research Council -0.4 points (-0.8 to -0.0; p = 0.05)), daytime arterial blood gases (PaCO2 -0.4 kPa (-0.8 to -0.2; p = 0.01); PaO2 0.8 kPa (0.0 to 1.5; p = 0.03)), 6-minute walking distance (77.3 m (46.4 to 108.0; p < 0.001)), Groningen Activity and Restriction scale (-3.8 points (-7.4 to -0.4; p = 0.03)), and forced expiratory volume in 1 second (115 ml (19 to 211; p = 0.019)). Exacerbation frequency was not changed.ConclusionsThe addition of NIPPV to pulmonary rehabilitation for 2 years in severe COPD patients with chronic hypercapnic respiratory failure improves HRQoL, mood, dyspnea, gas exchange, exercise tolerance and lung function decline. The benefits increase further with time.Trial registrationClinicalTrials.Gov (ID NCT00135538).

Health-related quality of life in COPD patients with chronic respiratory failure

The Maugeri Respiratory Failure (MRF-28) and Severe Respiratory Insufficiency (SRI) questionnaires were recently developed to assess health-related quality of life (HRQoL) in patients with chronic respiratory failure, although not exclusively in chronic obstructive pulmonary disease (COPD) patients. The aim of the present study was to investigate whether the MRF-28 and SRI are reliable and valid HRQoL questionnaires in COPD patients with chronic hypercapnic respiratory failure (CHRF). In total, 72 COPD patients with CHRF underwent pulmonary function and exercise testing, and completed the MRF-28, the SRI, the Chronic Respiratory Questionnaire (CRQ), the Hospital Anxiety and Depression Scale, the Groningen Activity and Restriction Scale and two dyspnoea indexes. Physical domain scores of the questionnaires correlated with exercise tolerance, dyspnoea and daily activities, while psychological domains correlated strongly with anxiety and depression. Anxiety scores accounted for 51 and 56% of the total explained variance in total CRQ and SRI scores, respectively. The emphasis of the MRF-28 was restrictions in activities of daily living (52% of total variance). In conclusion, the present study showed that the Maugeri Respiratory Failure and Severe Respiratory Insufficiency questionnaires were reliable and valid questionnaires in chronic obstructive pulmonary disease patients with chronic hypercapnic respiratory failure. While the emphasis in the Maugeri Respiratory Failure questionnaire is on activities of daily living, the Severe Respiratory Insufficiency questionnaire, like the Chronic Respiratory Questionnaire, is more related to anxiety and depression.

The Severe Respiratory Insufficiency Questionnaire scored best in the assessment of health-related quality of life in chronic obstructive pulmonary disease

OBJECTIVE There are limited data on health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure during an admission requiring ventilatory support. The aim was to assess and compare the reliability and validity of the Clinical COPD Questionnaire (CCQ), Chronic Respiratory Questionnaire (CRQ), Maugeri Respiratory Failure-28 (MRF-28) Questionnaire, and Severe Respiratory Insufficiency (SRI) Questionnaire in patients with very severe COPD. STUDY DESIGN AND SETTING One hundred eighty hospitalized patients filled out the CCQ, CRQ, MRF-28, SRI, Groningen Activity Restriction Scale (GARS), Hospital Anxiety and Depression Scale (HADS), and the Medical Research Council Dyspnea Scale (MRC). Reliability was examined by assessing distribution of total scores, floor and ceiling effects, and internal consistency (using Cronbach α coefficient). Construct validity between questionnaires and also the other measurements were tested with Spearman ρ. RESULTS All four questionnaires were feasible in this setting and had reasonable characteristics for distribution of total scores, floor and ceiling effects, internal consistency, and construct validity. On balance, the SRI scored best. Additionally, the SRI had a remarkable high explained variance by HADS, GARS, and MRC (73%). CONCLUSION The SRI performed slightly better than the CCQ, CRQ, and MRF-28, which renders it the preferred questionnaire for scoring HRQL in patients with very severe COPD.

Respiratory muscle activity and patient–ventilator asynchrony during different settings of noninvasive ventilation in stable hypercapnic COPD: does high inspiratory pressure lead to respiratory muscle unloading?

Introduction High-intensity noninvasive ventilation (NIV) has been shown to improve outcomes in stable chronic obstructive pulmonary disease patients. However, there is insufficient knowledge about whether with this more controlled ventilatory mode optimal respiratory muscle unloading is provided without an increase in patient–ventilator asynchrony (PVA). Patients and methods Ten chronic obstructive pulmonary disease patients on home mechanical ventilation were included. Four different ventilatory settings were investigated in each patient in random order, each for 15 min, varying the inspiratory positive airway pressure and backup breathing frequency. With surface electromyography (EMG), activities of the intercostal muscles, diaphragm, and scalene muscles were determined. Furthermore, pressure tracings were derived simultaneously in order to assess PVA. Results Compared to spontaneous breathing, the most pronounced decrease in EMG activity was achieved with the high-pressure settings. Adding a high breathing frequency did reduce EMG activity per breath, while the decrease in EMG activity over 1 min was comparable with the high-pressure, low-frequency setting. With high backup breathing frequencies less breaths were pressure supported (25% vs 97%). PVAs occurred more frequently with the low-frequency settings (P=0.017). Conclusion High-intensity NIV might provide optimal unloading of respiratory muscles, without undue increases in PVA.