Michael E. Wilson, MD, on the Use of Home NIPPV Among Patients With COPD, Hypercapnia
The use of home noninvasive positive pressure ventilation (NIPPV)—compared with no device use—is significantly associated with better clinical outcomes among individuals with chronic obstructive pulmonary disease (COPD) and hypercapnia, according to results of a new meta-analysis.1
While home use of bilevel positive airway pressure (BPAP) was significantly associated with lower risk of mortality, fewer patients with hospital admissions, and less need for intubation compared with no device use, noninvasive home mechanical ventilation was significantly associated with lower risk of hospital admission compared with no device use.
Michael E. Wilson, MD, who is a consultant for the Division of Pulmonary and Critical Care Medicine at the Mayo Clinic, is the lead author of the meta-analysis. Pulmonology Consultant asked him about his team’s findings, how the findings reflect the current treatment landscape, and how you can help your patients overcome the challenges associated with successful NIPPV use.
PULMONOLOGY CONSULTANT: What was the impetus for your meta-analysis?
Michael Wilson: The role for the use of home NIPPV in patients with COPD was unclear. Some studies showed benefit, and some studies showed no benefit. We conducted this meta-analysis in an attempt to understand the summary of currently available evidence.
PULM CON: What should clinicians take away from your findings? How do you hope clinicians implement these findings into their clinical practice?
MW: When summarizing the currently published evidence, there seems to be clear benefits for patients with COPD and hypercapnia when they utilize NIPPV. These benefits include reduced mortality, reduced intubation, and reduced hospitalizations. In addition, there seem to be improvements in symptoms such as reduced shortness of breath and improved sleep quality. There was insufficient data to determine whether using NIPPV improved quality of life.
Clinicians should consider measuring carbon dioxide levels of patients with moderate or severe COPD or in patients with COPD and symptoms of hypercapnia. If carbon dioxide levels are elevated, then clinicians should consider utilizing NIPPV for their patients.
PULM CON: What factors should clinicians consider when choosing between a BPAP device and a noninvasive home mechanical ventilator for patients with COPD and hypercapnia?
MW: There are very few studies that compare the efficacy of BPAP and home mechanical ventilator devices. Thus, we were unable to assess the efficacy of BPAP compared with home mechanical ventilator machines. Further research is needed in this area. My current practice is to consider a home mechanical ventilator machine when a patient has uncontrolled hypercapnia despite BPAP use. In addition, I would consider use of a home mechanical ventilator for patients who require considerable daytime BPAP (in addition to conventional nighttime use) and who may decompensate very rapidly if BPAP were temporarily stopped.
PULM CON: How do your results reflect the current landscape of home NIPPV use? And how do they highlight the direction in which the COPD treatment landscape needs to go?
MW: The results of this meta-analysis add to a growing literature that documents the efficacy of home NIPPV for patients with COPD and hypercapnia. While it is becoming clear that home NIPPV offers benefits to such patients, further research is needed to better understand exactly which device settings are best for which patients.
PULM CON: What are the main challenges of home NIPPV initiation and its proper continuation that patients may face? How can clinicians help patients overcome those challenges?
MW: One of the biggest challenges is helping patients understand the need for NIPPV and helping patients get used to this new device, which has become a daily part of their lives. Taking time to approach NIPPV in an individualized fashion is key to successful long-term use. There are several possible mask interfaces available, and finding the right fit is possible for nearly all patients. Issues such as dry mouth, nasal stuffiness, and mask leakage can usually be adequately addressed by close follow-up with the patient’s clinician team.
Reference:
- Wilson ME, Dobler CC, Morrow AS, et al. Association of home noninvasive positive pressure ventilation with clinical outcomes in chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2020;323(5):455-465. doi:10.1001/jama.2019.22343