High-intensity non-invasive positive pressure ventilation (NPPV) was originally described for chronic hypercapnic chronic obstructive pulmonary disease (COPD) patients in 2009, and refers to a specific ventilatory approach whereby NPPV settings are aimed at achieving the lowest arterial partial pressure of carbon dioxide (PaCO) values possible. Thus, high-intensity NPPV requires ventilator settings to be increased in a stepwise approach to either an individually tolerated maximum, or to the levels necessary to achieve normocapnia. This differs from the classic approach to low-intensity NPPV, which comprises considerably lower ventilator settings and typically fails to lower elevated PaCO values. The ongoing discussion about whether or not long-term NPPV should be used in chronic hypercapnic COPD patients is based on the observation that many studies in the last two decades have failed to provide evidence for this particular patient cohort. In addition, these trials preferably used low-intensity NPPV. There is now, however, increasing evidence to suggest that high-intensity NPPV is capable of improving important physiological parameters such as blood gases and lung function, as well as health-related quality of life. Moreover, this approach also produced positive outcomes following two recent randomized controlled trials, e.g., improved survival rates in stable COPD patients, and admission-free survival in patients with persisting hypercapnia following acute in-hospital NPPV to treat acute acidotic respiratory failure. As a consequence, the time has now come to evaluate the impact of long-term NPPV on both the physiological and clinical outcomes, with emphasis on the different approaches to NPPV. Therefore, the aim of the current review article is to elaborate on the clinical and physiological reasons for why high-intensity NPPV is favourable to low-intensity NPPV.

Background: Long-term non-invasive ventilation (NIV) is an established and increasingly used treatment option for patients with chronic hypercapnic chronic obstructive pulmonary disease (COPD). Following inpatient NIV establishment, inpatient control visits regularly occur thereafter. However, it remains unclear whether such control visits can also be performed in an outpatient setting, which, in turn, would reduce costs, patient burden and the complications related to hospitalization. Objectives: To investigate an outpatient setting with predefined criteria for hospitalization for patients with chronic hypercapnic COPD. Methods: An outpatient clinic located within the hospital in the vicinity of the respiratory care unit provided predefined criteria for hospitalization of COPD patients receiving long-term NIV therapy. The results of this setting were retrospectively analysed. Results: A total of 130 outpatient visits (80 patients) were analysed. In 93 cases (71.5%), hospital admission was not necessary, while hospitalization was performed in 37 cases (28.5%). Out of these, 7 cases with acute conditions required prompt hospitalization. Patients without hospitalization had better PaCO₂ values (45.40 ± 5.27 vs. 50.05 ± 8.04, p = 0.002) and Severe Respiratory Insufficiency Questionnaire Summary scores (55.54 ± 19.74 vs. 41.82 ± 19.59, p = 0.012). Conclusion: Outpatient control of long-term NIV in a hospital setting is feasible and has the capacity to identify stable COPD patients in whom NIV therapy is sufficient according to predefined criteria. These patients may not require hospitalization and may account for more than two thirds of cases.

IntroductionThe establishment of high-intensity (HI) noninvasive ventilation (NIV) that targets elevated PaCO2 has led to an increase in the use of long-term NIV to treat patients with chronic hypercapnic COPD. However, the role of the ventilation interface, especially in more aggressive ventilation strategies, has not been systematically assessed.MethodsVentilator settings and NIV compliance were assessed in this prospective cross-sectional monocentric cohort study of COPD patients with pre-existing NIV. Daytime arterialized blood gas analyses and lung function testing were also performed. The primary end point was the distribution among study patients of interfaces (full-face masks [FFMs] vs nasal masks [NMs]) in a real-life setting.ResultsThe majority of the 123 patients studied used an FFM (77%), while 23% used an NM. Ventilation settings were as follows: mean ± standard deviation (SD) inspiratory positive airway pressure (IPAP) was 23.2±4.6 mbar and mean ± SD breathing rate was 16.7±2.4/minute. Pressure support ventilation (PSV) mode was used in 52.8% of patients, while assisted pressure-controlled ventilation (aPCV) was used in 47.2% of patients. Higher IPAP levels were associated with an increased use of FFMs (IPAP <21 mbar: 73% vs IPAP >25 mbar: 84%). Mean compliance was 6.5 hours/day, with no differences between FFM (6.4 hours/day) and NM (6.7 hours/day) users. PaCO2 assessment of ventilation quality revealed comparable results among patients with FFMs or NMs.ConclusionThis real-life trial identified the FFM as the predominantly used interface in COPD patients undergoing long-term NIV. The increased application of FFMs is, therefore, likely to be influenced by higher IPAP levels, which form part of the basis for successful application of HI-NIV in clinical practice.

Background Veno-venous extracorporeal CO 2 removal (vv-ECCO 2 R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. Methods A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO 2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. Results Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO 2 R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO 2 R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO 2 R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 μV vs. 56 ± 20 μV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO 2 and pH values stable. Edi was the best predictor for vv-ECCO 2 R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. Conclusions This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO 2 R and NIV-NAVA. The Edi during vv-ECCO 2 R weaning was found to be the best predictor of tolerance to removing vv-ECCO 2 R. Electronic supplementary material The online version of this article (10.1186/s13054-019-2404-y) contains supplementary material, which is available to authorized users.

Background: The German guideline on long-term oxygen therapy (LTOT) was published in 2008 by the German Respiratory Society (DGP), while the British Thoracic Society (BTS) published their most recent guideline in 2015. Objectives: The aim of the present article was to highlight the major areas of consensus and disagreement in the recently published BTS and DGP guidelines on LTOT. Methods: The BTS and DGP guidelines were directly compared in terms of congruencies and differences. A critical appraisal was then performed and authors' suggestions were provided. Results: The 2 guidelines are almost congruent in 2 major areas, namely, (1) the indication criteria for LTOT in chronic obstructive pulmonary disease (COPD) patients at rest and (2) the recommended duration of LTOT over a 24-h period. However, 8 major areas in which the guidelines differ considerably were identified: (1) techniques for blood gas analysis; (2) timing of LTOT in stable patients; (3) LTOT in post-exacerbation COPD patients; (4) ambulatory oxygen therapy; (5) nocturnal oxygen therapy; (6) titration of oxygen flow rates; (7) follow-up visits; and (8) LTOT for patients who still smoke. Furthermore, the BTS guideline is much more detailed, includes more references (161 vs. 71) and is more up to date than the DGP guideline. Conclusion: There are major differences between the 2 guidelines. Many of the aspects raised by the BTS guideline appear to be reasonable with regard to the current literature, clinical experience and prescription practices. However, an international consensus on LTOT is lacking.

Our data therefore support PtcCO as a suitable means for monitoring PCO in patients undergoing invasive MV. This is in contrast to PetCO , which clearly underestimated PaCO , especially in patients with COPD.

BackgroundPatients who require a prolonged weaning process comprise a highly heterogeneous group of patients amongst whom the outcome differs significantly. The present study aimed to identify the factors that predict whether the outcome for prolonged weaning will be successful or unsuccessful.MethodsData from tracheotomised patients who underwent prolonged weaning on a specialised weaning unit were assessed retrospectively via an electronic and paper-bound patient chart. Factors for weaning success were analysed by univariate and multivariate analyses.ResultsOut of the 124 patients examined, 48.4% were successfully weaned (n = 60). Univariate analysis revealed that long-term home mechanical ventilation prior to current weaning episode; time between intubation and the first spontaneous breathing trial (SBT); time between intubation and the first SBT of less than 30 days; lower PaCO2 prior to, and at the end of, the first SBT; and lower pH values at the end of the first SBT were predictors for successful weaning. Following multivariate analysis, the absence of home mechanical ventilation prior to admission, a maximum time period of 30 days between intubation and the first SBT, and a non-hypercapnic PaCO2 value at the end of the first SBT were predictive of successful weaning.ConclusionsThe current analysis demonstrates that the evidence for respiratory insufficiency type II provided by clinical findings serves as a predictor of weaning failure.

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