Current Practices in Home Mechanical Ventilation for Chronic Obstructive Pulmonary Disease: A Real-Life Cross-Sectional Multicentric Study

Abstract

Purpose Home mechanical ventilation (HMV) use in chronic obstructive pulmonary disease (COPD) is becoming increasingly widespread. The aim of this study was to provide an accurate description of the current practices and clinical characteristics of COPD patients on HMV in Portugal. Methods The study was designed as a cross-sectional, multicenter real-life study of COPD patients established on HMV for at least 30 days. Data related to clinical characteristics, adaptation and ventilatory settings were collected. Results The study included 569 COPD patients on HMV from 15 centers. The majority were male, with a median age of 72 years and a high prevalence of obesity (43.2%) and sleep apnea (45.8%). A high treatment compliance was observed (median 8h/day), 48.7% with inspiratory positive airway pressure ≥20 cmH 2 O and oronasal masks were the preferred interface (91.7%). There was an equal distribution of patients starting HMV during chronic stable condition and following an exacerbation. Patients in stable condition were initiated in the outpatient setting in 92.3%. Despite the differences in criteria and setting of adaptation and a slightly lower BMI in patients starting HMV following an exacerbation, we found no significant differences regarding age, gender, ventilation pressures, time on HMV, usage, severity of airflow obstruction or current arterial blood gas analysis (ABGs) in relation to patients adapted in stable condition. Conclusion Patients were highly compliant with the therapy. In agreement with most recent studies and recommendations, there seems to be a move towards higher ventilation pressures, increased use of oronasal masks and an intent to obtain normocapnia. This study shows that chronic hypercapnic and post exacerbation patients do not differ significantly regarding patient characteristics, physiological parameters or ventilatory settings with one exception: chronic hypercapnic patients are more often obese and, subsequently, more frequently present OSA.

Long-term health-related quality of life in patients on home mechanical ventilation

“…As a real-life study, patients are less selected than RCTs and that is evident on the clinical characteristics of COPD patients, as obesity and concurrent OSA were not exclusion criteria. The considerable prevalence of these two characteristics has been described in other large real-life studies [ 3 , 25 – 27 ].…”

Versorgungsqualität in der außerklinischen Beatmung

“…Im Rahmen einer retrospektiven Analyse konnte gezeigt werden, dass in über der Hälfte der Fälle keine stationäre Einleitung notwendig war. Auch wenn diese retrospektiven Daten keine Aussage über die Effektivität der Therapie bezogen auf die unterschiedlichen Sektoren zulassen, zeigen diese Studien zumindest, dass die ambulante Durchführung einer außerklinischen Beatmung für nicht invasiv-beatmete Patient:innen möglich ist [45] (▶ Abb. 3).…”

“…Beispiele aus anderen europäischen Ländern machen deutlich, dass sowohl die Initiierung als auch die Kontrolle der Beatmung durchaus ambulant erfolgen kann 44 45 48 49 51 , insbesondere wenn es sich um eine nicht-invasive Beatmung handelt. Der Vorteil ambulanter Strukturen liegt nicht nur in der Vermeidung risikoreicher und belastender Transporte sondern ermöglicht auch eine Behandlung im vertrauten Umfeld der Betroffenen.…”

Chronic hypercapnic respiratory failure and non-invasive ventilation in people with chronic obstructive pulmonary disease

“…Severe complications from domiciliary non-invasive ventilation have not been reported in clinical trials 28-30 33 or real world studies. [34][35][36] Non-invasive ventilation side effects included aerophagia, mask related pressure ulcers, mask intolerance, dry mouth, and shortness of breath on discontinuation of non-invasive ventilation. Overall, the side effects led to discontinuation in a minority of patients (<15%) in clinical trials.…”

“…In large surveys of practicing physicians, inability to wean in hospital non-invasive ventilation is a frequent reason for initiation at home 34 and nearly half of all patients begin non-invasive ventilation during or immediately after an exacerbation. 35 Similar concerns have prompted the Optimal Non-invasive ventilation Medicare Access Promotion (ONMAP) panel in the US to recommend leaving the timing of initiation to the physician's discretion. 52 However, titration in hospital can be associated with increased length of stay and costs.…”