High‐pressure non‐invasive ventilation during exercise in COPD patients with chronic hypercapnic respiratory failure: A randomized, controlled, cross‐over trial

Abstract

Background and objective Patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnic respiratory failure (CHRF) characteristically have exercise intolerance and limitations in performing conventional training. Therefore, the aim of this study was to investigate the acute effects of non‐invasive ventilation (NIV) as a supportive tool during exercise in CHRF. Methods Two cycle endurance tests (CET) at 60% of the peak work rate were performed. Patients were randomly assigned to cycle in two conditions: (i) high‐pressure NIV (mean inspiratory positive airway pressure: 27 ± 3 cm H2O) along with oxygen supplementation or (ii) control: oxygen‐use only. Transcutaneously measured partial pressure of carbon dioxide (TcPCO2), oxygen saturation and heart rate were continuously recorded. Muscle oxygen availability of intercostal and vastus lateralis muscle was measured during exercise by near‐infrared spectroscopy (NIRS). Results A total of 20 patients with CHRF (forced expiratory volume in 1 s (FEV1): 19 ± 4% predicted, partial pressure of oxygen (PaO2): 55 ± 9 mm Hg, partial pressure of carbon dioxide (PaCO2): 51 ± 7 mm Hg) were recruited in a randomized cross‐over trial. On NIV, COPD patients increased cycle endurance time by 39% compared to oxygen‐use only (663 ± 360 vs 477 ± 249 s, P = 0.013). On NIV, TcPCO2 was significantly lower at rest (44.9 ± 6.2 vs 50.7 ± 6.6 mm Hg, P < 0.001) and at isotime (50.0 ± 5.5 vs 56.1 ± 6.2 mm Hg, P < 0.001). Oxygen availability in the intercostal muscles remained relatively constant with NIV compared to oxygen‐use only. Although patients cycled longer using NIV, a lower increase in exertional dyspnoea at the end of CET (median increase in Borg‐dyspnoea: 2 vs 4, P = 0.003) was reported. Conclusion NIV with high pressures as add‐on to oxygen supplementation increases cycle endurance time, mitigates exertional dyspnoea and limits exercise‐induced hypercapnia in COPD patients with CHRF.

Contemporary Concise Review 2019: Chronic obstructive pulmonary disease

“…The study by Gloeckl et al . provides new hope for these patients . Using a randomized cross‐over trial design, these investigators found that the use of NIMV in these COPD patients with stable hypercapnic respiratory failure led to a 39% increase in endurance time on a cycle ergometer than oxygen therapy alone with lower arterial PaCO 2 and better oxygenation.…”

Pulmonary rehabilitation, physical activity, respiratory failure and palliative respiratory care

“…Furthermore, we need to study the effects of interventions combining traditional PR and palliative care with innovative medical treatments for patients with different but advanced chronic respiratory diseases. Such interventions may include the addition of high-flow oxygen therapy for patients with severe exercise-induced desaturation,97 non-invasive ventilation for patients with pronounced hyperinflation and/or hypercapnia,98 endobronchial interventions for patients with severe emphysema99 100 and biologicals for patients with severe obstructive lung diseases 101. Finally, we should aim for (combined) therapies that are supportive for the patient to take the responsibility as specialists of their own lives: patients must become co-creators of value care 102…”

Pressuring stable patients with hypercapnic COPD to exercise

“…In a recent publication in Respirology , Gloeckl et al . reported on the acute effects of NIV during cycling exercise in 20 patients with severe COPD and daytime hypercapnia.…”

“…This finding is in keeping with a previous study using a high‐pressure ventilation strategy during ground walking in a similar group of COPD patients established on home bi‐level therapy showing improvements in oxygenation, dyspnoea and walking distance compared to oxygen therapy alone . It is important to note that, in the study by Gloeckl et al ., a highly select group of patients were enrolled, all of whom were very well acclimated to high inspiratory pressures, having used home NIV for a mean duration of 18 months. In addition, haemodynamic compromise with high‐pressure NIV is possible due to reduced venous return from high intra‐thoracic pressures .…”

“…It is important to note that, in the study by Gloeckl et al ., a highly select group of patients were enrolled, all of whom were very well acclimated to high inspiratory pressures, having used home NIV for a mean duration of 18 months. In addition, haemodynamic compromise with high‐pressure NIV is possible due to reduced venous return from high intra‐thoracic pressures . These factors may affect the generalizability of results to NIV‐naïve individuals or those with compromised cardiac performance.…”