Home Mechanical Ventilation for COPD: High-Intensity Versus Target Volume Noninvasive Ventilation

Abstract

BACKGROUND: High-intensity noninvasive ventilation (HI-NIV) is the most effective means of improving several physiological and clinical parameters in subjects with chronic hypercapnic COPD. Whether the newer hybrid mode using target tidal volume noninvasive ventilation (target V T NIV) provides additional benefits remains unclear. METHODS: Subjects with COPD successfully established on long-term HI-NIV were switched to target V T NIV. Optimal target V T settings according to nocturnal transcutaneous P CO 2 measurements were achieved following a randomized crossover trial using 8 mL/kg ideal body weight and 110% of individual V T during HI-NIV, respectively. The following parameters were compared at the beginning of the trial while subjects were on HI-NIV, and after 3 months on optimal target V T NIV: sleep quality by polysomnography, overnight gas exchange, subjects' tolerance, overnight pneumotachygraphic measurements during NIV, healthrelated quality of life (severe respiratory insufficiency questionnaire), exercise capacity (6-min walk test), and lung function. RESULTS: Ten of 14 subjects completed the study. There were no differences between HI-NIV and target V T NIV in any of the above-mentioned parameters. Specifically, the mean overnight transcutaneous P CO 2 was equivalent under each form of ventilation (both 45 ؎ 5 mm Hg, P ‫؍‬ .75). CONCLUSIONS: Switching subjects from well-established HI-NIV to target V T NIV shows no clinical benefits in chronic hypercapnic COPD. In particular, sleep quality, the control of nocturnal hypoventilation, daytime hypercapnia, overnight ventilation patterns, subjects' tolerance, health-related quality of life, lung function, and exercise capability were all similar in subjects who underwent HI-NIV and target V T NIV. Nevertheless, target V T NIV might offer some physiological advantages in breathing pattern and might be beneficial in some individual patients. (German Clinical Trials Register [www.drks.de] Registration DRKS00000450.)

Hot Topics in Noninvasive Ventilation: Report of a Working Group at the International Symposium on Sleep-Disordered Breathing in Leuven, Belgium

“…Two other studies investigated target-volume versus pressure-preset NIV in subjects with chronic hypercapnic COPD. 158,160 In line with the results of the previous study, 159 control of daytime and nocturnal hypoventilation, HRQOL, lung function, and exercise capacity were similar between these 2 modes. 158,160 A possible explanation for the disparity between the earlier studies and the more recent ones may be that protocolized NIV titration was performed in one study, 158 and higher inspiratory pressures were applied in the pressure-preset groups.…”

“…158,160 In line with the results of the previous study, 159 control of daytime and nocturnal hypoventilation, HRQOL, lung function, and exercise capacity were similar between these 2 modes. 158,160 A possible explanation for the disparity between the earlier studies and the more recent ones may be that protocolized NIV titration was performed in one study, 158 and higher inspiratory pressures were applied in the pressure-preset groups. [158][159][160] In 2 recently published bench studies, the effect of unintentional leaks on target-volume ventilation was investigated under different conditions.…”

“…158,160 A possible explanation for the disparity between the earlier studies and the more recent ones may be that protocolized NIV titration was performed in one study, 158 and higher inspiratory pressures were applied in the pressure-preset groups. [158][159][160] In 2 recently published bench studies, the effect of unintentional leaks on target-volume ventilation was investigated under different conditions. In a study by Khirani et al, 161 single-limb circuits with intentional leaks estimated the expiratory target volume more accurately compared with single circuits with an expiratory valve or ventilators using a double circuit.…”

“…154,155,157 However, 3 more recent trials could not confirm this advantage (Table 3). [158][159][160] Murphy et al 159 reported comparable results regarding daytime P CO 2 , QOL, weight loss, and improvements in Epworth Sleepiness Scale scores after a 3-month RCT in subjects with obesity-hypoventilation syndrome. Importantly, in this trial, an individual adjustment of ventilator settings according to a predefined protocol with inclusion of a nocturnal assessment period and aiming to achieve optimum nocturnal respiratory control was applied.…”

Schlaf- und Lebensqualität in der außerklinischen Beatmung

“…Insbesondere bei einer Beatmung mit hohen Beatmungsdrücken ("high intensity non-invasive positive pressure ventilation", HI-NPPV) muss demnach auf eine Reduktion mögli-cher Leckagegeräusche geachtet werden. Dagegen ließ sich nachweisen, dass eine Erhöhung der Beatmungsdrücke per se nicht mit einer Verschlechterung der Schlafqualität einhergeht [14,15,48].…”