Late presentation of acute hypercapnic respiratory failure carries a high mortality risk in COPD patients treated with ward-based NIV

Trethewey, Samuel P; Edgar, Ross; Morlet, Julien; Mukherjee, Rahul; Turner, Alice

doi:10.1016/j.rmed.2019.04.013

Cited by 7 publications

(10 citation statements)

References 27 publications

(28 reference statements)

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“…Age was also an important predictor of in-hospital mortality in non-COPD AHRF patients treated with NIV. This is consistent with studies done on AHRF due to COPD [ 14 , 23 ] and AHRF unrelated to COPD [ 20 ]. It was expected that an association between age and mortality would be found since age is not necessarily a limitation to the treatment and, in general, older age is associated with worse prognosis.…”

Section: Discussionsupporting

confidence: 93%

“…The British Thoracic Society ‘Quality Standards for Acute NIV in Adults' notes that “Patients who meet evidence‐based criteria for acute NIV should start NIV within 60 minutes of the blood gas result associated with the clinical decision to provide NIV and within 120 minutes of hospital arrival for patients who present acutely” [ 24 ]. This is because delays in treatment have been associated with reduced survival; however, it is also notable that some patients with COPD deteriorate late, and these also represent a poor prognostic group [ 23 ]. A longer wait for NIV application could result in high numbers of emergency hospital admissions, poor NIV capacity, or inadequate clarity within the hospital's NIV pathway.…”

Section: Discussionmentioning

confidence: 99%

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Ward-Based Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure Unrelated to Chronic Obstructive Pulmonary Disease

Faqihi

Parekh

Trethewey

et al. 2021

Canadian Respiratory Journal

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Background. The use of ward-based noninvasive ventilation (NIV) for acute hypercapnic respiratory failure (AHRF) unrelated to chronic obstructive pulmonary disease (COPD) remains controversial. This study evaluated the outcomes and failure rates associated with NIV application in the ward-based setting for patients with AHRF unrelated to COPD. Methods. A multicentre, retrospective cohort study of patients with AHRF unrelated to COPD was conducted. COPD was not the main reason for hospital admission, treated with ward-based NIV between February 2004 and December 2018. All AHRF patients were eligible; exclusion criteria comprised COPD patients, age < 18 years, pre-NIV pH < 7.35, or a lack of pre-NIV blood gas. In-hospital mortality was the primary outcome; univariable and multivariable models were constructed. The obesity-related AHRF group included patients with AHRF due to obesity hypoventilation syndrome (OHS), and the non-obesity-related AHRF group included patients with AHRF due to pneumonia, bronchiectasis, neuromuscular disease, or fluid overload. Results. In total, 479 patients were included in the analysis; 80.2% of patients survived to hospital discharge. Obesity-related AHRF was the indication for NIV in 39.2% of all episodes and was the aetiology with the highest rate of survival to hospital discharge (93.1%). In the multivariable analysis, factors associated with a higher risk of in-hospital mortality were increased age (odds ratio, 95% CI: 1.034, 1.017–1.051, P < 0.001 ) and pneumonia on admission (5.313, 2.326–12.131, P < 0.001 ). In the obesity-related AHRF group, pre-NIV pH < 7.15 was associated with significantly increased in-hospital mortality (7.800, 1.843–33.013, P = 0.005 ); however, a pre-NIV pH 7.15–7.25 was not associated with increased in-hospital mortality (2.035, 0.523–7.915, P = 0.305 ). Conclusion. Pre-NIV pH and age have been identified as important predictors of surviving ward-based NIV treatment. Moreover, these data support the use of NIV in ward-based settings for obesity-related AHRF patients with pre-NIV pH thresholds down to 7.15. However, future controlled trials are required to confirm the effectiveness of NIV use outside critical care settings for obesity-related AHRF.

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Ward-Based Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure Unrelated to Chronic Obstructive Pulmonary Disease

Faqihi

Parekh

Trethewey

et al. 2021

Canadian Respiratory Journal

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“…Furthermore, even though mean PaCO 2 was slightly higher in the OSAHS group (5.68 vs 5.4), it did not reach statistical significance; this implies that identifying OSAHS in COPD patients would require widespread screening, since the CO 2 would be an insufficiently sensitive distinguishing feature to adopt as a case finding approach. Such patients also appeared to have delayed weaning from acute NIV, although this was also not significant in multivariate analysis due to the small differences in ventilation duration driven by strict protocols for weaning in our unit [26] which may have limited our ability to detect any relationship. e value of routine sleep studies in the non-AHRF population was questionable given that significant problems occurred in only 15% of patients.…”

Section: Which Copd Patients Should Have a Sleep Study?mentioning

confidence: 85%

Development and Relevance of Hypercapnia in COPD

Dave

Wharton

Mukherjee

et al. 2021

Canadian Respiratory Journal

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Background. Identification of patients who may become hypercapnic, or develop acidotic hypercapnic respiratory failure (AHRF), is important in chronic obstructive pulmonary disease (COPD) to avoid hospital admission and select patients for use of home NIV. This study aimed to identify factors associated with presence and development of hypercapnia. Methods. 1224 patients, 637 with COPD and 587 with alpha 1 antitrypsin deficiency (AATD), from 4 previously established patient cohorts, were included in cross-sectional analyses of hypercapnia (PaCO2 ≥ 6.5 kPa or 48.8 mmHg), focusing on phenotypic features of COPD and mortality. Longitudinal associations of rising PaCO2 were also assessed. A second cohort of 160 COPD patients underwent sleep studies and 1-year follow-up, analysing in a similar way, incorporating additional information from their sleep studies if appropriate. Results. Hypercapnia was 15 times more common in usual COPD than AATD ( p < 0.01 ) after adjustment for baseline differences by regression. Independent predictors of hypercapnia in COPD included FEV1 and current use of oxygen; these variables, together with lack of emphysema, explained 11% of variance in CO2. Increasing PaCO2 also associated with higher risk of death ( p = 0.03 ). 44/160 patients exhibited sleep disordered breathing. The sleep study cohort also showed an association of low FEV1 with hypercapnia. Prior hospital admission for AHRF was also clinically significant, being a feature of almost double the number of hypercapnic patients in both test and sleep study COPD cohorts. Conclusion. Lower FEV1 and prior AHRF are the main associations of hypercapnia in COPD, which carries a poor prognosis, particularly worsening over time.

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“…After the YONIV trial, evidence of the safety of ward-based NIV started to emerge [17][18][19][20][21][22][23][24][25][26] and the technique is now widely used, especially in limitedresource settings [27]. A recent observational noninferiority study by Parker et al compared three models of NIV care for patients with COPD exacerbation: general ward with 1:4 nurse to patient ratio, thriceweekly consultant ward round, a high dependency unit with 1:2 nurse to patient ratio, twice daily ward rounds and an ICU with 1:1 nurse to patient ratio, twice daily ward rounds.…”

Section: Copd Exacerbationmentioning

confidence: 99%

“…The key steps for a successful ward-based NIV trial for COPD exacerbations are early recognition [25], frequent arterial blood gas monitoring in the first hours after ventilation onset [26], frequent circuit leak checks [24] and proper staff training [21]. Dres et al found that improvement in staff training and experience leads to an increasing number of NIV-treated patients and is associated with better outcomes [21].…”

Section: Copd Exacerbationmentioning

confidence: 99%

Non-Invasive Ventilation in a Non-Standard Setting – Is it Safe to Ventilate Outside the ICU?

Boyadzhieva

Kovacheva

Bektashev

et al. 2020

Acta Medica Bulgarica

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Non-invasive ventilation (NIV) is considered a fundamental method in treating patients with various disorders, requiring respiratory support. Often the lack of beds in the intensive care unit (ICU) and the concomitant medical conditions, which refer patients as unsuitable for aggressive treatment in the ICU, highlight the need of NIV application in general non-monitored wards and unusual settings – most commonly emergency departments, high-dependency units, pulmonary wards, and even ambulances. Recent studies suggest faster improvement of all physiological variables, reduced intubation rates, postoperative pulmonary complications and hospital mortality with better outcome and quality of life by early well-monitored ward-based NIV compared to standard medical therapy in patients with exacerbation of a chronic obstructive pulmonary disease, after a surgical procedure or acute hypoxemic respiratory failure in hematologic malignancies. NIV is a ceiling of treatment and a comfort measure in many patients with do-not-intubate orders due to terminal illnesses. NIV is beneficial only by proper administration with appropriate monitoring and screening for early NIV failure. Successful NIV application in a ward requires a well-equipped area and adequately trained multidisciplinary team. It could be initiated not only by attending physicians, respiratory technicians, and nurses but also by medical emergency teams. Ward-based NIV is supposed to be more cost-effective than NIV in the ICU, but further investigation is required to establish the safety and efficacy in hospital wards with a low nurse to patient ratio.

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Late presentation of acute hypercapnic respiratory failure carries a high mortality risk in COPD patients treated with ward-based NIV

Cited by 7 publications

References 27 publications

Ward-Based Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure Unrelated to Chronic Obstructive Pulmonary Disease

Ward-Based Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure Unrelated to Chronic Obstructive Pulmonary Disease

Development and Relevance of Hypercapnia in COPD

Non-Invasive Ventilation in a Non-Standard Setting – Is it Safe to Ventilate Outside the ICU?

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