Non-Invasive Ventilation as an Adjunct to Exercise Training in Chronic Ventilatory Failure: A Narrative Review

Abstract

Background: Chronic ventilatory failure (CVF) may be associated with reduced exercise capacity. Long-term non-invasive ventilation (NIV) may reduce patients’ symptoms, improve health-related quality of life and reduce mortality and hospitalisations. There is an increasing use of NIV during exercise training with the purpose to train patients at intensity levels higher than allowed by their pathophysiological conditions. Objective: This narrative review describes the possibility to train patients with CVF and NIV use as a tool to increase the benefits of exercise training. Methods: We searched papers published between 1985 and 2018 in (or with the summary in) English language in PubMed and Scopus databases using the keywords “chronic respiratory failure AND exercise,” “non invasive ventilation AND exercise,” “pulmonary rehabilitation” and “exercise training.” Results: Exercise training is feasible and effective also in patients with CVF. Assisted ventilation can improve exercise tolerance in different clinical conditions. In patients under long-term home ventilatory support, NIV administered also during walking results in improved oxygenation, decreased dyspnoea and increased walking distance. Continuous positive airway pressure and different modalities of assisted ventilation have been delivered through different interfaces during exercise training programmes. Patients with CVF on long-term NIV may benefit from exercising with the same ventilators, interfaces and settings as used at home. Conclusion: We need more randomised clinical trials to investigate the effects of NIV on exercise training in patients with CVF and define organisation and setting.

NIV Is not Adequate for High Intensity Endurance Exercise in COPD

“…However, it was within the ranges of those used in studies that found that NIV improved endurance capacity [19,20] and matched with the level of pressure support titrated to comfort used in Anekwe et al [13]. Based on the available evidence, we included patients with severe obstruction and ventilatory limitation [7,8,38] and did not include those patients who were eligible to home NIV to prevent bias relating to experience. However, although the NIV was initiated at rest and then titrated during exercise, in laboratory conditions and by a physiotherapist experienced in NIV, it is possible that the patients were insufficiently acclimatized to the NIV.…”

“…Nighttime NIV accompanying daytime PR has been suggested for these patients to improve general fatigue, gas exchanges and the benefits of PR [5,6]. In the context of a training session during PR, NIV has initially been studied during exercise, whether hypercapnia is present or not, as suggested by a recent systematic review [7] and an expert review [8]. The rationale for using NIV during exercise is based on physiologic studies supporting high intensity training [8,9].…”

“…In the context of a training session during PR, NIV has initially been studied during exercise, whether hypercapnia is present or not, as suggested by a recent systematic review [7] and an expert review [8]. The rationale for using NIV during exercise is based on physiologic studies supporting high intensity training [8,9]. As this might not be tolerable for most not hypercapnic patients [9], NIV is thought to relieve the work of breathing [10] and dyspnea [11].…”

“…The choice of the interface is of real concern because the high level of ventilation during exercise necessitates breathing through the mouth, which in turn may elicit important leaks and patient-ventilatory asynchrony that would compromise exercise capacity, therefore requiring an ONM. On the other hand, ONM is usually perceived as less comfortable than NM and could reduce the compliance [8].…”

Organizational aspects of pulmonary rehabilitation in chronic respiratory diseases

“…a home‐based walking programme) seems acceptable for patients with a mild degree of complexity. However, for patients with hypercapnia, hypoxaemia, very severe dyspnoea and/or recently hospitalized/frail patients, this approach seems to ignore many available possibilities, including but not limited to exercise training (on a stationary bicycle or treadmill, to really target and monitor the optimal training intensity) combined with non‐invasive ventilation with or without oxygen supplements; neuromuscular electrical stimulation for severely dyspnoeic and weakened patients; whole‐body vibration; resistance training using adequate apparatus; etc.…”