S115 Hot-hmv uk trial secondary outcome analysis: early readmission is reduced by the addition of home mechanical ventilation to home oxygen therapy in copd patients with chronic respiratory failure following a life-threatening exacerbation

Abstract

IntroductionHospital readmission following treatment for a life-threatening exacerbation of COPD with acute NIV is frequent and associated with an adverse impact in terms of lung function and health related quality of life. They have been identified as a priority area in the NHS with financial penalties for any patient readmitted within 28 days following discharge.MethodA multicentre open labelled randomised controlled trial recruited patients with persistent hypercapnia (PaCO2 > 7 kPa) 2–4 weeks following resolution of acute acidosis. Patients were randomised to either home oxygen therapy (HOT) or HOT and home mechanical ventilation (HOT-HMV). HMV was titrated overnight to control nocturnal hypercapnia. Follow up was for 12 months. The primary outcome, 12-month admission free survival, has been reported previously demonstrating a significant treatment effect (ERS 2016). Secondary outcome analysis included 28-day all-cause hospital readmission and 12 month exacerbation rate.Results116 patients were randomised (HOT = 59, HOT-HMV = 57), age 67 ± 10 years, FEV1 0.6 ± 0.2 L, PaCO2 7.9 ± 0.9 kPa. 28-day readmission was 22 (37%) in the HOT and 7 (12%) in the HOT-HMV arm (unadjusted HR 0.27, 0.12 to 0.63, p = 0.003; adjusted HR 0.26, 0.11 to 0.61, p = 0.002) (Figure 1). 12 month exacerbation rate was reduced from median 5 (1 to 9) per year in the HOT arm to 4 (2to 6) in the HOT-HMV arm (unadjusted HR 0.64 (0.44 to 0.94); p = 0.022; adjusted HR 0.66, 0.46 to 0.95, p = 0.026).ConclusionThe addition of HMV to HOT in patients with persistent hypercapnia following an acute life-threatening exacerbation of COPD reduces both 28-day readmission and 12 month exacerbation frequency. These data strongly support a change in clinical practice in the management of patients with severe COPD and persistent hypercapnia.Abstract S115 Figure 1Time to hospital re-admission by treatment arm

AJRCCM: 100-Year Anniversary.Homeward Bound: A Centenary of Home Mechanical Ventilation

“…This trend may continue in the future with the use of ventilators with more sophisticated modes designed to deliver a preset volume within physician prescribed pressure limits; such devices have been evaluated in acute COPD 60 , obesity 61 and mixed patient populations 62 Hence it seems that patients most likely to benefit from NIV are those who require NIV for an inpatient hypercapnic COPD exacerbation and who remain hypercapnic while convalescent 65 . Going forward it is well established that physical frailty is a good marker of the likelihood of readmission 66;67 , and it may be that patient selection for future trial could also profit by including a measure of physical function and/or combining NIV with a rehabilitation program 68 .…”

Review of the British Thoracic Society Winter Meeting 2016, 7–9 December, London, UK

“…In a randomised study likely to change clinical practice, Murphy et al 66 found that patients with persistent hypercapnia (PaCO 2 >7 kPa) following discharge treated with combined HMV/HOT had fewer 28-day re-admissions and a significant reduction in 12-month exacerbation rate compared with HOT alone. Dr Morris (Manchester) reviewed end-of-life planning in relation to community oxygen prescribing, and found that although median survival was low at around 6 months, only 33% had discussed a DNACPR (‘Do not attempt cardiopulmonary Resuscitation’) decision prior to death 67.…”