Editorial
Guidelines for Chronic Non-invasive Ventilation in COPD: From Experience to Evidence
Guías para la ventilación crónica no invasiva en la EPOC: de la experiencia a la evidencia
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[ 0 => array:4 [ "nombre" => "Manel" "apellidos" => "Luján" "email" => array:1 [ 0 => "mlujan@tauli.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Begum" "apellidos" => "Ergan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Service of Pneumology, Hospital de Sabadell Corporació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red (CIBERES), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Pulmonary and Critical Care, Dokuz Eylul University, School of Medicine, Izmir, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guías para la ventilación crónica no invasiva en la EPOC: de la experiencia a la evidencia" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The indication of chronic non-invasive mechanical ventilation (NIV) in patients with chronic obstructive pulmonary disease (COPD) has been controversial for the past 30 years. Despite the lack of support from high quality controlled studies, the number of prescriptions for NIV in patients with COPD was growing progressively. A consensus based on experts criteria appeared in 1999<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> with an essentially regulatory purpose of the prescriptions. Few years later, the Eurovent study demonstrated how heterogeneous the prescription of NIV in COPD in different European countries was. While in Italy or Austria, the prescription percentage of chronic NIV in COPD reached 50%, in others remained around 10%.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Twenty years after the publication of the regulatory consensus, the number of prescriptions in COPD has continued to grow exponentially. The main reasons given by the clinicians for its use have been recurrent exacerbations or the impossibility of NIV withdrawal after a severe exacerbation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> On the other hand, the evidence, although still far from solid, has increased considerably after the publication of some (few) high quality (but complex), controlled studies. The complexity of such studies to be performed can be summarized as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0015" class="elsevierStylePara elsevierViewall">The primary main of the studies, that not always had been focussed to either exacerbation or hospitalizations</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">The duration of follow-up: it is not uncommon to find studies with a duration greater than five years, including recruitment and follow-up period.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5</span></a> Otherwise, a long duration is completely necessary if you look at mortality. Under these conditions, the economic burden can be really high. Some recent studies, however, used composite endpoints (mortality or time until the next exacerbation) that have significantly shortened the follow-up period.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6,7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">Inclusion criteria: traditionally, hypercapnia in the stability phase was the main inclusion criterion, since it was considered a marker of severity and short or medium-term mortality after the hypoxemia has been corrected. But the PaCO<span class="elsevierStyleInf">2</span> threshold for initiating NIV has also been a matter of controversy. Studies including patients with PaCO<span class="elsevierStyleInf">2</span> values farther from normal have shown greater differences between the arms of the study (NIV vs conventional therapy). Thus, in a situation of stability, it seems reasonable to recommend a threshold value around 50<span class="elsevierStyleHsp" style=""></span>mm Hg to consider NIV therapy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> It is also especially important to rule out other factors that may contribute to the development of hypercapnia, such as the coexistence of apnea–hypopnea syndrome (overlap syndrome). More recent controlled studies used a different approach, including patients with persisting hypercapnia after an exacerbation that needed NIV in the acute phase. Similarly to severe hypercapnia in the stable phase, this phenotype identifies a particularly fragile population with a reduced ventilatory reserve. The fact of having received and tolerated NIV in the acute phase can even reduce the difficulties in the shift to the chronic use. However, a key point of this design is the appropriateness of the time frame to define the persistence of post-exacerbation hypercapnia. The experience of the Rescue study<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> showed that if too short periods of time are used (around 48<span class="elsevierStyleHsp" style=""></span>h of NIV withdrawal in the acute phase), many patients tend to normalize their PaCO<span class="elsevierStyleInf">2</span> spontaneously. For this reason, the use of a time frame between 2 and 4 weeks<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5,7</span></a> seems more appropriate to exclude patients with spontaneous normalization of PaCO<span class="elsevierStyleInf">2</span>, thus avoiding an over-prescription of NIV after an exacerbation.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">The experience of recruiting centers and the procedure of the therapy: Whether stable or post exacerbated patients are included, the required sample needs clearly a multicenter approach. The heterogeneity in the experience of recruiting centers requires a strict protocol on how to carry out and control the therapy. In this regard, monitoring of PaCO<span class="elsevierStyleInf">2</span> during adaptation and follow up and adjustment of parameters based on these results should be mandatory. A recent meta-analysis has already suggested that the use of high pressure support values (high intensity ventilation), with the aim to decrease PaCO<span class="elsevierStyleInf">2</span> significantly (at least 20%) was associated with better outcomes.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> As a consequence, more recent studies used pressure support values much higher than their predecessors.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5,7,10</span></a> Finally, it is also necessary to take into account the growing interest in automatic modes (volume assured pressure support or automatic expiratory pressure modes). Theoretically these modes are able to adapt to changes in ventilatory pattern or coexistence of upper airway obstructions during the use of therapy.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Assessment of patient centered outcomes: Patient centered outcomes such as dyspnea, health-related quality of life and sleep quality are critically important for the effectiveness of NIV. However, the assessment methods varied widely across studies ending up with heterogenous results.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5,10</span></a> The impact of NIV on sleep is still uncertain as sleep quality has been studied to a lesser extent with different methods which were mostly subjective. Ideally, we need to use validated and specific tools to measure the effect of NIV in these critically important outcomes in COPD patients with chronic respiratory failure.</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">The recently published guidelines on Long term Home Non-Invasive Ventilation for Management of COPD by the European Respiratory Society<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> have tried to cover all these aspects. The content is structured around 4 main PICO questions, suggesting the use of NIV in chronic stable hypercapnic COPD patients and in patients with COPD following a life-threatening episode of acute hypercapnic respiratory failure requiring acute NIV, if hypercapnia persists following the episode. At same time, the target of the procedure should be directed to the normalization or reduction of PaCO<span class="elsevierStyleInf">2</span> values using fixed pressure support mode as a first choice instead of more complex volume-assured modes. Attention has also been given to some questions (narrative) with less evidence in the literature. These questions provide an additional insight into the complexity of the procedure (phenotypic differences such as the presence of comorbidities, heterogeneity in the use of interfaces or even in ventilator models) and, at same time, are focused on important issues for the research in the immediate future, such as the appropriate way of monitoring these patients. Although PaCO<span class="elsevierStyleInf">2</span> monitoring (daytime and overnight continuous by transcutaneous CO<span class="elsevierStyleInf">2</span> sensors) is the recommended way to follow-up patients under NIV, it may lack specificity to determine the ultimate cause of suboptimal ventilation. Therefore, centers with more experience use routinely some advanced monitoring tools, such as polygraphy under NIV or information transfer from the built in software of the ventilators. The influence on outcome of persisting events or asynchronies during ventilation in COPD, classified based on the consensus of experts<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">11,12</span></a> remains to date unclear.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally, although the clinicians using the above guidelines may feel uncomfortable about the low level of evidence of the recommendations, we believe that this only emphasizes on the complexity of their implementation in the daily clinical practice. It should be compulsory that their clinical application is accompanied by high levels of technical and clinical skills and continuous medical education. Ultimately, and as experience was the forerunner of the evidence, the clinical application of evidence requires high levels of experience and expertise.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD, and nocturnal hypoventilation – a consensus conference report" ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.116.2.521" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1999" "volumen" => "116" "paginaInicial" => "521" "paginaFinal" => "534" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10453883" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0070" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 0 | 7 |
| 2024 October | 43 | 31 | 74 |
| 2024 September | 83 | 30 | 113 |
| 2024 August | 58 | 36 | 94 |
| 2024 July | 58 | 25 | 83 |
| 2024 June | 61 | 18 | 79 |
| 2024 May | 93 | 23 | 116 |
| 2024 April | 47 | 21 | 68 |
| 2024 March | 41 | 23 | 64 |
| 2024 February | 38 | 19 | 57 |
| 2024 January | 42 | 23 | 65 |
| 2023 December | 35 | 25 | 60 |
| 2023 November | 72 | 24 | 96 |
| 2023 October | 111 | 68 | 179 |
| 2023 September | 71 | 51 | 122 |
| 2023 August | 56 | 38 | 94 |
| 2023 July | 71 | 31 | 102 |
| 2023 June | 77 | 27 | 104 |
| 2023 May | 68 | 26 | 94 |
| 2023 April | 65 | 27 | 92 |
| 2023 March | 96 | 51 | 147 |
| 2023 February | 79 | 29 | 108 |
| 2023 January | 60 | 31 | 91 |
| 2022 December | 103 | 39 | 142 |
| 2022 November | 93 | 30 | 123 |
| 2022 October | 79 | 53 | 132 |
| 2022 September | 56 | 39 | 95 |
| 2022 August | 69 | 39 | 108 |
| 2022 July | 57 | 35 | 92 |
| 2022 June | 29 | 23 | 52 |
| 2022 May | 58 | 35 | 93 |
| 2022 April | 44 | 24 | 68 |
| 2022 March | 30 | 39 | 69 |
| 2022 February | 19 | 18 | 37 |
| 2021 September | 0 | 1 | 1 |
| 2021 August | 1 | 2 | 3 |
| 2021 April | 4 | 6 | 10 |
| 2021 March | 2 | 0 | 2 |
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