This document discusses the use of noninvasive ventilation (NIV) in patients with chronic obstructive pulmonary disease (COPD). It finds that NIV is the standard of care for COPD patients experiencing acute respiratory failure during acute exacerbations, as it can reduce mortality and morbidity. For stable COPD patients with persistent hypercapnia after an exacerbation, adding NIV to supplemental oxygen may prolong the time to readmission or death compared to oxygen alone. NIV may also provide benefits for some stable COPD patients with hypercapnia or who have both COPD and obstructive sleep apnea.

1. Noninvasive Ventilation in COPD:
From Acute to Chronic
Wei-Chih Chen, MD
Department of Chest Medicine, Taipei Veterans General Hospital
Institute of Emergency and Critical Care Medicine, National Yang-Ming University

2. Ventilatory support
2
Stable AE
GOLD 2019

3. Role of NIV in AECOPD
AECOPD + acute respiratory failure
NIPPV
Standard of care in hospitalized patients
Mortality↓
Morbidity↓
3GOLD 2019

4. Indications for
non-invasive ventilation (NIV)
At least one of the following:
• Respiratory acidosis (arterial pH ≤
7.35 and/or PaCO2 ≥ 45mmHg)
• Severe dyspnea with clinical signs
suggestive of respiratory muscle
fatigue, increased work of breathing,
or both, such as use of respiratory
accessory muscles, paradoxical
motion of the abdomen, or
retraction of the intercostal spaces
Evidence to support use of NIV
Strong evidence
• COPD with acute exacerbations
• Acute cardiogenic pulmonary edema
(using CPAP)
• Immunocompromised patients
Less strong evidence
• Asthma
• Community-acquired pneumonia (COPD
patients)
• Post-operative respiratory failure
• Facilitation of weaning in COPD patients
• Avoidance of extubation failure
• Do-not-intubate patients
4
© 2019 Global Initiative for Chronic Obstructive Lung Disease
Slutsky AS, Mechanical ventilation, Springer, 2005

5. Indications for invasive mechanical ventilation
Pulmonary
• Respiratory arrest
• Respiratory pauses with loss of consciousness or gasping for air
• Life-threatening hypoxemia in patients unable to tolerate non-invasive ventilation (NIV)
• Massive aspiration
• Persistent inability to remove respiratory secretions
• Unable to tolerate NIV or NIV failure
Cardiovascular
• Cardiac arrest
• Severe ventricular arrhythmias
• Severe hemodynamic instability without response to fluids and vasoactive drugs
• Heart rate < 50/min with loss of alertness
Neurologic
• Diminished consciousness, psychomotor agitation inadequately controlled by sedation
5© 2019 Global Initiative for Chronic Obstructive Lung Disease

6. General aspect of mechanical ventilation
• Oxygenation
FiO2
PEEP
• Ventilation
Tidal volume, respiratory rate
Minute ventilation
• Monitoring and alarm system
6

7. Target
• Keep pH > 7.3
PaCO2 < 50 mmHg
PaO2 > 55 mmHg, SpO2 > 88%
• To decrease work of breathing
• Lung protection
Keep plateau pressure < 30 cmH2O
7

8. NIPPV in AECOPD – Respiratory rate
8BMJ 2003;326:185

9. NIPPV in AECOPD – Mortality
9
BMJ 2003;326:185

10. NIPPV in AECOPD – Risk of intubation
10BMJ 2003;326:185

11. NIPPV in AECOPD – Treatment failure
11
BMJ 2003;326:185

12. 12
BMJ 2003;326:185

13. 13
HCUP-NIS
Database
In AECOPD
8% Need MV
5% Initial IMV
3% Initial NIV
In NIV
4.6% Transition
To IMV
Am J Respir Crit Care Med.
2012;185(2):152-9.

14. 14
NIV and AECOPD
outcomes
Mortality↓
HAP↓
Length of stay↓
Cost↓
Readmission -
Premier Inpatient Database
2008 - 2011
JAMA Intern Med. 2014;
174(12):1982-1993.

15. Role of NIV in stable COPD
COPD + Obstructive sleep apnea
CPAP
Survival↑
Hospital admission↓
15GOLD 2019

16. 16
Prospective cohort study
Heart failure, myocardial
infarction, stroke excluded
Median follow-up 9.4 years
Am J Respir Crit Care Med 2010; 182: 325–331

17. 17

18. 18
Am J Respir Crit Care Med 2010; 182: 325–331

19. Role of NIV in stable COPD
After discharge post AECOPD
NIPPV
Undetermined
Time to readmission or death within 12
months↑ in persistent hypercapnia
Survival↑ (?)
19GOLD 2019

20. 20
ERJ 2007;30: 293-306

21. 21
RCT Non-RCT
PaO2
PaCO2
ERJ 2007;30: 293-306

22. NIV in stable hypercapnic COPD
22
Int J COPD.
2017;12:2977-2985.

23. NIV in stable hypercapnic COPD
23Int J COPD. 2017;12:2977-2985.

24. 24
JAMA. 2017;317(21):2177-2186.

25. •The population studied: patients with persistent
hypercapnia (PaCO2 >53 mm Hg) 2 weeks to 4
weeks after resolution of respiratory acidemia
•The intervention given: NIV + O2
•The comparator given: O2 alone
•The outcomes considered: Time to readmission or
death within 12 months
•Exclusion: BMI >35, OSAS, other RF
25
PICOJAMA. 2017;317(21):2177-2186.

26. 26
VPAP IIISTa Harmony 2
Interface: nasal, oronasal, or total face masks
By patients’ preference
JAMA. 2017;317(21):2177-2186.

27. 27
JAMA. 2017;317(21):2177-2186.

28. 28
JAMA. 2017;317(21):2177-2186.

29. Median home NIV usage per night
29
JAMA. 2017;317(21):2177-2186.

30. 30
JAMA. 2017;317(21):2177-2186.

31. 31
JAMA. 2017;
317(21):2177-2186.

32. NIV in COPD
32
COPD + OSA: Beneficial
Hypercapnic: Might be
beneficial in selected patients
AE + ARF: Standard

33. 陳威志醫師
臺北榮總胸腔部
陽明大學醫學系暨急重症醫學研究所
wiji.chen@gmail.com