How to treat COPD patients with home NIV:
best practices

Clinical trial data showthat higher inspiratory
pressures targeted
at reducing elevatedcarbon dioxide levels
contribute to thesuccess of home NIV
therapy.1,2,11

Improving elevatedarterial carbon
dioxide levels
should be one of themain goals of home
NIV.3

High-intensity
NIV does notappear to have anegative impact oncompliance, sleep
quality, or qualityof life.1,4,13

After careful selection of patientsmost likely to benefit from home NIV,
the next step is to deliver effective
therapy that is well tolerated.
Establishing adequate home NIV
ventilator settings and targets could
be important contributors to thesuccess of treatment,5 but the mostimportant factor when treating chronic
hypercapnic respiratory failure in COPD
is to ensure that treatment is delivered
to ameliorate nocturnal hypoventilationand improve daytime gas exchange.6
Earlier studies of home NIV used
moderate inspiratory positive airway
pressure (IPAP) levels of 12–14 cmH2O
and pressure support modes witha nasal mask but failed to show any
overall benefit of treatment.7-9

In contrast, two more recent studies
that used a different approach tohome NIV, with higher IPAP, pressurecontrolled ventilation or pressuresupport mode and a higher back-up
rate, reported significant improvements
in outcome and mortality with home
NIV.1,2 However, another study using
high intensity NIV did not show
significant improvements in patient
outcomes.10
This indicates that pressure alone is
not sufficient to ensure the successof home NIV. Careful selection ofpatients with persistent hypercapnia
and, in particular, effective reduction
in carbon dioxide levels during home
NIV therapy are also essential.11

Titration and monitoring
Interfaces used in published studies
of successful high-intensity NIV are
usually those that cover both the noseand mouth.11 Patient comfort is a key
factor in mask selection and plays
and important role in compliance withtherapy.
Home NIV is generally initiated andtitrated in hospital, with the goal oftitration being to control nocturnal
hypoventilation and reduce carbon
dioxide using a moderate to high IPAP
approach. However, rapidly evolving
telemedicine technology might allow

home initiation and follow-up of NIV.
Home initiation of NIV was just as goodas in-hospital NIV initiation in COPD
patients with chronic hypercapnic
respiratory failure.12High-intensity NIV with the higher
IPAP and back-up rate required toadequately reduce CO2 levels does notappear to have a negative impact oncompliance, sleep quality, or qualityof life.1,4,13 Nevertheless, evaluationof patient tolerance of IPAP and theback-up respiratory rate should beperformed during the titration process,and patients need to be given time toacclimatise to higher pressure settings.

1	Murphy P et al. Effect of Home Noninvasive Ventilation With Oxygen Therapy vs Oxygen Therapy Aloneon Hospital Readmission or Death After an Acute COPD Exacerbation. A Randomized Clinical Trial, JAMA.
Published online May 21, 2017. doi:10.1001/jama.2017.4451.
2	Köhnlein T, et al., Non-invasive positive pressure ventilation for the treatment of severe stable chronic
obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. Lancet Respir
Med 2014;2:698-705.
3	Nocturnal non-invasive positive pressure ventilation for COPD. Windisch W et al. Expert Rev Respir Med. 2015
Jun; 9(3):295-308.
4	Dreher M, et al. Noninvasive ventilation in COPD: impact of inspiratory pressure levels on sleep quality. Chest
2011;140:939-45.
5	Storres JH, et al. Home noninvasive ventilatory support for patients with chronic obstructive pulmonary
disease: patient selection and perspectives. Int J COPD 2018;13:753-60.
6	Murphy PB, Hart N. Home non-invasive ventilation for COPD: how, who and when? Arch Bronconeumol
2018;54:149-54.
7	Casanova et al. Long-term controlled trial of nocturnal nasal positive pressure ventilation in patients withsevere COPD. Chest 2000;118:1582-90.

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Overall though, long-term compliance
rates were 5.9–7.6 h/night.1,2,10
Careful monitoring is essential forpatients initiated on high-intensity
NIV. This could be facilitated bytelemedicine technology providing
ventilatory data, patient-ventilator
asynchrony, transcutaneous gas
measures and other relevant
parameters.

8	Clini et al. The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease
patients. Eur Respir J 2002;20:529-38.
9	McEvoy et al. Nocturnal non-invasive nasal ventilation in stable hypercapnic COPD: a randomised controlled
trial. Thorax 2009;64:561-6.
10	Struik FM, et al. Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after
ventilatory support for acute respiratory failure: a randomised, controlled, parallel-group study. Thorax
2014;69:826-34.
11	Storres JH, et al. Home noninvasive ventilatory support for patients with chronic obstructive pulmonary
disease: patient selection and perspectives. Int J COPD 2018;13:753-60.
12	Duiverman ML, Vonk JM, Bladder G, et alHome initiation of chronic non-invasive ventilation in COPD patientswith chronic hypercapnic respiratory failure: a randomised controlled trialThorax Published Online First: 04
September 2019. doi: 10.1136/thoraxjnl-2019-213303.
13	Dreher M, et al. High-intensity versus low-intensity non-invasive ventilation in patients with stable hypercapnic
COPD: a randomised crossover trial. Thorax 2010;65:303-8.

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