Who and when:selecting patients for home NIV
Patients recoveringfrom acute respiratory
failure associated with anexacerbation of COPD shouldbe evaluated at 2–4 weeks
after resolution of respiratory
acidosis, and those withpersistent hypercapnia should
be given home NIV.1

Stable COPD
patients withchronic hypercapnic
respiratory failure
also benefit fromhome NIV.2

Differences in thetiming of home
NIV initiation might
explain different
outcomes between
studies.1,3There is now a significant body ofevidence to support home noninvasive ventilation (NIV) as aneffective strategy for the managementof patients with advanced severe
chronic obstructive pulmonary disease(COPD) and chronic hypercapnic
respiratory failure, including those who
remain persistently hypercapnic after
recovering from an acute exacerbation
episode.1,2
When considering the results of recent
clinical trials, it is important to carefully
evaluate the patient phenotype, and thetiming and delivery of NIV to ensurethat home NIV is provided to patientsmost likely to benefit from therapy.4
The HOT-HMV trial enrolled patients
who had persistent hypercapnia at least
2 weeks after an acute exacerbationof COPD and showed a significant
improvement in time to death or first
readmission after 1 year of home NIV +home oxygen therapy (HOT) comparedwith HOT alone.1

In contrast, when home NIV
was initiated early after an acuteexacerbation, improvements in
PaCO2 were similar in the NIV andcontrol groups.3 This indicated general
resolution of hypercapnia during earlyrecovery after an acute exacerbation. It
is therefore likely that the reason thesepatients did not benefit from home
NIV is because they did not actually
have chronic hypercapnia or respiratory
failure.5
A notable difference between thetwo post-exacerbation studies was
the timing of home NIV initiation,and this is the likely explanation
for the contrasting findings.5
Otherwise, patients in both studies
were similar, having comparable levelsof hypercapnia and type II respiratory
failure at baseline.1,3,5
In terms of patient management inclinical practice, clinicians need to beaware that almost 50% of the patients
screened for the HOT-HMV trial had
spontaneous resolution of hypercapnia
within 2–4 weeks after resolution ofrespiratory acidosis.4

Flow diagram showing patient selection for home NIV based on clinical trial data.1,2

ACUTE EXACERBATION
OF COPD WITH ACUTERESPIRATORY FAILURESTABLE COPD
WITH PRESERVED
EXERCISE CAPACITY(Murphy et al. JAMA 2017;317:2177-86)(Köhnlein et al. Lancet Respir Med 2014;2:698-705)

Reassess 2-4 weeks post exacerbation

Symptoms of chronic hypoventilation

No persistent
hypercapnia

Persistent hypercania

No persistent
hypercapnia

Standard care

Add home NIV
to standard careStandard care

The HOmeVent registry

Current usage and guidelines

For patients with chronic
hypercapnic COPD, current registrydata suggest that a relevant
proportion of those in GOLD stage 3or 4 exhibit chronic hypercapnia andmight therefore be candidates forhome NIV treatment. The HOmeVentregistry6 was set up to determine theprevalence of chronic hypercapnia in
COPD outpatients. 231 COPD patientswere enrolled in the registry from 10
clinics in Germany, of which 58% wereGOLD stage 3 and 42% were GOLDstage 4. A quarter of the patients hadPaCO2 ≥45mmHg and of these 9%
had PaCO2 ≥ 50mmHg.6

Global Initiative for Chronic Obstructive Lung Disease (GOLD)
guidelines state that home NIV may improve hospitalisation-free survival
in selected patients after recent hospitalisation, particularly those withpronounced daytime persistent hypercapnia (PaCO2 ≥52 mmHg’, Level ofEvidence = B).7
European Respiratory Society (ERS) guidelines.
A multidisciplinary ERS Task Force committee has published evidence-based
recommendations that conditionally support the application of LTH-NIV toimprove health outcomes by using fixed pressure settings and targeting areduction in carbon dioxide in COPD patients with persistent hypercapnic
respiratory failure.8In many European countries, home NIV is also used for COPD patients
after prolonged weaning from mechanical ventilation if required to control
symptoms of hypoventilation and hypercapnia, as recommended in German
guidelines.9 Further clinical evidence is required to support this indication.

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	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.
4	Murphy PB, Hart N. Home non-invasive ventilation for COPD: how, who and when? Arch Bronconeumol
2018;54:149-54.

ResMed.com

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	Dreher M, Neuzeret PC, Windisch W, et al. Prevalence Of Chronic Hypercapnia In Severe Chronic Obstructive
Pulmonary Disease: Data From The HOmeVent Registry. Int J Chron Obstruct Pulmon Dis. 2019;14:2377–2384.
Published 2019 Oct 18. doi:10.2147/COPD. S2228037
7	Vogelmeier CF, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive
Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care Med. 2017;195(5):557-82.
8	Ergan B, Oczkowski S, Rochwerg B, et al. European Respiratory Society Guideline on Long-term Home NonInvasive Ventilation for Management of Chronic Obstructive Pulmonary Disease. Eur Respir J 2019; in press(https://doi.org/10.1183/13993003.01003-2019).
9 Schönhofer B, et al. S2k-Guideline “Prolonged Weaning”. Pneumologie 2015;69:595–607.

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