COPD treatment

Nocturnal NIPPV

  • Casanove, CHEST 2000
    • NIV improves quality of life, reduces CO2 retention, reduces dyspnea
    • no change in mortality or hospitalization
  • Murphy 2017:
    • prolongs time to readmission or death for patients with persistent hypercapnia after hospitalization for exacerbation
  • Struik 2013: no benefit in gas exchange, quality of life, lung function test in stable COPD
  • Kohnlein 2014: Gold 4 pts with CO2 > 52 showed mortality benefit with IPAP 22 and rate 16

Obtaining NIV

  • chronic hypercapnia: pCO2 > 52
  • nocturnal hypoxemia: spO2 < 88 for > 5 min on 2L or patient's baseline O2
  • documentation that sleep apnea has been considered or ruled out

Oxygen Therapy

The use of supplemental oxygen has been shown to improve quality of life and decrease mortality in patients with COPD and resting hypoxemia with an arterial PO2 of 55 mm Hg or less, or oxygen saturation as measured by pulse oximetry of 88% or less. Patients with cor pulmonale, heart failure, or erythrocytosis should be offered the use of supplemental oxygen if the Po2 is 59 mm Hg or less or the oxygen saturation is 89% or less. Some patients may not qualify for oxygen at rest but may desaturate during sleep, exertion, or air travel. Supplemental oxygen is typically prescribed if the oxygen saturation as measured by pulse oximetry falls below 89% in these situations, but the benefits are less defined.

Noninvasive Mechanical Ventilation

Noninvasive mechanical ventilation (NIV), also termed noninvasive positive pressure ventilation (NIPPV), can be used for acute and chronic respiratory failure. For patients with a COPD exacerbation and acute hypercapnic respiratory failure with acidosis, NIV improves symptoms and reduces intubation rates, length of hospital stay, and mortality. It may also be beneficial in COPD patients with pneumonia, to help with discontinuing mechanical ventilation, and for palliative care. It does not replace intubation and mechanical ventilation in critically ill patients, comatose patients, or patients who have sustained a cardiac arrest. NIV is generally well tolerated, and improvement of the pH and PCO2 within 1 to 2 hours predicts success. The benefit of using NIV in the treatment of chronic respiratory failure or in the outpatient setting is less clear. It may, especially if used at night, provide additional symptomatic relief when added to medical therapy in patients with severe COPD.