Pulmonary Rehabilitation* Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

Andrew L. Ries, MD, MPH, FCCP (Chair); Gerene S. Bauldoff, RN, PhD, FCCP; Brian W. Carlin, MD, FCCP; Richard Casaburi, PhD, MD, FCCP; Charles F. Emery, PhD; Donald A. Mahler, MD, FCCP; Barry Make, MD, FCCP; Carolyn L. Rochester, MD; Richard ZuWallack, MD, FCCP; Carla Herrerias, MPH

Disclosures

CHEST. 2007;131(5):4S-42S. 

In This Article

Noninvasive Ventilation

Noninvasive positive-pressure ventilation (NPPV) includes the techniques of continuous positive airway pressure, pressure support, and proportional assist ventilation (PAV). A metaanalysis[170] of nocturnal NPPV in stable hypercapneic patients with COPD, which included four eligible trials, showed that this therapy did not improve lung function, gas exchange, or sleep efficiency, but may have led to an increased walk distance. The rationale for NPPV as an adjunct to exercise training is that through unloading the respiratory muscles, the decreased work of breathing might allow for improved tolerance of exercise training and the ability to achieve higher levels of exercise intensity.[171] In a systematic review of NPPV in seven trials that met specified inclusion criteria (describing a total of 65 patients with COPD), van't Hul and colleagues[172] concluded that dyspnea and exercise endurance were significantly improved in the short term with the application of this therapy. However, these short-term effects on dyspnea and exercise performance must be differentiated from the ability of repeated NPPV use to enhance outcomes from pulmonary rehabilitation.

In this evidence-based review, we were able to identify several trials that evaluated NPPV as an adjunct to an exercise training or pulmonary rehabilitation program ( Table 11 ). Garrod and colleagues[173] randomized 45 patients with severe COPD to 12 weeks of exercise training with or without nocturnal NPPV via nasal mask. The median settings for NPPV were 16 cm H2O inspiratory and 4 cm H2O expiratory bilevel pressure ventilation. Compared with the exercise-training-only group, those patients using nocturnal NPPV as an adjunct to exercise training had a significantly increased shuttle walk distance (72 m) and greater improvement in health status.

Two trials[174,175] evaluated the adjunctive effect of NPPV during supervised exercise training. Bianchi and colleagues[174] randomized 33 men with moderate-to-severe COPD (mean FEV1, 44% predicted) beginning a 6-week pulmonary rehabilitation program into receiving mask PAV or spontaneous breathing during exercise training. Five of the 18 patients in the PAV group dropped out because of lack of compliance with the equipment. There were no between-group differences in dyspnea, leg fatigue, exercise performance, or health status. In a similar trial, but including patients with more severe disease (mean FEV1, 27% predicted), Hawkins and colleagues[175] found that PAV during 6 weeks of high-intensity cycle exercise training led to better outcomes. Compared to those patients breathing without assistance during exercise training, the PAV group had a 15.2% higher training intensity, higher peak work rate, and a trend (p = 0.09) of lower lactate levels at the isowork rate. There was no significant between-group difference in exercise endurance.

Johnson and colleagues[176] randomized 39 patients with severe COPD (mean FEV1, 34% predicted) who were undergoing 6 weeks of pulmonary rehabilitation into the following three groups: (1) heliox breathing; (2) nasal NPPV therapy; and (3) spontaneous breathing during exercise training. Bilevel pressure ventilation was administered via nasal mask, with inspiratory positive airway pressure at 8 to 12 cm H2O (as tolerated) and expiratory positive airway pressure at 2 cm H2O. NPPV allowed for a longer exercise time during training, but there were no between-group differences in the percentage change in peak workload.

Costes and colleagues[177] randomized 14 patients with severe COPD into NPPV or spontaneous-breathing groups. Bilevel pressure ventilation settings were adjusted to tolerance. All were given 24 sessions of exercise training over 8 weeks. The NPPV group demonstrated greater improvement in peak VO 2 following exercise training compared to the group trained conventionally.

More recently, van't Hul and colleagues[178] randomized 29 patients with COPD into the following two groups: (1) inspiratory pressure support (10 cm H2O) as an adjunct to an 8-week high-intensity cycle exercise-training program; and (2) sham therapy (inspiratory support at 5 cm H2O) with exercise training. Although both the patients and the investigator assessing the outcomes were blinded to the treatment group, the physiotherapists supervising exercise training were not. Significant between-group improvements in favor of the treatment group were seen in shuttle walk distance and cycle endurance time.

In summary, several randomized trials have compared spontaneous breathing with NPPV as an adjunct to exercise in patients with COPD. Obvious methodological issues exist with respect to blinding patients and investigators, differences in exercise training and outcome assessments, and the small numbers of subjects. However, it appears that this therapy does confer an immediate postrehabilitation benefit in improving exercise tolerance in selected patients with more advanced disease.

22. As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. Grade of recommendation, 2B

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