COMMENTARY

With Hypercapnic Respiratory Failure, Comorbidities Are Common

Aaron B. Holley, MD

Disclosures

August 09, 2017

Comorbidities and Subgroups of Patients Surviving Severe Acute Hypercapnic Respiratory Failure in the Intensive Care Unit

Adler D, Pépin JL, Dupuis-Lozeron E, et al
Am J Respir Crit Care Med. 2017;196:200-207

The Study

In a recent issue of the American Journal of Respiratory and Critical Care Medicine, Adler and colleagues describe comorbidities in a cohort of patients with acute hypercapnic respiratory failure (AHRF). All patients were admitted to the intensive care unit, and most were treated with noninvasive positive pressure ventilation (NIPPV). The two main causes of AHRF were chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS), and many patients had comorbid hypertension, heart failure with preserved ejection fraction (HFpEF), and/or severe obstructive sleep apnea (OSA). The mean age of the study population was about 69 years, about 54% were current smokers, and 56% were obese.

Viewpoint

This was a well-done, very detailed study. It's also depressing. The results leave me wondering what we can do with the data.

I do not think anyone who works in the field of pulmonary and critical care medicine should be surprised. An entire section of the Global Initiative for Chronic Obstructive Lung Disease guidelines is dedicated to the topic of comorbid disease in patients with COPD.[1] Given their older age and high rates of tobacco use, it's no wonder they have high rates of hypertension and HFpEF. The same can be said for OHS. Given the patients' age and body mass index, the high rates of severe OSA when using the most recent American Academy of Sleep Medicine scoring criteria should not surprise anyone.[2,3] Nor should the presence of OSA among patients with OHS.[4] However, most patients had not been previously diagnosed with COPD, HFpEF, OSA, or OHS.

Many of the patients were discharged home on NIPPV, and one would assume that this stabilized the airway and treated (at least partially) the OSA. It also may have augmented cardiac function for those with HFpEF and improved COPD-related outcomes.[5,6] What it did not do was change readmission rates. We know now to look for comorbid disease in patients admitted to the intensive care unit with AHRF. Unfortunately, we do not know how to use the information to improve short-term outcomes. The accompanying editorial laments this fact.[7]

The high rates of tobacco use worldwide and rising obesity levels in first-world countries mean that AHRF is here to stay. NIPPV is a very effective acute treatment. Ideally, though, COPD and OHS would be diagnosed before AHRF, as would HFpEF and OSA. It may be that AHRF is a marker for a later stage in the disease process, a stage at which outcomes are more difficult to affect.

Abstract

Comments

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