In-Home Initiation of Non-Invasive Ventilation for COPD Patients Safe, Feasible

By Scott Baltic

October 08, 2019

NEW YORK (Reuters Health) - For patients with chronic obstructive pulmonary disease (COPD) and stable hypercapnic respiratory failure, initiating chronic non-invasive ventilation (NIV) at home is as effective as doing so in a hospital, Dutch researchers have found.

It also reduces costs by more than half and appears to be safe, Dr. Marieke Duiverman of University Medical Center Groningen, in the Netherlands, and colleagues report in Thorax, online September 4.

The researchers say theirs was the first randomized controlled study to show these results. They note that while high-intensity NIV has become the standard of care for patients with COPD and chronic hypercapnic respiratory failure, it is often thought the delicate process of initiating and titrating NIV should take place at the hospital.

However, the team adds, "there is little consensus" about the settings in which this should be done (a pulmonary ward, a respiratory care unit or an intensive-care unit) and the costs vary considerably.

To investigate the feasibility of starting NIV at home, the researchers did a single-center, parallel-group randomized trial including 67 adult patients with COPD and chronic hypercapnic respiratory failure. They excluded patients with unstable severe cardiac comorbidities and those who lived in a nursing home or used or had used continuous positive airway pressure at home.

Patients randomized to in-hospital initiation were started on chronic NIV according to the pulmonary ward's normal procedure. At-home NIV initiation was assisted by a specially trained nurse who installed the equipment and explained the procedures.

Telemedicine was used to retrieve information from the ventilator (BiPAP A40 and BiPAP A30 from Philips Respironics). Ventilator settings could be changed remotely.

After six months, daytime partial CO2 pressure had decreased significantly in both the in-hospital initiation and the at-home initiation groups. At-home initiation was found to be non-inferior to in-hospital initiation, with an adjusted mean difference of 0.04 kPa (95% confidence interval, -0.31 to 0.38 kPa).

Similarly, no significant differences were seen between the groups with respect to lung function, health-related quality of life, or COPD exacerbations.

NIV initiation at home took significantly longer than that in the hospital, a mean of 14.5 days versus seven days, respectively. However, it cost only 3,768 euros (4,131 dollars) versus 8,537 euros (9,360 dollars) with hospital initiation.

Dr. Gerard J. Criner of the department of thoracic medicine and surgery at the Lewis Katz School of Medicine, Temple University, in Philadelphia, said the resources and increased costs needed for inpatient initiation of NIV "have contributed to the limited application of NIV in hypercapnic patients with COPD who may otherwise be eligible for this type of therapy."

He raised some concerns about the new study's limitations, however, including a higher dropout rate in the home group (22%) versus the hospital group (16%). In addition, the study was done at a single center that is experienced in the use of NIV, and especially home NIV.

Given that, although these findings are encouraging, "the overall results will be difficult to extrapolate to broad clinical use without properly conducted multicenter trials," Dr. Criner, who was not involved in the research, told Reuters Health by email.

The study was funded by the Dutch Lung Association, with support from Philips Respironics. Three of the authors disclosed ties to the company.

Dr. Duiverman declined to comment on the findings.

SOURCE: https://bit.ly/2nee12Q

Thorax 2019.

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