Oct 282017

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are one of the top causes of hospital admission -- and readmission: up to 30% of patients "bounce back" to the hospital within 90 days after a COPD exacerbation.

Patients with severe COPD exacerbations with acute hypercapneic respiratory failure often receive noninvasive ventilation (NIV), commonly known as BiPAP, a popular trade name.

A randomized trial published in JAMA raises the possibility that patients with severe COPD may do better after discharge with BiPAP on a nightly basis at home.

Authors enrolled 116 U.K. patients with severe COPD (FEV1 ~0.6 liter) who had recovered to a state of resting hypercapnia without acidemia (pCO2 ~59 mm Hg), within 4 weeks after their recent hospitalizations for COPD exacerbations. None were severely obese, and none had been intubated.

Half received nightly NIV (BiPAP or a competitor), all received nocturnal oxygen. Those assigned to NIV did better:

  • The 57 patients receiving nightly NIV with oxygen had a significantly longer median time to readmission or death (4.3 months vs 1.4 months).
  • In 12 months, the risk of readmission or death was 63% in the NIV group, and 80% in the supplemental oxygen-only group.
  • The rate of death at 12 months was similar (16 vs 19 patients).
  • The average number of exacerbations per year was reduced by one (three in the NIV+oxygen group, compared to four in the oxygen-only group). Since each  exacerbation represented a near-death experience (and costly hospitalization) in these very ill patients, this effect may be significant.
  • Patients didn't report worse quality of life associated with wearing NIV, and it may have improved slightly.

The findings were in contrast to the RESCUE trial published in 2014, which did not show any benefit of nocturnal NIV in patients with COPD after severe exacerbations. The RESCUE patients' COPD was not as severe as in the current trial.

BiPAP and its competitors cost about $300/month as rentals, and about $3000 as a one-time purchase. These retail prices are rarely paid by the patient, as the machines are provided and serviced in contracted arrangements with large durable medical equipment companies.

The grim outcomes in the trial makes plain that patients with very severe COPD experiencing exacerbations with hospitalization have a low expected survival and high likelihood of re-hospitalization.

Take away: This small but well-conducted U.K. trial suggests NIV may be helpful after hospitalizations for COPD exacerbations in patients with severe COPD, severe resting hypercarbia, short life expectancy and high likelihood for readmission. Previous studies suggest nightly NIV is probably unhelpful for the majority of patients with COPD.

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