Home noninvasive ventilation in severe COPD: in whom does it work and how?

Tim Raveling; Judith M Vonk; Nicholas S Hill; Peter C Gay; Ciro Casanova; Enrico Clini; Thomas Köhnlein; Eduardo Márquez-Martin; Tessa Schneeberger; Patrick B Murphy; Fransien M Struik; Huib A M Kerstjens; Marieke L Duiverman; Peter J Wijkstra

doi:10.1183/23120541.00600-2023

Home noninvasive ventilation in severe COPD: in whom does it work and how?

ERJ Open Res. 2024 Feb 12;10(1):00600-2023. doi: 10.1183/23120541.00600-2023. eCollection 2024 Jan.

Authors

Tim Raveling^{1

2}, Judith M Vonk^{2

3}, Nicholas S Hill⁴, Peter C Gay⁵, Ciro Casanova⁶, Enrico Clini⁷, Thomas Köhnlein⁸, Eduardo Márquez-Martin^{9

10}, Tessa Schneeberger^{11

12}, Patrick B Murphy¹³, Fransien M Struik¹, Huib A M Kerstjens^{1

2}, Marieke L Duiverman^{1

2}, Peter J Wijkstra^{1

2}

Affiliations

¹ Department of Pulmonary Diseases and Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
² Groningen Research Institute of Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
³ Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
⁴ Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University Medical Center Boston, Boston, MA, USA.
⁵ Department of Pulmonary and Critical Care Medicine and the Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA.
⁶ Department of Pulmonary, Research Unit, Hospital Universitario La Candelaria, Universidad de La Laguna, Tenerife, Spain.
⁷ Respiratory Diseases Unit, Dept of Medical and Surgical Sciences SMECHIMAI, University Hospital of Modena Policlinico, University of Modena Reggio-Emilia, Modena, Italy.
⁸ Pneumological Specialist Center, Teuchern, Germany.
⁹ Medical-Surgical Unit of Respiratory diseases, University Hospital Virgen del Rocío, Seville, Spain.
¹⁰ CIBER-ES, Instituto de Salud Carlos III, Madrid, Spain.
¹¹ Department of Pulmonary Rehabilitation, Philipps-University of Marburg, Marburg, Germany.
¹² Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany.
¹³ Lane Fox Clinical Respiratory Physiology Research Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.

Abstract

Background: Not all hypercapnic COPD patients benefit from home noninvasive ventilation (NIV), and mechanisms through which NIV improves clinical outcomes remain uncertain. We aimed to identify "responders" to home NIV, denoted by a beneficial effect of NIV on arterial partial pressure of carbon dioxide (P_aCO₂), health-related quality of life (HRQoL) and survival, and investigated whether NIV achieves its beneficial effect through an improved P_aCO₂.

Methods: We used individual patient data from previous published trials collated for a systematic review. Linear mixed-effect models were conducted to compare the effect of NIV on P_aCO₂, HRQoL and survival, within subgroups defined by patient and treatment characteristics. Secondly, we conducted a causal mediation analysis to investigate whether the effect of NIV is mediated by a change in P_aCO₂.

Findings: Data of 1142 participants from 16 studies were used. Participants treated with lower pressure support (<14 versus ≥14 cmH₂O) and with lower adherence (<5 versus ≥5 h·day^-1) had less improvement in P_aCO₂ (mean difference (MD) -0.30 kPa, p<0.001 and -0.29 kPa, p<0.001, respectively) and HRQoL (standardised MD 0.10, p=0.002 and 0.11, p=0.02, respectively), but this effect did not persist to survival. P_aCO₂ improved more in patients with severe dyspnoea (MD -0.30, p=0.02), and HRQoL improved only in participants with fewer than three exacerbations (standardised MD 0.52, p=0.03). The results of the mediation analysis showed that the effect on HRQoL is mediated partially (23%) by a change in P_aCO₂.

Interpretation: With greater pressure support and better daily NIV usage, a larger improvement in P_aCO₂ and HRQoL is achieved. Importantly, we demonstrated that the beneficial effect of home NIV on HRQoL is only partially mediated through a reduction in diurnal P_aCO₂.