In-Home Device Associated With Lower Mortality Risk, Less Need for Intubation in Patients With COPD

February 11, 2020

In-home noninvasive positive pressure ventilation via bilevel positive airway pressure devices exhibited lower risk of mortality, fewer patients with all-cause hospital admission, and less need for intubation, but had no significant difference in quality-of-life for patients with chronic obstructive pulmonary disease (COPD) and hypercapnia, according to study findings.

In-home noninvasive positive pressure ventilation (NIPPV) via bilevel positive airway pressure (BPAP) devices exhibited lower risk of mortality, fewer patients with all-cause hospital admission, and less need for intubation, but had no significant difference in quality of life (QOL) for patients with chronic obstructive pulmonary disease (COPD) and hypercapnia, according to study findings published in JAMA.

Many patients with COPD additionally suffer from hypercapnia, the retention of carbon dioxide that may lead to acute respiratory failure and hospitalization. In-hospital use of NIPPV among patients who experienced acute respiratory failure due to an acute exacerbation of COPD has been linked with decreased mortality, decreased need for intubation, shorter hospital length of stay, and fewer complications.

However, lead study author Michael Wilson, MD, pulmonary and critical care physician at Mayo Clinic, highlighted in a press release that randomized clinical trials (RCTs) have exhibited contrasting findings related to home use of NIPPV for chronic hypercapnic respiratory failure in individuals with COPD. “There were indications that at-home therapy might be beneficial, but there were conflicting studies and guidelines as to what would be best for our patients,” said Wilson.

Study authors sought to develop a systematic review to delineate the association of home NIPPV with clinical outcomes and adverse events in patients with COPD and hypercapnia. Researchers evaluated the use of NIPPV via BPAP devices and noninvasive home mechanical ventilator (HMV) devices in the study, with eligible studies including RCTs (n = 21) and comparative observational studies (n = 12) that enrolled adults with COPD and hypercapnia who used home NIPPV for more than 1 month (n = 51,085).

Primary outcomes were mortality, all-cause hospital admissions, need for intubation, and QOL at the longest follow-up. BPAP and HMV use were compared in a meta-analysis with no device use in patients with COPD and hypercapnia.

In the study findings, the use of BPAP compared with no device exhibited a significantly lower risk of mortality (22.31% vs 28.57%; risk difference [RD], −5.53% [95% CI, −10.29% to −0.76%]; odds ratio [OR], 0.66 [95% CI, 0.51-0.87]; P = .003), fewer patients with all-cause hospital admissions (39.74% vs 75.00%; RD, −35.26% [95% CI, −49.39% to −21.12%]; OR, 0.22 [95% CI, 0.11-0.43]; P < .001), and lower need for intubation (5.34% vs 14.71%; RD, −8.02% [95% CI, −14.77% to −1.28%]; OR, 0.34 [95% CI, 0.14-0.83]; P = .02).

Conversely, the use of BPAP was not significantly associated with the total number of all-cause hospital admissions (rate ratio [RR], 0.91 [95% CI, 0.71-1.17]; P = .47) or QOL (standardized mean difference, 0.16 [95% CI, −0.06 to 0.39]; P = .15). Noninvasive HMV use compared with no device was similarly shown to be associated with fewer all-cause hospital admissions (RR, 0.50 [95% CI, 0.35-0.71]; P < .001), but had no impact on mortality risk (21.84% vs 34.09%; RD, −11.99% [95% CI, −24.77% to 0.79%]; OR, 0.56 [95% CI, 0.29-1.08]; P = .49).

No statistically significant difference in total number of adverse events in patients using NIPPV compared with no device was observed (0.18 vs 0.17 per patient; P = .84).

While the benefits from NIPPV via BPAP exhibit definite improvements within mortality risk and intubation use, Wilson stressed that clinicians should remain cautious, as the studies examined involved varied types of patients with COPD. “Patients with COPD should talk with their physicians to determine whether a breathing device such as a BiPAP machine might be a good choice for them,” said Wilson.

As most of the RCTs and comparative analyses were of low to moderate quality and some measurements were based on small numbers of studies, study authors suggest that further research is required to confirm findings.

Reference

Wilson ME, Dobler CC, Morrow AS, et al. Association of home noninvasive positive pressure ventilation with clinical outcomes in chronic obstructive pulmonary disease: a systematic review and meta-analysis [published online February 4, 2020]. JAMA. doi: 10.1001/jama.2019.22343.