Unmet Goals Should Prompt COPD Support Review: Gerard Criner, MD

Respiratory support beyond inhalers should be considered for patients with advanced chronic obstructive pulmonary disease (COPD) whenever treatment goals go unmet, and 4 patient groups in particular warrant a conversation about additional therapies, said Gerard J. Criner, MD, FACP, FACCP, chair and professor of thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University and director of the Temple Lung Center, in an interview with The American Journal of Managed Care^® (AJMC^®) for GOLD International COPD Conference 2026.

Criner described exacerbations as sentinel events that often bring patients to care. He explained that the evidence for long-term oxygen rests largely on trials of patients with severe oxygen desaturation at rest. An earlier AJMC analysis¹ found continuous oxygen therapy to be cost-effective for such patients, while nocturnal oxygen therapy was not. He also discussed home noninvasive ventilation (NIV) for persistent hypercapnia after discharge, the unsettled outpatient role of high-flow nasal therapy, and the practical barriers to home ventilation. Hospitals continue to look for ways to limit COPD readmissions, and one community hospital’s care management program² reduced its annual readmission rate from 21.5% to 13.6%.

This interview was edited for clarity.

AJMC: Which patients with advanced COPD should be evaluated for respiratory support beyond inhalers, and what are the triggers for that evaluation?

Criner: It’s in any patient where the goals for treatment aren’t met, if that’s improvement of symptoms of cough, mucus production, shortness of breath, or related to exacerbations, which are sentinel events in the life of a COPD patient. Those are most of the reasons why patients present, and that’s your goal as a clinician, trying to alleviate their symptoms.

AJMC: Long-term oxygen has been a clear benefit in severe resting hypoxemia, but the evidence is weaker for moderate desaturation. How do you decide who is a candidate for long-term oxygen?

Criner: The information is mainly based on the survival benefit from the national treatment trials that were done in the UK as well as the United States to show benefit for patients who have severe oxygen desaturation at rest. In some patients that don’t have clear-cut improvements in hospitalization or mortality, those that don’t have resting hypoxemia but just desaturate and are hypoxemic, that’s approved by Medicare. Patients that see benefit with that use of therapy should receive it, but not all people that don’t see benefit with that therapy based on a long-term oxygen treatment trial should be prescribed it.

AJMC: How should clinicians screen for persistent hypercapnia after an exacerbation, and when should home NIV follow?

Criner: We recommend that people [for whom] you’re trying to decrease their readmission to the hospital, who have persistent hypercapnia after hospital discharge from 2 weeks or greater, should be considered for the use of that therapy.

AJMC: Trial results for home NIV have varied. What do you think explains the differences, such as pressure settings, patient selection, and adherence?

Criner: [It’s] more dependent upon the right patient population. Those who suffer from chronic hypercapnia associated with hypoventilation are the patients that respond the best to the use of NIV.

AJMC: Where does high-flow nasal therapy fit for chronic or recurrent respiratory failure in COPD?

Criner: It’s used in the hospital, but used as an outpatient right now hasn’t been firmly shown to be a benefit. Those are the ongoing clinical trials that are done, 1 in the US [and] 2 outside the US, trying to address the patient population to see what the long-term benefits are of using that therapy.

AJMC: What are the biggest practical barriers to home ventilation, such as device access, coverage, mask tolerance, and follow-up?

Criner: Yes, all that. Those are the big, big issues.

AJMC: When should supportive respiratory therapies be discussed alongside goals of care, and how do you start these conversations with patients?

Criner: Looking at the individual patient profile and what their goals of care are makes it something to discuss when you see an individual patient. Maybe not all patients, but definitely patients that suffer from either severe resting hypoxemia or hypoxemia with desaturation or chronic hypercapnia, or frequent hospitalizations despite maximal therapy. Those are the patient groups [with whom] you would have this type of discussion to see if they would benefit from these additional therapies.

REFERENCES

1. Oba Y. Cost-effectiveness of long-term oxygen therapy for chronic obstructive pulmonary disease. Am J Manag Care. 2009;15(2):97-104.
2. Rodriguez A. Study evaluates impact of care management programs on COPD readmission rates. AJMC. June 27, 2018. Accessed November 2, 2026. https://www.ajmc.com/view/study-evaluates-care-management-programs-on-copd-readmission-rates