Home mechanical ventilation for chronic obstructive pulmonary disease: What next after the HOT‐HMV trial?

Abstract

The benefits of acute non-invasive ventilation to treat acidotic exacerbations of chronic obstructive pulmonary disease (COPD) are well-established. Until recently, the evidence for home mechanical ventilation (HMV) to treat patients with stable COPD had been lacking. This has subsequently been addressed by the application of higher levels of pressure support combined with targeted management of chronic respiratory failure, which demonstrated a reduction in all-cause mortality. Similarly, the previous trial of home oxygen therapy (HOT) and HMV delivered following an acute exacerbation failed to demonstrate an improvement in outcome. With the focus on patients with persistent hypercapnic respiratory failure in the recovery phase following a life-threatening exacerbation combined with targeted reduction in carbon dioxide, HOT and HMV (HOT-HMV) was shown to be clinically effective in reducing the time to readmission or death and cost effective in both the United Kingdom and United States healthcare systems. Future work will need to focus on promoting adherence to home ventilation and novel auto-titrating ventilator modes to facilitate and optimize the set-up of overnight ventilatory support in different target population such as COPD patients with obstructive sleep apnoea and COPD patients with episodic nocturnal hypoventilation.

Contemporary Concise Review 2019: Chronic obstructive pulmonary disease

“…NIMV is highly effective in reducing rehospitalization rates in patients with severe COPD and persistent hypercapnia (PaCO 2 >45 mm Hg). As highlighted by Suh et al ., the use of high‐intensity NIMV during the first 30 days post‐hospital discharge reduces the risk of readmission by over 70% . However, it should be noted that the target IPAP is ~24 cm H 2 O and EPAP is ~4 cm H 2 O for these patients and with the explicit goal of reducing daytime PaCO 2 by on average 20%.…”

Challenges to and opportunities for the implementation of non‐invasive positive pressure ventilation in the Asia‐Pacific region

“…The use of non-invasive positive pressure ventilation (NPPV) has become common and, in many cases, the first choice for mechanical ventilation worldwide. [1][2][3][4][5] In China, the majority of tertiary hospitals are equipped with NPPV ventilators; however, there is an imbalance of resources between different regions and hospitals (see Appendix S1, Supplementary Information, for the history and development of NPPV for respiratory failure in China). There is also a disparity in the economic, scientific and technological uptake among countries of the Asia-Pacific region, with many still developing economically.…”

Non‐invasive ventilation: A glimpse into the future

“…Despite successful in‐hospital benefits of NIV, survivors of acute hypercapnic respiratory failure (AHRF) experience high rates of readmission and life‐threatening events post‐discharge . Suh et al . highlight several important lessons arising from the recent home oxygen theraphy‐home mechanical ventilation (HOT‐HMV) trial: the value of implementing NIV during the post‐exacerbation recovery period (i.e.…”

“…Despite successful in-hospital benefits of NIV, survivors of acute hypercapnic respiratory failure (AHRF) experience high rates of readmission and lifethreatening events post-discharge. 6 Suh et al 7 highlight several important lessons arising from the recent home oxygen theraphy-home mechanical ventilation (HOT-HMV) trial 8 : the value of implementing NIV during the post-exacerbation recovery period (i.e. 2-4 weeks post-discharge), rather than at discharge, in order to accurately identify those with persisting rather than transient hypercapnia; and the need to apply a level of ventilatory support that is sufficient to ameliorate nocturnal hypoventilation.…”

“…The importance of monitoring patients during NIV titration is highlighted in a number of reviews 7,9,10,14 and is the primary focus of the review by Borel et al 17 These authors provide an excellent discussion around the potential value and limitations of using the in-built monitoring capabilities now incorporated in newer home ventilator devices. Whether access to this data improves short or long-term outcomes requires further evaluation.…”