Impact of High-Intensity-NIV on the heart in stable COPD: a randomised cross-over pilot study

Abstract

BackgroundAlthough high-intensity non-invasive ventilation has been shown to improve outcomes in stable COPD, it may adversely affect cardiac performance. Therefore, the aims of the present pilot study were to compare cardiac and pulmonary effects of 6 weeks of low-intensity non-invasive ventilation and 6 weeks of high-intensity non-invasive ventilation in stable COPD patients.MethodsIn a randomised crossover pilot feasibility study, the change in cardiac output after 6 weeks of each NIV mode compared to baseline was assessed with echocardiography in 14 severe stable COPD patients. Furthermore, CO during NIV, gas exchange, lung function, and health-related quality of life were investigated.ResultsThree patients dropped out: two deteriorated on low-intensity non-invasive ventilation, and one presented with decompensated heart failure while on high-intensity non-invasive ventilation. Eleven patients were included in the analysis. In general, cardiac output and NTproBNP did not change, although individual effects were noticed, depending on the pressures applied and/or the co-existence of heart failure. High-intensity non-invasive ventilation tended to be more effective in improving gas exchange, but both modes improved lung function and the health-related quality of life.ConclusionsLong-term non-invasive ventilation with adequate pressure to improve gas exchange and health-related quality of life did not have an overall adverse effect on cardiac performance. Nevertheless, in patients with pre-existing heart failure, the application of very high inspiratory pressures might reduce cardiac output.Trial registrationThe trial was registered in the Deutsches Register Klinischer Studien (DRKS-ID: DRKS00007977).Electronic supplementary materialThe online version of this article (doi:10.1186/s12931-017-0542-9) contains supplementary material, which is available to authorized users.

European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD

“…In the past two decades, a number of published RCTs aimed at exploring the role of LTH-NIV in those with hypercapnic COPD; however, most did not specifically target normalisation or significant reduction in P aCO 2 or directly address nocturnal alveolar hypoventilation. High-intensity NIV, a form of pressure-limited controlled ventilation, that combined stepwise titration of IPAP up to 30 cmH 2 O with an high backup rate just below the patient's spontaneous breathing frequency, was introduced as a novel therapeutic option in an attempt to maximally decrease elevated P aCO 2 to normal levels and, at the same time, to achieve the total control of the patient's spontaneous respiratory activity aiming for substantial rest of the diaphragm [35,64,65]. Given to the greater capability of correcting nocturnal alveolar hypoventilation, high-intensity NIV has been reported to be more efficient in terms of clinical and physiological benefits (reduction of nocturnal and diurnal P aCO 2 levels; improvement in FEV 1 , patient-reported exercise-related dyspnoea score, 6MWD and HRQL) than conventional "low-intensity" NIV.…”

“…Given to the greater capability of correcting nocturnal alveolar hypoventilation, high-intensity NIV has been reported to be more efficient in terms of clinical and physiological benefits (reduction of nocturnal and diurnal P aCO 2 levels; improvement in FEV 1 , patient-reported exercise-related dyspnoea score, 6MWD and HRQL) than conventional "low-intensity" NIV. Paradoxically, delivery of higher levels of pressure support was associated with better compliance to the treatment, probably as consequence of a greater subjective benefits perceived by chronically symptomatic patients [64][65][66][67].…”

Non-Invasive Ventilation as an Adjunct to Exercise Training in Chronic Ventilatory Failure: A Narrative Review

“…The effectiveness of the proposed pressures as high as needed to reduce PaCO 2 in the long term [7] during exercise training in patients with CVF is still unknown. Long-term NIV with adequate pressure to improve gas exchange did not have an overall adverse effect on cardiac performance [63]. Nevertheless, confirming an earlier study [64] in patients with pre-existing heart failure, the application of very high inspiratory pressures might reduce cardiac output [63].…”

“…Long-term NIV with adequate pressure to improve gas exchange did not have an overall adverse effect on cardiac performance [63]. Nevertheless, confirming an earlier study [64] in patients with pre-existing heart failure, the application of very high inspiratory pressures might reduce cardiac output [63]. However, the cardiovascular effects of the intrathoracic pressures during exercise in patients with CVF and different cardiovascular functions are unknown.…”

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

“…However, the adverse cardiovascular effects of HI‐NIV, due to increased intrathoracic pressure resulting in reduced venous return with a subsequent reduction in cardiac output and increased pulmonary vascular resistance, need to be considered carefully. Although the application of HI‐NIV is associated with an acute fall in cardiac output, it should be noted that medium‐term cardiovascular safety, in terms of echocardiographic measures of cardiac function, has been demonstrated …”