Survival and end-of-life aspects among subjects on long-term noninvasive ventilation

Abstract

Background: The need for noninvasive ventilation (NIV) is commonly considered a predictor of poor survival, but life expectancy may vary depending on the underlying disease. We studied the factors associated with decreased survival and end-of-life characteristics in an unselected population of subjects starting NIV. Methods: We conducted a retrospective study including 205 subjects initiating NIV from 1/1/ 2012-31/12/2015 who were followed up until 31/12/2017. Results: The median survival time was shorter in subjects needing help with activities of daily living than in independent subjects (hazard ratio (HR) for death 1.7, 95% CI 1.2-2.6, P = 0.008) and was also shorter in subjects on long-term oxygen therapy (LTOT) than in those not on LTOT (HR for death 2.8, 95% CI 1.9-4.3, P < 0.001). There was marked difference in survival according to the disease necessitating NIV, and subjects with amyotrophic lateral sclerosis or interstitial lung disease seemed to have the shortest survival. The two most common diseases resulting in the need for NIV were chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS). The median survival time was 4.4 years in COPD subjects, but the median survival time was not reached in subjects with OHS (HR for death COPD vs. OHS: 3.2, 95% CI 1.9-5.5, P < 0.001). Most of the deceased subjects (55.6%) died in the hospital, while only 20.0% died at home. The last hospitalization admission leading to death occurred through the emergency room in 44.4% of the subjects. Conclusions: Survival among subjects starting NIV in this real-life study varied greatly depending on the disease and degree of functional impairment. Subjects frequently died in the hospital after admission through the emergency department. A comprehensive treatment approach with timely advance care planning is therefore needed, especially for those needing help with activities of daily living and those with both NIV and LTOT.

Home non-invasive ventilation: An observational study of aetiology, chronic respiratory failure of multiple aetiologies, survival and treatment adherence

“…The most common single causes of CRF were SA, OAD, OHS, and NMD. The distribution of the diagnostic categories is in line with previous European studies [ 1 , 4 , 26 , 27 ] with the entity of SA being an exception. This could be explained by three major reasons.…”

“…Over 70 % of the patients were adherent in the categories of OAD, NMD, CWD, and multimorbid CRF. Overall adherence was comparable to the previous studies in Finland [ 27 ] and other European countries [ 4 , 26 , 28 ]. In ventilator settings IPAP and pressure support appeared slightly lower compared to the ones reported in the latest publications [ 26 , 28 ].…”

The prevalence of non-invasive ventilation and long-term oxygen treatment in Helsinki University Hospital area, Finland

“…Treatment durations and survival of our COPD patients were in line with other studies even though our patients were older (on average 74.5 vs 62.2–70.6 years) [ 2 , 26 – 29 ], and had many co-morbidities. Our patients’ hypercapnia was similar to many studies [ 2 , 27 , 28 ]; in only one study was the hypercapnia markedly lower (48.5 mmHg = 6.5 kPa) [ 29 ]. Many of these studies were done with high-intensity NIV.…”

“…However, recent studies have shown positive impact on COPD patients’ long-term survival with NIV. In studies, NIV-treated COPD patients’ one year mortality was 12–28% and in control group 33–46% [ 2 , 26 ], and three and four year mortalities, 43.9–45.5%[ 27 – 29 ].…”

Home ventilation for patients with end-stage chronic obstructive pulmonary disease

“…Even though starting chronic NIV might lead to improved HRQL, more stable disease and sometimes better survival, palliative care should be part of the treatment as patients at this stage suffer from wide variety of severe symptoms 50 , 51 . Unfortunately, in a study performed in Finland, end-of-life decisions were made in only 39% of the patients with end-stage COPD and only 23% of the patients in their cohort died at home 52 . The likelihood to die at home may be increased by palliative care 53 .…”