Disclosures: Three study authors report receiving grants from the Agency for Healthcare Research and Quality. Coleman reports he has received personal fees from Hill-Rom. Kalhan reports he has received personal fees from AstraZeneca, Boehringer Ingelheim, Boston Consulting Group, Boston Scientific, CVS Caremark and GlaxoSmithKline. Gates reports no relevant financial disclosures.
February 05, 2020
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Home noninvasive positive pressure ventilation may improve COPD outcomes

Disclosures: Three study authors report receiving grants from the Agency for Healthcare Research and Quality. Coleman reports he has received personal fees from Hill-Rom. Kalhan reports he has received personal fees from AstraZeneca, Boehringer Ingelheim, Boston Consulting Group, Boston Scientific, CVS Caremark and GlaxoSmithKline. Gates reports no relevant financial disclosures.
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A meta-analysis recently published in JAMA suggests that home noninvasive positive pressure ventilation, or NIPPV, may potentially lower the risk for death, hospital admission and intubation among patients with COPD and hypercapnia.

The researchers wrote, however, that the quality of evidence was low to moderate and that analyses of some outcomes were based on a limited number of studies.

For the systematic review and meta-analysis, the researchers searched several databases for studies published from 1995 to 2019 that enrolled adults with COPD and hypercapnia who used home NIPPV, delivered via bilateral positive airway pressure (BPAP) devices or noninvasive home mechanical ventilators, for longer than 1 month.

Overall, 21 randomized clinical trials, 12 observational studies and more than 50,000 patients in total were included in the analysis. Of these patients, 434 patients died and 27 were intubated.

A meta-analysis recently published in JAMA suggests that home noninvasive positive pressure ventilation, or NIPPV, may potentially lower the risk for death, hospital admission and intubation among patients with COPD and hypercapnia.
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Positive outcomes

Results showed that BPAP, as compared with no device, was linked to lower risk for mortality in 13 studies (OR = 0.66; 95% CI, 0.51-0.87), fewer all-cause hospital admissions in one study (OR = 0.22; 95% CI, 0.11-0.43) and less need for intubation in three studies (OR = 0.34; 95% CI, 0.14-0.83). However, there appeared to be no difference with use of BPAP vs. no device in the total number of all-cause hospital admissions in five studies (RR = 0.91; 95% CI, 0.71-1.17) or quality of life in nine studies (standardized mean difference, 0.16; 95% CI, –0.06 to 0.39).

Although noninvasive home mechanical ventilator use, as compared with no device, was also associated with fewer all-cause hospital admissions in one study (RR = 0.5; 95% CI, 0.35-0.71), it was not significantly associated with mortality in two studies (OR = 0.56; 95% CI, 0.29-1.08).

Notably, in a post-hoc analysis restricted to randomized clinical trials only, NIPPV, as compared with no device, was not linked to a difference in mortality in eight studies (OR = 0.72; 95% CI, 0.49-1.05), need for intubation in one study (OR = 0.48; 95% CI, 0.04-5.64) or quality of life in eight studies (standardized mean difference, 0.1; 95% CI, –0.09 to 0.29).

In the six studies directly comparing NIPPV — BPAP or home mechanical ventilators — with no device use, the total number of adverse events did not differ between groups (0.18 vs. 0.17 per patient; P = .84).

Significant limitations

Despite their findings, several limitations hamper the ability to draw firm conclusions, according to the researchers. Not only was the evidence level rated low to moderate, but the potential for bias and significant heterogeneity among the studies included in the meta-analysis presented issues.

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In an accompanying editorial, John M. Coleman III, MD, Khalilah L. Gates, MD, and Ravi Kalhan, MD, MS, all from the division of pulmonary and critical care medicine at Northwestern Feinberg University School of Medicine, also highlighted these limitations and discussed future directions for research.

“Despite a low to moderate quality evidence base, the authors report favorable signals in terms of both reduced mortality and hospitalization with the use of NIPPV. However, the heterogeneity of how NIPPV was delivered across the studies makes it challenging to make clinical decisions regarding implementation of this therapy. Recent evidence suggests that delivery of high levels of pressure support and adequate backup respiratory rates (to reduce work of breathing as much as possible) are key factors for achieving a clinical benefit with NIPPV,” they wrote. “Pivotal clinical trials focused on further testing of these specific modes of support in specific populations of patients with COPD (eg, patients with recent exacerbation vs. stable patients with chronic respiratory failure) are essential to determine how to implement this therapy most appropriately in clinical practice.” – by Melissa Foster

Disclosures: Three study authors report receiving grants from the Agency for Healthcare Research and Quality. Coleman reports he has received personal fees from Hill-Rom. Kalhan reports he has received personal fees from AstraZeneca, Boehringer Ingelheim, Boston Consulting Group, Boston Scientific, CVS Caremark and GlaxoSmithKline. Gates reports no relevant financial disclosures.