Home NIV, in conjunction with pharmacological treatments, can keep frequent flyers out of the hospital
Chronic obstructive pulmonary disease (COPD) is a growing problem in the U.S. and across the world. This chronic lung condition includes chronic bronchitis and emphysema, and involves persistent, non-reversible airflow limitation. Elastic lung recoil is reduced due to destruction of the parenchyma, resulting in increased airtrapping and ineffective ventilation. Loss of parenchyma also decreases gas exchange. Airway inflammation occurs which narrows the airway lumen, contributing to airflow obstruction, and contributes to chronic cough and increased mucus production (also contributing to airflow obstruction).
Respiratory failure in COPD may involve hypoxemia (described as Type 1 respiratory failure) due to impaired gas exchange or hypercapnia (Type 2 respiratory failure) due to impaired ventilation.1 Acute exacerbation of COPD (AECOPD) usually requires hospitalization, and after discharge, readmissions are problematic for these patients.1 A “frequent flyer” is someone who has repeated admissions for COPD. Readmission rates within 30 days of discharge in the U.S. have been found to be 22.6% while in the United Kingdom, some 24% of COPD patients are readmitted (increasing to 43% when examined on a 90 day basis).2 This article will explore the ways the healthcare community can help keep frequent flyers home and in the best health given their condition.
Risk Factors and predictive tools for COPD readmission
Comorbid conditions are linked to increased risk of readmission of individuals hospitalized for COPD. 2 These include congestive heart failure (CHF), lung cancer, anxiety, depression, obesity, osteoporosis, chronic kidney disease, diabetes mellitus, hypertension, and obstructive sleep apnea (OSA).2 Good management of comorbid conditions can help improve the overall health and attitude for COPD patients and assist in reducing all-cause hospital readmissions.2
Several models have been developed to predict COPD readmissions. The early models, designed to predict mortality, provided a modest predictive value for readmission. These include the models labeled as ADO (age, dyspnea, and airflow obstruction), BODEX (BMI, airflow obstruction, dyspnea, and exacerbation) and DOSE (dyspnea, obstruction, smoking, and exacerbation). The later models include LACE (length of hospital stay, acuity of admission, comorbidities, and emergency department use) and CODEX (comorbidity, obstruction, dyspnea, and previous severe exacerbations). Most recently, the PEARL index (previous admissions, extended Medical Research Council score, dyspnea score, age, right and left-sided heart failure), has proven to be superior to the other five predictive models. PEARL classifies patients into three risk groups (low, moderate, or high) for readmission or death within 90 days.2
The impact of Non-Invasive Ventilation (NIV) and Bi-level Positive Airway Pressure (BiPAP)
Home use of NIV has been shown to reduce COPD admissions in many studies.3 Home NIV delivers mechanical ventilatory support using an interface such as a nasal mask, oronasal mask, or full face mask. It uses a pressure control approach to deliver flow and pressure based on a set frequency and/or patient-triggered breaths. These machines generally have several choices for settings (pressure or volume control, pressure support, PEEP, BiPAP, CPAP), and high level monitoring in real time with alarms and back-up settings, and are capable of operating on battery power (usually for several hours). Supplemental oxygen may be included to address hypoxemia.
A dedicated BiPAP device is generally less complex and less costly, and used for sleep-disordered breathing. BiPAP delivers a pressure controlled breath (defined by the Inspiratory Positive Airway Pressure setting – IPAP) coupled with a positive expiratory pressure baseline (defined by the Expiratory Positive Airway Pressure setting – EPAP). A dedicated Continuous Positive Airway Pressure (CPAP) device is also used for treating sleep disordered breathing. CPAP delivers positive expiratory pressure for spontaneous breathing and is the least complex, and least costly of the three devices (NIV, BiPAP, and CPAP). BiPAP and CPAP devices usually have no battery back power and few to no alarms in comparison to NIV.
In a systematic review and meta-analysis of home NIV and BiPAP in COPD patients (published in 2020), these approaches were found to reduce all-cause hospital admissions compared to using no device.3 In a large observational study of 48,856 patients, researchers found that NIV significantly decreased all-cause hospital admissions when compared individually to BiPAP and CPAP.4
Pharmacological treatment for COPD
The first line of treatment for COPD includes inhaled corticosteroids (ICS), short-acting beta-agonists (SABA), short-acting muscarinic antagonists (SAMA), long-acting beta-agonists (LABA), long-acting muscarinic antagonists (LAMA), and combinations of these inhaled agents (for example SAMA/SABA, LAMA/LABA, LABA/ICS, LAMA/LABA/ICS). The appropriate pharmacologic approach is important – one study found that risk of hospital readmission for patients with COPD was reduced by 41% when a LABA/ICS combination was used compared to either LABA or ICS alone.5
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) project provides guidelines for pharmacologic approaches to COPD (and also includes recommendations for use of NIV).6 Vaccination against influenza (and pneumonia for those >65 years old) are included in the GOLD guidelines to reduce risk of lower respiratory infections. Long-term therapy using a phosphodiesterase-4 (PDE4) inhibitor and antibiotics such as azithromycin and erythromycin have been shown to reduce exacerbations in COPD.6 Supplemental oxygen should also be included when considering medications for COPD patients – particularly when hypoxemia (either chronic, exertional, or nocturnal) is present.6 Careful initial assessment, follow-up to check on effectiveness of therapy, adjustments to therapy, and continuing follow-up is needed to assure that the best relief/control of symptoms has been achieved with the least side effects.
Best practice – NIV and appropriate pharmacologic therapy in a comprehensive plan
As discussed earlier, NIV can reduce readmission for COPD patients when combined with the appropriate pharmacologic approach, patients can delay or avoid hospitalization.1 Patient adherence to therapy (regarding both NIV/BiPAP and pharmacologic stategies) is important and non-adherence will contribute to risk of exacerbation and readmission.1 Patient education including the purpose and importance of the therapies, self-management, and use of a care plan can help increase adherence. Correct selection and proper fitting of the patient interface for providing NIV will also improve adherence to this therapy. Written material for COPD patients should be produced at the 5th or 6th grade reading level. Support groups are also valuable in helping COPD patients learn about their disease and often help increase adherence to therapy as they hear others discuss their issues and successes in dealing with COPD. Discussions concerning palliative care, hospice, and end-of-life issues should be included in the overall approach as well.
Providing support with NIV and the right medications help patients stay at home and stay out of the emergency department and the hospital. Dealing with COPD can be complex and confusing for patients as they must deal with various inhalers, masks, devices, and settings for NIV/BiPAP (and supplemental oxygen if needed), along with possible depression and anxiety,3 and the other issues of life with a chronic disease. For the healthcare team, having a good understanding of all the aspects of NIV and the various medications available for treating COPD will contribute to the best approach when working with this patient population.
- Nava S, Ergan B. Long-term non-invasive ventilation (NIV) for COPD patients with chronic respiratory failure. EMJ Respir. 2013;1:54-62.
- Kong CW, Wilkinson TM. Predicting and preventing hospital readmission for exacerbations of COPD. ERJ Open Research. 2020 Apr 1;6(2).
- Wilson ME, Dobler CC, Morrow AS, Beuschel B, Alsawas M, Benkhadra R, Seisa M, Mittal A, Sanchez M, Daraz L, Holets S. Association of home noninvasive positive pressure ventilation with clinical outcomes in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Jama. 2020 Feb 4;323(5):455-65.
- Vasquez MM, McClure LA, Sherrill DL, Patel SR, Krishnan J, Guerra S, Parthasarathy S. Positive airway pressure therapies and hospitalization in chronic obstructive pulmonary disease. The American journal of medicine. 2017 Jul 1;130(7):809-18.
- Soriano JB, Kiri VA, Pride NB, Vestbo J. Inhaled corticosteroids with/without long-acting β-agonists reduce the risk of rehospitalization and death in COPD patients. American Journal of Respiratory Medicine. 2003 Feb;2(1):67-74.
- The 2021 GOLD report: https://goldcopd.org/2021-gold-reports/. Accessed 6/4/2021.
About the author: Bill Pruitt, MBA, RRT, CPFT, AE-C, FAARC, is a writer, lecturer, and consultant and recently retired from over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. He also volunteers at the Pulmonary Clinic at Victory Health Partners in Mobile, AL.