Adding Home-Based Ventilation to COPD Therapy Can Prolong Time to Readmission, Death

A recent study published in JAMA found that patients with chronic obstructive pulmonary disease (COPD) who received noninvasive ventilation in addition to home oxygen therapy went longer without being readmitted to the hospital or dying than those who received only home oxygen therapy.

Hospital readmissions are a common occurrence in patients with COPD: in 2013, about 20% of patients returned to the hospital within 28 days of discharge. Home-based noninvasive ventilation has become more popular in Europe as a strategy to prevent costly and dangerous exacerbations of COPD, but trials have not confirmed its clinical or physiological efficacy.

The current study, conducted in England, aimed to determine whether adding ventilation to the usual treatment of home oxygen therapy for COPD could prolong the time to readmission or death. Participants were randomly assigned to groups that would receive either a minimum of 15 hours of oxygen therapy daily or the oxygen therapy plus at least 6 hours of noninvasive ventilation every night. All patients also had access to the tools recommended by the British Thoracic Society for managing COPD, including inhaled bronchodilator therapy and smoking cessation support.

In the 12-month study period, the median time to all-cause readmission or death was 1.4 months in the oxygen therapy group and 4.3 months in the oxygen therapy plus ventilation group. The oxygen plus ventilation group had a 17% absolute reduction in the risk of being readmitted or dying within 12 months, as their risk was 63.4% compared with 80.4% in the group receiving oxygen therapy alone.

There was no significant difference in 12-month mortality outcomes between the 2 groups, but the oxygen plus ventilation group did have significantly fewer exacerbations in that year than the oxygen-only group. The oxygen plus ventilation group also reported significantly greater health-related quality of life than the oxygen-only group at 6 weeks, using one questionnaire, and at 3 months, using a different questionnaire. After the 3-month mark, the quality of life scores, as measured by either questionnaire, did not significantly differ between the study groups.

According to the researchers, this small and brief improvement in health-related quality of life in the ventilation group “is perhaps unsurprising given the severity of disease in the COPD cohort enrolled and the high levels of physical impairment at baseline.” They found the results encouraging, as they indicated that adding noninvasive ventilation to a home oxygen therapy regimen did not add to patients’ health burden, as had been found in a prior trial, but did improve clinical outcomes.

To explain these findings, the study authors pointed to previous studies that found noninvasive ventilation could improve ventilatory response to hypercapnia, the excessive carbon dioxide buildup that can occur in the bloodstream in response to insufficient respiration. They also cited imaging studies that “suggest that high-pressure noninvasive ventilation may contribute to airway remodeling and improved ventilation-perfusion matching.”

The researchers recommended that future studies investigate the mechanisms by which ventilation therapy may benefit patients with COPD. In the meantime, their findings “support the use of in-home, high-pressure noninvasive ventilation in patients who have persistent hypercapnia for 2 to 4 weeks after resolution of respiratory acidemia requiring acute noninvasive ventilation,” they concluded.