Current guidelines recommend long-term, high-intensity noninvasive ventilation (NIV) for patients with COPD with chronic hypercapnic respiratory failure to reduce PaCO₂, symptoms, hospitalizations, and mortality.1 Many patients struggle with intolerance due to various factors, leading to missed opportunities for clinicians to improve outcomes.
Patient education regarding the need for NIV, how it works, and treatment duration has been shown to improve tolerability.2 Giving informational tools, motivational and behavioral support, and encouraging participation in support groups both in person and via televisits have also shown improved compliance.3 Encouraging patients to use NIV while engaged in distracting activities (ie, watching TV), utilizing a prolonged acclimatization period, and referring patients with insomnia to cognitive behavioral therapy may also be helpful.4,5
Studies suggest that nasal masks, compared with oronasal masks, are associated with better adherence and a lower residual apnea hypopnea index. Managing nasal symptoms (if present), using humidification, nasal steroids, or nasal surgery can further improve comfort and effectiveness. Oral leaks may be addressed with chin straps or by reviewing the mask seal. Despite the advantages of nasal masks, oronasal masks are effective for many patients, including those with persistent oral leaks.6 An in-lab titration study or “PAP-NAP” (if available) are the most helpful ways to ensure proper mask fitting in real time. Therapy reports can also differentiate causes of obstructive or central apneas, and device adjustments can be made in clinic.
Higher inspiratory positive airway pressures (IPAP) have been associated with improved adherence compared with lower pressures and are more effective in improving PCO2, dyspnea, and FEV1; although, a gradual increase in IPAP may be necessary for patient adaptation. Lower expiratory PAP (EPAP) may be sufficient for some patients with COPD to prevent rebreathing in a single-limb passive circuit. Higher EPAP or auto-EPAP may be required to overcome upper airway obstruction in patients with OSA, to match intrinsic positive end-expiratory pressure in patients with breath stacking, or to stent airways during exhalation, which may correct expiratory flow limitations.7 Referral for an in-lab titration study targeting high-intensity NIV may be required to determine optimal settings and proper mask fitting. In patients with severe COPD, dyssynchronous breathing may result from insufficient expiratory time. This can be improved by optimizing trigger settings and shortening inspiratory time, by increasing cycle sensitivity to “high,” and by selecting shorter inspiratory and rise times.
High-intensity NIV is vital for patients with COPD with hypercapnic respiratory failure. Success depends on overcoming patient intolerance. Patient-oriented interventions can help maximize NIV effectiveness and improve patient outcomes.
References
1. Macrea M, Oczkowski S, Rochwerg B, et al. Long-term noninvasive ventilation in chronic stable hypercapnic chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;202(4):e74-e87. doi:10.1164/rccm.202006-2382ST
2. McCormick JL, Clark TA, Shea CM, et al. Exploring the patient experience with noninvasive ventilation: a human-centered design analysis to inform planning for better tolerance. Chronic Obstr Pulm Dis. 2022;9(1):80-94. doi: 10.15326/jcopdf.2021.0274
3. Yu DSF, Li PWC, Lau JCC, et al. Health communication and adherence to noninvasive ventilation in chronic hypercapnic respiratory failure: a randomized clinical trial. JAMA Netw Open. 2024;7(12):e2451614. doi:10.1001/jamanetworkopen.2024.51614
4. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173-178. PMID: 18250209; PMCID: PMC2645251.
5. doi: 10.1513/pats.200708-119MGSweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019;42(12):zsz178. PMID: 31403168. doi: 10.1093/sleep/zsz178
6. Genta PR, Kaminska M, Edwards BA, et al. The importance of mask selection on continuous positive airway pressure outcomes for obstructive sleep apnea. An official American Thoracic Society workshop report. Ann Am Thorac Soc. 2020;17(10):1177-1185. doi:10.1513/AnnalsATS.202007-864ST
7. Kaminska M, Adam V, Orr JE. Home noninvasive ventilation in COPD. Chest. 2024;165(6):1372-1379. doi:10.1016/j.chest.2024.01.030