Cost effectiveness of HOT-HMV therapy
Following the outcome of the HOT-HMV study1, a health economics analysis was performed to assess the cost effectiveness of HOT-HMV when compared to HOT alone among COPD patients in the UK with persistent hypercapnia after a life-threatening exacerbation.2
The analysis indicates that the probability of HOT-HMV being cost effective is 62%, based on £30,000 willingness to pay.
The Köhnlein study
Mortality risk reduction of 76% over 1 year with NIV3
This randomised, controlled trial showed a significant improvement in survival for stable hypercapnic COPD patients who were effectively treated with NIV.
Improved quality of life3
Using the St George’s Respiratory Questionnaire, the study also showed that patients treated with NIV reported a significantly improved quality of life.
Who and when: selecting patients for home NIV
Patients recovering from acute respiratory failure associated with an exacerbation of COPD should be evaluated at 2–4 weeks after resolution of respiratory acidosis, and those with persistent hypercapnia should be given home NIV.1
Stable COPD patients with chronic hypercapnic respiratory failure also benefit from home NIV.3
Differences in the timing of home NIV initiation might explain different outcomes between studies.1,4
Flow diagram showing patient selection for home NIV based on clinical trial data.1,3
Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines state that home NIV may improve hospitalisation-free survival in selected patients after recent hospitalisation, particularly those with pronounced daytime persistent hypercapnia (PaCO2 ≥52 mmHg’, Level of Evidence = B).5
A multidisciplinary ERS Task Force committee have published evidence-based recommendations for the clinical application of long-term home NIV in chronic hypercapnic COPD patients:6
- Use of long-term home NIV in stable hypercapnic COPD;
- Use of long-term home NIV in COPD patients following a COPD exacerbation requiring acute NIV;
- Use of NIV settings targeting a reduction in carbon dioxide;
- Use of fixed pressure support as first choice ventilator mode.
How to treat COPD patients with home NIV: best practices
Improving elevated arterial carbon dioxide levels should be one of the main goals of home NIV.7
Clinical trial data show that higher inspiratory pressures targeted at reducing elevated carbon dioxide levels contribute to the success of home NIV therapy.1,3
High-intensity NIV does not appear to have a negative impact on adherence, sleep quality, or quality of life.8
Careful monitoring is essential for patients initiated on high-intensity NIV. This could be facilitated by telemedicine technology providing ventilatory data, patient-ventilator asynchrony, transcutaneous gas measures and other relevant parameters.
[Webinar] Home NIV in stable COPD: how and why?
With over 20 years of experience in the field of non-invasive ventilation, Professor Windisch explores the evolution of the treatment from early negative studies using low intensity pressure ventilation to today’s evidence based approach to improve survival and quality of life in patients with stable hypercapnic COPD.
*As shown by 3 and 6 months results on quality of life and compliance
- Murphy P et al. Effect of Home Noninvasive Ventilation With Oxygen Therapy vs Oxygen Therapy Alone on Hospital Readmission or Death After an Acute COPD Exacerbation. A Randomized Clinical Trial, JAMA. Published online May 21, 2017. doi:10.1001/jama.2017.4451.
- Murphy PB et al. Cost-Effectiveness of Home Oxygen Therapy-Home Mechanical Ventilation (HOT-HMV) for the Treatment of Chronic Obstructive Pulmonary Disease (COPD) with Chronic Hypercapnic Respiratory Failure Following an Acute Exacerbation of COPD in the United Kingdom (UK). American Journal of Respiratory and Critical Care Medicine 2018;197:A2517.
- Köhnlein T, et al., Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. Lancet Respir Med 2014;2:698-705.
- Struik FM, et al. Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure: a randomised, controlled, parallel-group study. Thorax 2014;69:826-34.
- Vogelmeier DF, et al. Global strategy for diagnosis, management, and prevention of COPD. Am J Respir Crit Care Med 2017;195:557-82.
- Ergan B, Oczkowski S, Rochwerg B, et al. European Respiratory Society Guideline on Long-term Home Non-Invasive Ventilation for Management of Chronic Obstructive Pulmonary Disease. Eur Respir J 2019; in press (https://doi.org/10.1183/13993003.01003-2019).
- Nocturnal non-invasive positive pressure ventilation for COPD. Windisch W et al. Expert Rev Respir Med. 2015 Jun; 9(3):295-308.
- Dreher M, et al. Noninvasive ventilation in COPD: impact of inspiratory pressure levels on sleep quality. Chest 2011;140:939-45.