While the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients.The European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients.The task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode.Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.
In the 17th century the ringing of a church bell at an unusual time always signified some extraordinary event, summoning the entire local community to take action [...]
To the Editor :
The disappointing results of the randomised trials on the use of noninvasive ventilation (NIV) in stable hypercapnic chronic obstructive pulmonary disease (COPD) patients [1] necessitates a search for the reasons for NIV inefficiency in long term treatment. Windisch et al. [2] suggested that NIV aimed at increasing maximum-tolerated inspiratory positive airway pressure and taking over patients breathing rhythm by a ventilator is a key factor in the success of NIV. The new idea proposed by Windisch et al. [3], called high intensity noninvasive positive pressure ventilation (Hi-NPPV), seems to be attractive, but requires verification. Therefore, we would like to congratulate Lukacsovits et al. [4] on their excellent physiological study of the short-term effects of Hi-NPPV published in the April 2012 issue of the European Respiratory Journal . However, we believe that some aspects of this study need to be critically discussed.
Firstly, Lukacsovits et al. [4] …
Although eosinophilic pleural effusion (EPE) has been a subject of numerous studies, its clinical significance still remains unclear. The aim of our study was to evaluate: 1) the relative incidence and aetiology of EPE; 2) the predictors of malignancy in patients with EPE; and 3) the relationship between repeated thoracentesis and pleural fluid eosinophilia. A retrospective analysis of 2,205 pleural fluid samples from 1,868 patients treated between 1995 and 2007 was performed. We identified 135 patients with EPE (7.2% of all patients with pleural effusion) and 153 EPE samples. The most common condition associated with EPE was malignancy (34.8%) followed by infectious (19.2%), unknown (14.1%), post-traumatic (8.9%) and miscellaneous (23.0%) pleural effusions. The incidence of malignancy was significantly higher in patients with a lower (< or =40%) pleural fluid eosinophil percentage. 40 patients with EPE underwent a second thoracentesis. In 16, eosinophilia was present in both pleural fluid samples, 14 revealed pleural fluid eosinophilia only after the second thoracentesis and 10 had eosinophilia only in the first pleural fluid sample. Pleural fluid eosinophilia should not be regarded as a predictor of nonmalignant aetiology. Probability of malignancy is lower in effusions with a high eosinophil percentage. The incidence of EPE in patients undergoing second thoracentesis is not different to that found during the first thoracentesis.
Chronic respiratory diseases limit exercise capacity, due to breathlessness and hypoxemia. A decrease in daily activity results in impairment of quality of life and higher mortality. Oxygen therapy improves exercise capacity. The main mechanism of this improvement in COPD patients is a reduction in dynamic hyperinflation. The benefits of oxygen therapy is present not only in patients with severe hypoxemia at rest (PaO2 < 60 mm Hg) requiring long-term oxygen therapy, but also in mild hypoxemic patients who develop desaturation during exercise. An improvement in exercise tolerance is proportional to the administered oxygen flow. Provision of oxygen flow from ambulatory source may be continuous or intermittent only during inspiration. Both methods seem to be comparable in terms of improving exercise tolerance and reducing hypoxemia. Ambulatory oxygen should be prescribed to all patients on long-term oxygen therapy who report outdoor activity. Moreover, normoxemic patients with severe exertional desaturation and low exercise tolerance should also be prescribed ambulatory oxygen. The flow of oxygen should be titrated to prevent desaturation during activities. The long-term effects of ambulatory oxygen such as improvement of quality of life and increasing daily activity have not been confirmed and require further investigation.
Introduction: TM seems to be an ideal tool to improve quality of care of the growing number of HNIV patients. However, the organization of such care as well as clinical outcomes are unknown. Methods: Multicenter, observational, prospective study. Two groups of patients were eligible for the study: 1. ventilated for more than 6 months and 2. starting HNIV. Trained staff analyzed ventilation quality alerts daily, excluding weekends, and intervened according to a formal protocol. Alerts' thresholds were set individually for each patient. Patients were clinically assessed before TM initiation and after 3 months by arterial blood gas analysis, overnight pulse oximetry, questionnaires SRI, S3-NIV and CAT. Results: Between October 2022 and August 2023, a 3-month follow-up was completed in 52 patients (38 in group 1 and 14 (30%) in group 2; mean age 66 years old (range 28-92): 27 (52%) patients with COPD, 14 (27%) with restrictive disorders, 7 (13%) obesity hypoventilation syndrome, 4 (8%) neuromuscular disease. In the 2nd and 3rd month of TM, mean ventilation time increased in relation to the period before TM by 49 and 37 minutes, respectively (p< 0.05). Significant changes was observed in group 2 between 1st and 3rd month: mean AHI decreased from 8,2±8 in to 5,5±4,8, and mean leaks from 12,5±10 l/min to 10,7±9 l/min. After three months of TM mean pCO2 decreased by 4,8 mmHg in Group 2 and did not changed in Group 1, and pO2 increased by 4 mmHg in both Groups. Mean T90 was reduced by 7% in all. There was no significant changes in SRI, S3-NIV and CAT. Conclusions: Preliminary results of the study suggest that TM may improve the quality of HNIV and physiological parametres of gas exchange.
Noninvasive ventilation (NIV) is currently one of the most commonly used support methods in hypoxaemic and hypercapnic acute respiratory failure (ARF). With advancing technology and increasing experience, not only are indications for NIV getting broader, but more severe patients are treated with NIV. Depending on disease type and clinical status, NIV can be applied both in the general ward and in high-dependency/intensive care unit settings with different environmental opportunities. However, it is important to remember that patients with ARF are always very fragile with possible high mortality risk. The delay in recognition of unresponsiveness to NIV, progression of respiratory failure or new-onset complications may result in devastating and fatal outcomes. Therefore, it is crucial to understand that timely action taken according to monitoring variables is one of the key elements for NIV success. The purpose of this review is to outline basic and advanced monitoring techniques for NIV during an ARF episode.
BACKGROUND:Current vaccines against SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and vaccine booster programs aim to reduce hospitalizations due to severe COVID-19 (coronavirus disease 2019). It is now accepted that vaccination does not completely prevent infection and that breakthrough COVID-19 does occur. This study included 53 vaccinated patients who were hospitalized at a single center in Poland with breakthrough COVID-19 and aimed to evaluate the factors associated with their clinical course. MATERIAL AND METHODS:This study covered the period 26 November 2021 to 11 March 2022. All patients had been vaccinated against COVID-19 with one of the following 4 vaccines: the mRNA-1273 (Moderna) mRNA vaccine (Spikevax); the BNT162b2 (Pfizer-BioNTech) mRNA vaccine (nucleoside-modified) (Comirnaty); the Ad26.COV2.S (Janssen/J0ohnson & Johnson) recombinant vaccine (Jcovden); and the AZD1222 (ChAdOx1) (Oxford/AstraZeneca) recombinant vaccine (Vaxzevria). RESULTS:The course of COVID-19 in vaccinated patients was relatively similar. The patients vaccinated more than 24 weeks earlier rarely needed a stay in the Intensive Care Unit (ICU) (P=0.021), and the occurrence of deaths was significantly lower in this group (P=0.046). Women remained in hospital considerably longer than men (P=0.011). Age and comorbidities did not affect the course of this infection. CONCLUSIONS:Despite the many advantages of the COVID-19 vaccination, our observations indicate a potential risk of infection after vaccination. The assessment of the course of COVID-19 in vaccinated patients gives the possibility to compare different vaccines and indicate factors that can reduce immunity.
Oxygen increases exercise capacity in COPD patients with resting (RH) and exertional hypoxaemia (EH). Pulling the oxygen source on a wheeled cart is beneficial versus carrying it on a shoulder. However, pulling the cart may impair walking speed and reduce the possibility of ambulation. The aim of the study was to verify if walking with oxygen canister pulled by patient on a cart is beneficial versus walking without any load.
COPD patients with RH and EH in random order performed 2 standardized 6-min walking tests: without oxygen supplementation and with oxygen (flow 6 l/min) from canister transported on a wheeled cart.
We studied 34 pts (19 males, mean age 72±7 yrs, mean FEV1 1±0,4 l (41±12% pred.): 15 with RH (mean PaO2 52±4 mmHg) and 19 with EH (mean PaO2 66±4 mmHg). In 6 EH patients (32%) and in 10 RH patients (67%) 6MWD improved with O2 supplementation. In spite of significant improvement in SaO2 during tests with O2, neither dyspnea nor distance improved significantly in both groups. In RH 6MWD increased insignificantly by 13 m (295±110 m vs. 307±97 m) and in EH increased by only 2 m (356±94 m vs. 358±70 m). Despite the high O2 flow, 8 RH patients (53%) and 7 EH (37%) had SaO2 < 90% at the end of test. RH patients who desaturated had lower PaCO2 (44±6 vs. 53±6 mmHg, p<0.01). EH patients who desaturated covered longer 6MWD with (411±41 m vs. 326±65 m; p<0.01) and without oxygen (415±46 m vs. 322±99 m; p=0.03).
Oxygen supplementation from canister pulled on wheeled cart does not improve 6MWD; however, it may be more beneficial for exercise capacity in patients with RH than EH. Oxygen flow of 6 l/min does not protect against hypoxaemia during strenuous exercise.
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