From the Guidelines
Home BiPAP therapy is indicated for COPD patients with chronic hypercapnic respiratory failure, typically when PaCO2 is consistently above 45 mmHg, as evidenced by the 2020 American Thoracic Society clinical practice guideline 1. Specific indications include:
- Frequent COPD exacerbations requiring hospitalization
- Persistent hypercapnia after an acute exacerbation
- Nocturnal hypoventilation symptoms
- Sleep-disordered breathing in COPD To implement:
- Start with low pressures (e.g., IPAP 8-10 cmH2O, EPAP 4-5 cmH2O) and titrate up as tolerated
- Aim for at least 4 hours of use per night
- Regular follow-up to assess adherence, symptom improvement, and blood gas changes BiPAP helps by reducing work of breathing, improving gas exchange, and resting respiratory muscles, which can lead to improved quality of life, reduced hospitalizations, and potentially improved survival in select COPD patients with chronic hypercapnic respiratory failure, as supported by the latest guidelines 1. Key considerations for initiating home BiPAP therapy include:
- Patient selection, with a focus on those with severe hypercapnia and frequent exacerbations
- Appropriate titration of pressures to ensure patient comfort and adherence
- Regular monitoring and follow-up to assess treatment efficacy and adjust therapy as needed, in line with the recommendations outlined in the 2020 American Thoracic Society clinical practice guideline 1.
From the Research
Indications for Home BiPAP Therapy in COPD Patients
The following are indications for home Bi-level Positive Airway Pressure (BiPAP) therapy in patients with Chronic Obstructive Pulmonary Disease (COPD):
- Severe hypercapnic COPD, characterized by a daytime partial pressure of carbon dioxide (P CO2) ≥50 mmHg in a stable condition or with persistent hypercapnia ≥53 mmHg >14 days following an exacerbation with mechanical ventilation 2
- Chronic hypercapnic respiratory failure due to stable COPD, with a significant decrease of hypercapnia during spontaneous breathing 3
- Patients with persistent hypercapnia, defined as a PaCO2 >7kPa or 50mmHg 4
- Frequent or infrequent exacerbator phenotype, with the timing of assessment in the recovery phase, 2-4 weeks after resolution of acute acidosis, to delineate transient from persistent hypercapnia 4
- Patients with COPD and obstructive sleep apnoea (OSA) both with and without hypercapnia, where home positive airway pressure therapy (NIV or continuous positive airway pressure; CPAP) may be beneficial 4
Key Considerations
When considering home BiPAP therapy for COPD patients, the following factors are important:
- The patient's blood gas levels, with a focus on reducing hypercapnia 3, 2
- The patient's lung function, including forced expiratory volume in 1 s (FEV1) 2
- The patient's quality of life, including health-related quality of life (HRQoL) and disease-specific aspects of HRQL 3, 2, 5
- The use of remote-monitoring and volume-assured auto-EPAP NIV mode, which may improve outcomes and reduce hospital readmissions 6