What is the management of Non-Invasive Positive Pressure Ventilation (NIPPV) for hypercapnic respiratory failure?

From the Guidelines

For patients with chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease (COPD), the use of nocturnal noninvasive ventilation (NIV) in addition to usual care is suggested, as it has been shown to improve outcomes in these patients. This approach is supported by the American Thoracic Society clinical practice guideline published in 2020 1. The guideline recommends starting with nocturnal NIV and adjusting the settings to achieve targeted normalization of PaCO2, which is a key factor in managing hypercapnic respiratory failure.

When initiating NIV, it is essential to consider the patient's individual needs and adjust the settings accordingly. The guideline suggests that patients with chronic stable hypercapnic COPD undergo screening for obstructive sleep apnea before initiation of long-term NIV 1. Additionally, the guideline recommends against initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure, instead favoring reassessment for NIV at 2–4 weeks after resolution 1.

In terms of specific settings, the guideline suggests using NIV with targeted normalization of PaCO2 in patients with hypercapnic COPD on long-term NIV 1. This approach can help improve outcomes and reduce the risk of complications associated with hypercapnic respiratory failure. It is also important to note that NIV should be used in conjunction with other treatments, such as bronchodilators, corticosteroids, and antibiotics, as needed, to manage the underlying condition and prevent exacerbations.

Overall, the use of nocturnal NIV in addition to usual care is a recommended approach for managing chronic hypercapnic respiratory failure in patients with COPD, as it can help improve outcomes and reduce the risk of complications. This approach is supported by the most recent and highest quality evidence available, including the 2020 American Thoracic Society clinical practice guideline 1.

Key points to consider when managing NIPPV for hypercapnic respiratory failure include:

• Starting with nocturnal NIV and adjusting settings to achieve targeted normalization of PaCO2
• Screening for obstructive sleep apnea before initiation of long-term NIV
• Avoiding initiation of long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure
• Using NIV in conjunction with other treatments, such as bronchodilators, corticosteroids, and antibiotics, as needed.

From the Research

Management of NIPPV for Hypercapnic Respiratory Failure

• Noninvasive ventilation (NIV) is considered the standard of care for the management of acute hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease exacerbation 2.
• NIV helps improve dyspnea and gas exchange, reduces the need for endotracheal intubation, and morbidity and mortality rates 2, 3.
• The use of NIV decreased the risk of mortality by 46% and decreased the risk of needing endotracheal intubation by 65% 3.
• High-flow nasal therapy may be used in some patients with acute hypercapnic respiratory failure, but more information is needed before specific recommendations can be made 2.
• Auto-titrating noninvasive ventilation (NIV) has been shown to decrease PaCO2 more efficiently and rapidly in hypercapnic ICU patients compared to volume-assured mode 4.
• The use of high-pressure NIV for acute hypercapnic respiratory failure in COPD has been associated with improved survival in a retrospective cohort study 5.

Key Considerations

• NIV should be delivered safely in a dedicated setting, from emergency rooms to high dependency or intensive care units and wards 2.
• The choice of NIV mode and settings should be individualized based on patient characteristics and response to treatment 3, 4.
• Close monitoring of patients receiving NIV is essential to ensure effective treatment and minimize complications 3, 6.

Treatment Outcomes

• NIV has been shown to improve symptoms, gas exchange, and reduce the need for endotracheal intubation and mortality in patients with acute hypercapnic respiratory failure 2, 3.
• Auto-titrating NIV has been associated with a faster decrease in PaCO2 and improved ventilatory parameters compared to volume-assured mode 4.
• High-pressure NIV has been associated with improved short-term and long-term survival rates in patients with COPD and acute hypercapnic respiratory failure 5.