Out-patient or home management of patients with severe COPD following a hospitalization or severe exacerbation remains challenging. These patients are at risk for respiratory failure or are in a state of incipient respiratory failure that can be difficult to manage. Aside from supplemental oxygen, additional adjuncts to therapy have been the subject of decades of investigation1,-,3 with nocturnal ventilatory support and variable success. Marked improvement in outcomes were realized with a shift in treatment strategies to noninvasive ventilation (NIV) providing more intensive support with a reduction in PaCO2.4,-,6 This experience has formed the basis of mostly conditional recommendations on NIV for chronic hypercapnic patients with COPD.7
A stronger endorsement was tempered by questions about concomitant sleep disorders, mask issues, training, adherence to therapy, and the process of initiation of support with some uncertainty about the PaCO2 targets for reduction, whether reduction be normalization or just below a threshold such as 48 mm Hg. More recent experience suggests home initiation is possible, but small numbers of actual participants remain a concern.8,9 The difficulties of application of NIV cannot be overstated as benefit is only achieved with consistent use. Successful …
Correspondence: Guy W Soo Hoo MD MPH. E-mail: Guy.soohoo{at}va.gov
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