Research ArticleOriginal Research

Timing of Treatment Outcomes and Risk Factors for Failure of BPAP in Patients Hospitalized for COPD Exacerbation

Christopher L Mosher, Jeremy M Weber, Bhargav S Adagarla, Megan L Neely, Scott M Palmer and Neil R MacIntyre
Respiratory Care December 2022, 67 (12) 1517-1526; DOI: https://doi.org/10.4187/respcare.10155

Abstract

BACKGROUND: Patients hospitalized for COPD exacerbation have an increased risk of mortality, particularly among those who fail bi-level positive airway pressure (BPAP) for hypercapnic respiratory failure subsequently requiring invasive mechanical ventilation. Therefore, we sought to investigate the treatment course of BPAP and factors associated with BPAP treatment failure.

METHODS: We performed a retrospective cohort study using real-world evidence to investigate subjects with COPD who were treated with BPAP during a hospitalization for COPD exacerbation. Treatment outcomes were defined within 7 d from BPAP initiation as either failure, persistent, or success. Failure was defined as death or progression to invasive ventilation. Persistent was defined as receiving BPAP during hospital day 7. Success was defined as liberation from BPAP prior to hospital day 7 and not meeting criteria for failure. Unadjusted multinomial logistic regression models were used to examine the association between BPAP treatment outcomes and 17 recipient characteristics.

RESULTS: Among the 427 clinical encounters, 78% were successful, 10% were persistent, and 12% experienced failure. The median time to failure and success was 8 h and 16 h, respectively. Increasing age, body mass index (BMI), bicarbonate level, and creatinine level were significantly associated with either BPAP treatment failure, persistent treatment, or both.

CONCLUSIONS: The first 8 h following initiation of BPAP is a critical time period where patients are at high risk for life-threatening decompensation. Careful consideration should be given to increasing age, BMI, bicarbonate level, and creatinine level as these factors were associated with BPAP treatment failure or persistent treatment.

Introduction

COPD is a leading cause of death in the United States.1 COPD exacerbations are clinically defined as acute events characterized by worsening dyspnea, cough, and sputum production.2 COPD exacerbations are common events that resulted in 1,075,575 COPD-related hospitalizations in 2010 and are associated with increased mortality and significant medical cost.3 Bi-level positive airway pressure (BPAP) delivered noninvasively via face mask is an evidence-based treatment for acute or acute-on-chronic hypercapnic respiratory failure due to COPD exacerbation.2 BPAP is preferred over invasive mechanical ventilation as initial therapy in this clinical scenario due to its proven safety and mortality benefit.2,4,5

Despite the wide acceptance of BPAP as an initial therapy, patients hospitalized with COPD exacerbations continue to have significant in-hospital mortality.6 Contributing to this mortality are patients who are initially treated with BPAP and subsequently fail, requiring invasive ventilation. This specific population has been shown to have considerably worse mortality, even in comparison to patients treated initially with invasive ventilation.7-9 It is clear that a deeper understanding of the clinical course following BPAP initiation and factors associated with BPAP treatment failure are needed to improve COPD exacerbation outcomes.2,10 We conducted a retrospective cohort study using real-world evidence to identify the timing of short-term treatment outcomes and risk factors associated with short-term BPAP treatment outcomes among hospitalized subjects treated with BPAP during COPD exacerbation.

QUICK LOOK

Current Knowledge

Hospitalized patients who fail bi-level positive airway pressure (BPAP) therapy for the treatment of COPD exacerbation have considerably worse mortality, even in comparison to patients treated initially with invasive ventilation. Previously identified risk factors for BPAP treatment failure include older age, rapid heart rate and breathing frequency, severity of acidosis, Glasgow coma scale, and APACHE scores. A majority of BPAP treatment failure events occurs within 48 h of initiating therapy.

What This Paper Contributes to Our Knowledge

In a retrospective electronic health record–derived COPD cohort study, half of the subjects who experienced BPAP treatment failure or success occurred within 8 h and 16 h of initiating BPAP therapy, respectively. Increasing age, body mass index, bicarbonate level, and creatinine level were identified as risk factors present on admission associated with BPAP treatment failure or persistent treatment in the first 7 d of COPD exacerbation hospitalization.

Methods

We performed a retrospective cohort study investigating subjects with COPD who were treated with BPAP during a hospitalization for COPD exacerbation in the Duke Health network of hospitals from May 2013–January 2020. The study was approved by the institutional review board (Pro00101829) at Duke University Medical Center. The Duke Health network of hospitals encompasses 3 hospital locations: a quaternary university medical center located in Durham, North Carolina, the Durham County hospital, and an academic-affiliated hospital in Raleigh. All subjects were treated following a standard institutional BPAP protocol facilitated by a respiratory therapist and health care provider. An oronasal mask was used with initial inspiratory positive airway pressure settings 5–10 cm H2O and expiratory positive airway pressure settings 5 cm H2O. These settings along with FIO2 were then adjusted to subject comfort with a tidal volume range of 4–8 mL/kg predicted body weight and pulse oximetry targets of 89–96%. Patients were coached on the use of BPAP, and appropriate backup rates and alarms were utilized.

To identify our cohort, we leveraged Duke electronic health care records (EHRs) to identify subjects who met all of the following study criteria: (1) ≥ 18 y of age; (2) documented obstructive lung disease defined as FEV1/FVC < 70% on previous spirometry; (3) prescription of a long-acting β-agonist inhaler, anti-cholinergic inhaler, or combination inhaler on out-patient medication list (Table 1S, see related supplementary materials at http://www.rcjournal.com); (4) prior health care encounter diagnosis of COPD defined by International Classification of Diseases (ICD)-9 or -10 codes or EHR problem list diagnosis of COPD (Table 2S, see related supplementary materials at http://www.rcjournal.com); (5) ICD-9 or -10 code for COPD exacerbation on admission to emergency department (ED) or hospital discharge summary; and (6) treatment with BPAP device in ED prior to admission to the hospital. Patients were excluded if they had a prior history of lung transplantation.

The analysis was performed at the level of the clinical encounter. Therefore, subjects may have more than one hospitalization during the study period. The analysis was completed using SAS 9.4 (SAS Institute, Cary, North Carolina) and R 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria). Subject demographics and characteristics for each clinical encounter were described with continuous characteristics reported as mean (SD), median (Q1 = 25th percentile, Q3 = 75th percentile), and range. If missing values were present in a continuous variable, then the frequency and percentage of missing were reported. Categorical variables were presented as frequency and percent. If missing values were present in a categorical variable, then they were removed from the denominator when calculating percentages. Variables were measured at the time of hospital admission unless indicated otherwise.

Seven-Day BPAP Treatment Outcomes

Seven-day study outcomes were grouped into either treatment success, persistent, or failure. Treatment success was defined as the subject did not require invasive ventilation or experience death within first 7 full days from BPAP initiation and was either (1) discharged prior to hospital day 7 or (2) hospital stay was >7 d from BPAP initiation but did not receive BPAP on day 7. Persistent treatment was defined as the subject remained in the hospital for at least 7 full days after BPAP initiation and received BPAP at any point (daytime or nocturnally) during the 24-h period of hospital day 7. Treatment failure was defined as the subject died or required invasive ventilation within 7 full days of BPAP initiation. Two subject encounters reflected a transition from BPAP to tracheostomy in their oxygen device EHR. We assumed these subjects had a preexisting tracheostomy and required subsequent escalation to invasive ventilation due to worsening clinical status. Thus, these encounters were included in the treatment failure group. The Kaplan-Meier method was used to determine the incidence of success or failure over the first 7 d after BPAP initiation. The persistent group was removed from this analysis due to that group only being able to experience their event time on hospital day 7 by definition.

Risk Factors and Outcome Modeling

We selected 17 covariates to be included in our analysis informed by prior investigations including a number of covariates that had previously not been well studied.11-13 The covariates included were age, sex, race, body mass index (BMI), last recorded FEV1% predicted, history of COPD exacerbation in last 12 months, diabetes, coronary artery disease, heart failure with or without reduced ejection fraction, obstructive sleep apnea, bicarbonate, hemoglobin, albumin, creatinine, breathing frequency, abnormal heart rate (heart rate < 60 or > 120 beats/min), and low blood pressure (systolic blood pressure < 90 or diastolic blood pressure < 60 mm Hg). These covariates were measured at time of hospital admission and clinical data present within 24 h of BPAP initiation in the ED. Initial models were performed using complete case analysis. This meant that if missing values were present in a variable then the encounters utilized for modeling that particular variable were a subset of the ones used for the complete variables. This resulted in different populations between some variables. Unadjusted multinomial logistic regression models were fit to assess if there was an association between each risk factor and the odds of the 3 short-term treatment outcomes. The linearity assumption for continuous covariates was checked using a lack-of-fit test comparing a model with a linear fit versus a model using a restricted cubic splines fit. For simplicity, separate logistic regression models for persistent versus successful and failed versus successful were fit to perform this check. If the lack-of-fit P value was < .05 in either comparison, then piece-wise linear splines were created to account for the violation in the multinomial model. The association between each covariate and short-term treatment outcomes was described by the failure versus successful and the persistent versus successful treatment odds ratios (OR) and 95% CI, along with the overall, multidegree-of-freedom global association P value. P values < .05 were considered statistically significant in all analyses. No adjustment for multiple testing was performed. Creatinine was log2 (base 2) transformed due to extreme right skew. Multiple imputation using the full conditional specific method was used to create a complete analytic data set to perform a sensitivity analysis (Table 4S, see related supplementary materials at http://www.rcjournal.com). Parameter estimates and standard errors were combined across 30 imputed data sets using Rubin rules.

Results

Our analysis cohort included 280 subjects totaling 427 clinical encounters (Fig. 1). Nearly 75% of subjects only had one encounter, but the number of encounters per subject ranged from 1–12 with a median (Q1, Q3) of 1 (1, 2). The mean (SD) age was 69.5 (9.2) y, with slightly more females (53%) (Table 1). Nearly 60% and 39% of encounters involved subjects who identified as white and Black, respectively. The most common comorbid disease was diabetes (39%). Among the 39% of encounters where blood gas laboratory measurements were available prior to starting the subject on BPAP, the median (Q1, Q3) PaCO2 was 80.7 (62.0, 98.1), and pH was 7.3 (7.2, 7.3) (Table 3S, see related supplementary materials at http://www.rcjournal.com).

Fig. 1.
Fig. 1.

Flow chart. (1) Obstructive lung disease defined as FEV1/FVC < 70%; (2) COPD diagnosis defined as COPD diagnosis by International Classification of Diseases (ICD)-9, ICD-10 (encounter diagnosis or electronic health record problem list diagnosis); (3) COPD medication defined as long-acting β-agonist, long-acting muscarinic antagonist, or combination inhaler, and (4) COPD exacerbation hospitalization encounter diagnosis. PFT = pulmonary function test; BPAP = bi-level positive airway pressure; ED = emergency department.

View this table:
Table 1.

Baseline Characteristics and Clinical Variables

Frequency and Timing of 7-Day BPAP Treatment Outcomes

Among the 427 clinical encounters, 78% were successful, 10% were persistent, and 12% experienced failure. By 48 h, 81% and 67% of failures and successes had occurred, respectively, (Fig. 2). The median time to failure and success was 8 h and 16 h, respectively. Among the 52 failed encounters, invasive ventilation and death were the first qualifying failure events in 45 and 7 encounters, respectively. Among those requiring invasive ventilation, 39 and 6 required invasive ventilation within 48 h and after 48 h of BPAP initiation, respectively.

Fig. 2.
Fig. 2.

Kaplan-Meier plot showing time to event for the successful and failed groups.

Persistent-Treatment Group Characteristics and Discharge Outcomes

Forty-two encounters required BPAP through day 7 (persistent group). Twenty-five (60%) of these encounters involved subjects who were already receiving chronic BPAP therapy as out-patients, and all were ultimately discharged on BPAP. Of the 17 persistent encounters involving subjects not on chronic BPAP, 8 were ultimately discharged with chronic out-patient BPAP. No subjects died after hospital day 7 from the persistent group, and only 1 subject required invasive ventilation while hospitalized after hospital day 7. Subjects in the persistent group were ultimately discharged to the following locations: home or self-care (36%), home health service (29%), skilled nursing facility (24%), and home or in-patient hospice (12%).

Risk Factors Associated with BPAP Treatment Failure and Persistent Treatment

In univariable analysis, 4 of the 17 characteristics assessed were significantly associated with either BPAP treatment failure or persistent treatment in the first 7 d of hospitalization; they were age (P = .03), BMI (P = .02), bicarbonate level (P = .004), and creatinine level (P = .02) (Table 2). Age was found to be significantly non-linear in the persistent versus successful comparison but not the failed versus successful comparison (P = .007 and .21, respectively). Therefore, piece-wise linear splines with a knot at 70 y were created and included in the age multinomial model. Log2(creatinine) was found to be significantly non-linear in both the persistent versus successful and failed versus successful comparison (P = .003 and .033, respectively). Therefore, piece-wise linear splines with a knot at log2(creatinine) = 0, or creatinine = 1 mg/dL on the normal scale, were created and included in the model.

View this table:
Table 2.

Unadjusted Association Between Factors and Persistent Bi-level Positive Airway Pressure Use/Failure

Treatment failure.

Age when ≤ 70 and > 70 y old was associated with higher odds (OR 1.18 [95% CI 0.86–1.61] per 5-y increase) and lower odds (OR 0.88 [95% CI 0.64–1.23] per 5-y increase) of treatment failure, respectively, but these results were not significant (Fig. 3). BMI was associated with a higher odds of treatment failure (OR 1.05 [95% CI 1.01–1.08] per 1-unit increase in BMI). Bicarbonate level was associated with a higher odds of failure, but this result was not significant (OR 1.03 [95% CI 1.00–1.06] per 1-mmol/L unit increase). Log2(creatinine) ≤ 0 was associated with lower odds of failure, but this result was not significant (OR 0.56 [95% CI 0.23–1.37] per 1-unit increase in log2[creatinine]). Whereas when log2(creatinine) was > 0, we found a higher odds of treatment failure (OR 1.89 [95% CI 1.08–3.32] per one = unit increase in log2[creatinine]).

Fig. 3.
Fig. 3.

Forest plot showing failed versus successful short-term treatment outcomes. BMI = body mass index; HR = heart rate; SBP = systolic blood pressure; DBP = diastolic blood pressure.

Persistent treatment.

Age ≤ 70 and > 70 y old was associated with higher odds (OR 1.48 [95% CI 1.02–2.15] per 5-y increase) and lower odds (OR 0.40 [95% CI 0.22–0.72] per 5-y increase) of being in the persistent treatment group, respectively, (Fig. 4). BMI had no effect on the odds of persistent treatment (OR 1.01 [95% CI 0.98–1.05] per 1-unit increase in BMI). Bicarbonate level was associated with higher odds of persistent treatment (OR 1.06 [95% CI 1.02–1.09]). Log2(creatinine) ≤ 0 and > 0 was associated with lower odds of persistent treatment (OR 0.32 [95% CI 0.13–0.80] per 1-unit increase in log2[creatinine]) and higher odds of persistent treatment (OR 2.23 [95% CI 1.22–4.08] per 1-unit increase in log2[creatinine]), respectively.

Fig. 4.
Fig. 4.

Forest plot showing persistent versus successful short-term treatment outcomes. BMI = body mass index; HR = heart rate; SBP = systolic blood pressure; DBP = diastolic blood pressure.

Sensitivity Analysis

Sensitivity analysis using multiple imputation found similar results to complete case analysis (Table 4S, see related supplementary materials at http://www.rcjournal.com). Age, BMI, bicarbonate level, and creatinine level remained significant, and the remaining variables analyzed were found to be not significant. OR and confidence intervals were similar between complete case and sensitivity analysis.

Discussion

We utilized real-world evidence from the EHR to define a retrospective COPD cohort to investigate the timing of short-term treatment outcomes and risk factors associated with BPAP treatment outcomes among subjects hospitalized for COPD exacerbation. Whereas risk factors for BPAP failure have been assessed in previous studies,11-16 we believe our results meaningfully contribute to the literature in the following ways. First, we found the median time to BPAP treatment failure and success was 8 h and 16 h, respectively, (Fig. 2). Much of the previous evidence dichotomizes time to BPAP failure into early and late, mostly defined as < 48 h and > 48 h, respectively.17-22 Furthermore, time to successful liberation of BPAP has previously not been thoroughly studied. Second, we identified increasing age, BMI, bicarbonate level, and creatinine level as risk factors associated with treatment failure or persistent treatment (Table 2). Whereas increasing age has been previously recognized as a risk factor for BPAP failure,13,15,16 BMI, bicarbonate level, and creatinine level had not previously been well recognized as risk factors for BPAP failure or persistent treatment.

We observed a 12% BPAP treatment failure rate and found that 81% of BPAP failure events occurred within 48 h, which is consistent with prior results.2,4,23 Previous studies identified the first 48 h as a high-risk time period for BPAP failure but did not specify the timing of failure within 48 h.4,18,20,21 We identified the 0–8-h time period following initiation of BPAP from the ED to be a critical time period where the patient is at high risk for BPAP failure (Fig. 2). This specific time period had previously not been well appreciated. Our findings strengthen the current rationale and importance of close clinical monitoring and interval patient reassessment, especially early in the BPAP treatment course.

Previous studies have identified clinical characteristics associated with BPAP treatment failure in COPD exacerbation.11-16 Our results provide several important additional observations. We identified increasing BMI and creatinine level when > 1 mg/dL as risk factors associated with BPAP failure. The former could potentially be explained by obesity’s known deleterious effects on pulmonary function,24 thereby limiting a patient’s ability to compensate during critical illness. Increased creatinine level is consistent with prior studies that have reported that elevated serum urea nitrogen level is a risk factor for BPAP failure.16,25,26 Collectively, recognition of BMI and creatinine level as risk factors could be used to further enhance assessment of BPAP failure risk on hospital admission.

Increasing levels of serum bicarbonate were found to be associated with higher odds of persistent BPAP treatment. Among the persistent treatment group, 40% were newly started on long-term nocturnal BPAP on hospital discharge. This is relevant because current American Thoracic Society clinical practice guidelines recommend against initiating long-term nocturnal BPAP during admission for acute-on-chronic hypercapnic respiratory failure as a conditional recommendation with low certainty. Guideline authors instead recommend reassessment for nocturnal BPAP in 2–4 weeks following hospitalization.27 Evidence to support this recommendation does not consider the potential benefits of initiating nocturnal BPAP during index hospitalization. Further evidence is needed to help guide decision-making related to beginning nocturnal BPAP during hospitalization versus waiting 2–4 weeks after hospitalization. Future studies should consider potential benefits of beginning nocturnal BPAP during hospitalization and the likelihood that hypercapnia will resolve without further treatment in 2–4 weeks after hospital discharge.

Our study has several important limitations to consider regarding our findings in subjects with COPD hospitalized for COPD exacerbation and treated with BPAP. First, our cohort was retrospective; and although we emphasized validity and reproducibility through our rigorous cohort selection criteria, it is possible these criteria were too restrictive, resulting in exclusion of patients with COPD and informative clinical data. Second, as a result of our inclusion criteria, our cohort was relatively small with a limited number of events. These limitations prevented us from performing multivariable modeling, and therefore, we cannot exclude the potential for confounding to be present. Third, our data are reflective of real-world evidence generated through routine clinical care. We used diagnosis codes and EHR charting to determine cases and treatment outcomes. This approach, whereas common in studies relying on health care claims and EHR data, may include inaccuracies. However, the additional inclusion criteria we used helped to strengthen our confidence in our case cohort validity, and our failure event rate was similar to prior studies.2 Fourth, a number of covariates we intended to investigate we were unable to include in our analysis due to a high proportion of missingness (Table 3S, see related supplementary materials at http://www.rcjournal.com). In an attempt to account for this, we performed a complete case analysis followed by a sensitivity analysis using multiple imputation. The findings of each analysis identified the same risk factors, in the same direction, with similar effect estimates. Fifth, multinomial logistic regression does not fit into the standard generalized estimating equations or mixed-effect modeling frameworks. As such, we assumed all encounters were independent from each other. Failing to account for potential correlation among the encounters would not impact the OR estimates but may have led to artificially reducing their standard errors, and thus overstating the statistical significance.

Conclusions

We found a majority of treatment successes and failures occurred within the initial 48 h of starting BPAP treatment. Specifically, we identified the first 8 h following initiation of BPAP as a critical time period where patients are at high risk for life-threatening decompensation. We identified increasing age, BMI, bicarbonate level, and creatinine level as risk factors associated with BPAP treatment failure or persistent treatment in the first 7 d of hospitalization. In total, our results suggest that careful consideration should be given to these risk factors on admission and highlight the importance of close clinical monitoring and interval reassessment, particularly within the first 8 h of BPAP treatment.

Footnotes

  • Correspondence: Christopher L Mosher MD MHS, Duke Clinical Research Institute, 300 W. Morgan Street, Office 521, Durham, NC, 27701. E-mail: christopher.mosher{at}duke.edu

  • See the Related Editorial on Page 1642

  • Dr MacIntyre discloses relationships with InspiRx, Phillips, Hillrom, and Inogen. The remaining authors have disclosed no conflicts of interest.

  • Dr Mosher received research support from the National Institutes of Health (NIH) (5T32HL007538-35) and support through the CHEST Foundation to complete this project. The NIH and CHEST Foundation were not involved in the research study or in the presentation of our findings.

  • Supplementary material related to this paper is available at http://www.rcjournal.com.

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