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LetterCorrespondence

FIO2, PaO2, or Else – What Matters in Noninvasive Ventilation in Stable COPD?

Irena Sarc, Kristina Ziherl and Antonio M Esquinas
Respiratory Care August 2021, 66 (8) 1368-1370; DOI: https://doi.org/10.4187/respcare.08560
Irena Sarc
Noninvasive Ventilation DepartmentUniversity Clinic of Respiratory and Allergic DiseasesGolnik, Slovenia
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  • For correspondence: [email protected]
Kristina Ziherl
Noninvasive Ventilation DepartmentUniversity Clinic of Respiratory and Allergic DiseasesGolnik, Slovenia
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Antonio M Esquinas
Intensive Care UnitHospital Morales MeseguerMurcia, Spain
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To the Editor:

We read with great interest the article by Cardinale et al1 on Embedded Image delivered by noninvasive ventilation (NIV) compared with long-term oxygen therapy (LTOT) at the same flow. We would like to add some comments regarding this study.

The article offers evidence that in NIV with home-care ventilators, the addition of oxygen does not deliver the same Embedded Image as the same flow of oxygen applied via nasal cannula (0.25 vs 0.30). This is not surprising, given the oxygen dilution in higher NIV flows. However, Embedded Image does not directly translate into Embedded Image when different modalities of oxygen delivery are used. Therefore, the comparison of nasal cannula and NIV is inappropriate, and some key points have to be addressed.

First, the authors have not provided data on Embedded Image achieved under different oxygen delivery modalities. Oxygenation data would provide crucial information on the clinical relevance of the difference in Embedded Image observed in the study. It has been established that NIV alone influences gas exchange. Ambrosino et al2 compared spontaneous breathing with pressure-support ventilation without oxygen supplementation and reported a significant improvement in pH, Embedded Image, and Embedded Image under NIV. Therefore, the combined effect of NIV and oxygen likely compensates for lower Embedded Image delivery by NIV. The effect on arterial gases cannot be assumed from Embedded Image but should be determined directly through arterial gas measurement. In our clinical practice, oxygen supplementation is titrated during NIV to reach target oxygen saturation and Embedded Image regardless of Embedded Image and is not simply translated from LTOT flows. In Table 1 we provide data on 3 patients with COPD on NIV at follow-up in recent months to show the comparison of blood gases on spontaneous and pressure-support ventilation, measured within hours. All 3 subjects signed an informed consent, the study was approved by the ethics council. The analysis demonstrates higher Embedded Image on NIV compared to LTOT on the same or lower oxygen flow. Cardinale et al1 reported that a 2.5-fold increase of LTOT oxygen flow was required during NIV to achieve the same Embedded Image. This is inconsistent with our clinical experience with NIV oxygen flows (Table 1) and is a further sign that Embedded Image during NIV is not the sole determinant of Embedded Image. Additionally, published data,3 our clinical experience (Table 1), and the present study itself show that patients with COPD require relatively low flows of oxygen during NIV. Therefore we believe the real clinical target in oxygenation is Embedded Image and not Embedded Image.

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Table 1.

Comparison of Embedded Image Between Pressure-Support Ventilation and LTOT Spontaneous Breathing in Patients With COPD

Second, it is encouraging that the study demonstrated on average similar Embedded Image during the daytime and during the nighttime NIV trials (0.24 vs 0.25), although the same mask type was utilized for all subjects. Potential poor fit of the mask could cause higher unintentional leakage (and further Embedded Image decrease) overnight, but the study found low levels of leakage. Nevertheless, results reported by Storre et al4 indicate that major leaks influence both Embedded Image and Embedded Image, but, more importantly, Embedded Image and Embedded Image were measured and compared within different NIV circuit setups. In our opinion, the issue of leaks influencing Embedded Image should be addressed with optimal mask selection and with oxygen titration for the specific NIV circuit setup used for a patient.

Finally, the authors speculate that lower Embedded Image during NIV might explain the lack of benefits of NIV across some earlier studies performed in patients with COPD. Even if we assume that significant arterial hypoxemia does occur during NIV (which the present study did not demonstrate), we believe that the lack of benefit in these studies is better explained by lower inspiratory pressures used in earlier studies and failure to significantly influence the level of Embedded Image.5 Furthermore, nocturnal oxygen desaturation itself is frequent in patients with COPD (ie, present in up to 48%).6 Several studies have reported that the addition of nocturnal oxygen and correction of nocturnal oxygen desaturation do not influence the survival of subjects with COPD with nocturnal oxygen desaturation per se.6 However, the 2 studies of NIV in COPD demonstrating the survival benefit of NIV used higher inspiratory pressures and achieved a significant reduction of Embedded Image.7 Higher inspiratory pressures lead to higher leaks, which in turn will decrease Embedded Image. Considering all these facts, it is more likely that the survival benefit of NIV in COPD is linked to increased alveolar ventilation when higher pressures are used, and that the potential of lower Embedded Image does not seem to be crucial.

To conclude, the results of the study by Cardinale et al1 demonstrate lower Embedded Image at the same oxygen flows in NIV compared to spontaneous breathing, but further studies are needed to determine the impact of this finding on oxygenation or relevant clinical outcomes.

Footnotes

  • Correspondence: Irena Sarc MSc, Noninvasive Ventilation Department, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia. E-mail: irena.sarc{at}klinika-golnik.si
  • Copyright © 2021 by Daedalus Enterprises

References

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    1. Cardinale M,
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    3. Esnault P,
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    5. Nguyen C,
    6. Daranda E,
    7. et al
    . In COPD, nocturnal noninvasive ventilation reduces the FIO2 delivered compared with long-term oxygen therapy at the same flow. Respir Care 2020;65(12):1897-1903.
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    1. Ambrosino N,
    2. Nava S,
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    . Physiologic evaluation of pressure support ventilation by nasal mask in patients with stable COPD. Chest 1992;101(2):385-391.
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    1. Windisch W,
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    . High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD. Int J Med Sci 2009;6(2):72-76.
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    OpenUrlAbstract/FREE Full Text
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    1. Windisch W,
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  6. 6.↵
    1. Hatipoğlu U,
    2. Stoller JK
    . Supplemental oxygen in patients with stable chronic obstructive pulmonary disease: evidence from Nocturnal Oxygen Treatment Trial to Long-term Oxygen Treatment Trial. Curr Opin Pulm Med 2018;24(2):179-186.
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    1. Storre JH,
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    7. Windisch W
    . Home noninvasive ventilatory support for patients with chronic obstructive pulmonary disease: patient selection and perspectives. Int J Chron Obstruct Pulmon Dis 2018;13:753-760.
    OpenUrl
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Respiratory Care: 66 (8)
Respiratory Care
Vol. 66, Issue 8
1 Aug 2021
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FIO2, PaO2, or Else – What Matters in Noninvasive Ventilation in Stable COPD?
Irena Sarc, Kristina Ziherl, Antonio M Esquinas
Respiratory Care Aug 2021, 66 (8) 1368-1370; DOI: 10.4187/respcare.08560

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FIO2, PaO2, or Else – What Matters in Noninvasive Ventilation in Stable COPD?
Irena Sarc, Kristina Ziherl, Antonio M Esquinas
Respiratory Care Aug 2021, 66 (8) 1368-1370; DOI: 10.4187/respcare.08560
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