- Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the world and is the fourth leading cause of death in the United States.
- To date, the only therapeutic interventions known to reduce mortality in COPD are smoking cessation and long-term treatment with continuous supplemental oxygen for patients who have severe hypoxemia at rest.
- Recently, interest in the use of noninvasive ventilation (NIV) in chronic hypercapnic COPD has been renewed with studies of so-called “high-intensity” NIV, which refers to inspiratory pressures higher than those used in most previous randomized controlled trials (RCTs) as well as controlled ventilation with higher-than-baseline respiratory rates to maximally reduce the PaCO2.
Application of Guideline Recommendations for Different Stakeholders
(“The ATS recommends...”)
(“The ATS suggests...”)
|For Patients||Most individuals in this situation would want the recommended course of action, and only a small proportion would not.||The majority of individuals in this situation would want the suggested course of action, but many would not.|
|For Clinicians||Most individuals should receive the recommended course of action. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.||Different choices are likely to be appropriate for different patients and therapy should be tailored to the individual patient’s circumstances. Those circumstances may include the patient’s or family’s values and preferences.|
|For Policymakers||The recommendation can be adapted as policy in most situations, including for use as performance indicators.||Policy making will require substantial debates and involvement of many stakeholders. Policies are also more likely to vary between regions. Performance indicators would have to focus on the fact that adequate deliberation about the management options has taken place.|
- For patients with chronic (FEV1/FVC < 0.70 and resting PaCO2 > 45 mm Hg [not during exacerbation]) hypercapnic respiratory failure due to chronic obstructive pulmonary disease (COPD).
- The ATS suggests the use of nocturnal noninvasive ventilation (NIV) in addition to usual care for patients with chronic stable hypercapnic COPD (conditional recommendation, moderate certainty).
- The ATS suggests that patients with chronic stable hypercapnic COPD undergo screening for obstructive sleep apnea before initiation of long-term NIV (conditional recommendation, very low certainty).
- The ATS suggests NOT initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure, favoring instead reassessment for NIV at 2–4 weeks after resolution (conditional recommendation, low certainty).
- The ATS suggests NOT using an in-laboratory overnight polysomnogram (PSG) to titrate NIV in patients with chronic stable hypercapnic COPD who are initiating NIV (conditional recommendation, very low certainty).
- The ATS suggests NIV with targeted normalization of PaCO2 in patients with hypercapnic COPD on long-term NIV (conditional recommendation, low certainty).