High-intensity non-invasive ventilation in stable hypercapnic COPD: Evidence of efficacy and practical advice

High-flow nasal oxygen therapy in patients with hypercapnic respiratory failure: A systematic review and meta-analysis

BACKGROUND

Noninvasive ventilation (NIV) is recommended as the first-line respiratory support method for patients with hypercapnic respiratory failure (HRF). However, the need for well-trained operators and the occurrence of treatment discomfort may limit its efficacy. High-flow nasal oxygen therapy (HFNO) is a convenient respiratory support with user-friendly operation, high comfort, and good compliance. This systematic review and meta-analysis was performed to compare the therapeutic effects of HFNO and other noninvasive respiratory support methods [NIV or conventional oxygen therapy (COT)] in patients with acute HRF (AHRF) or chronic HRF (CHRF).

METHODS

We searched the PubMed, Web of Science, Embase, and Cochrane Library databases from inception to May 2024 to identify randomized clinical trials comparing the impact of HFNO and NIV/COT in adults with HRF.

RESULTS

Sixteen studies (1630 patients) were included. Compared with NIV, HFNO did not improve the primary outcome of PaCO2 in patients with AHRF or CHRF [AHRF: MD = -0.81, 95 % CI = -3.40 to 1.77; CHRF: MD = 1.82, 95 % CI = 0.44 to 3.20]. However, HFNO showed advantages over COT (AHRF: MD = -2.03, 95 % CI = -3.48 to -0.59; CHRF: MD = -2.64, 95 % CI = -4.24 to -1.03).

CONCLUSIONS

The evidence of its clinical efficacy in hypercapnic patients remains inconclusive. Further studies are needed to generate more evidence for the application of HFNO in patients with HRF and to determine the subset of patients for whom may be preferable.

Clinical benefit of chronic non-invasive ventilation in severe stable COPD: a matter of persistent hypercapnia improvement

PURPOSE

In patients with chronic obstructive pulmonary disease (COPD) treated with chronic non-invasive ventilation (NIV), the relation between improvements in nocturnal transcutaneous partial pressure of CO2 (PtcCO2) and daytime arterial partial pressure of CO2 (PaCO2) remains uncertain. Also, to what extent improvements in nocturnal PtcCO2 result in better health-related quality of life (HRQL), exercise capacity, lung function and survival has not been investigated.

PATIENTS AND METHODS

Patients with COPD who were initiated on chronic NIV were prospectively followed for 6 months. Daytime PaCO2 and nocturnal PtcCO2 were measured before NIV initiation. NIV targeted normocapnia (PaCO2/mean PtcCO2<6.0 kPa) or to reduce baseline values >20%. HRQL was measured with the Severe Respiratory Insufficiency questionnaire (SRI) and exercise capacity with the 6-min walk test (6MWT). Patients were divided into three groups: group 1: neither PtcCO2 nor PaCO2 reductions reached the target; group 2: both PtcCO2 and PaCO2 targets were reached; group 3: only PtcCO2 target was reached.

RESULTS

177 participants were included with both transcutaneous and daytime gas exchange data. In total, 66% reached nocturnal gas exchange targets. However, in only 17%, this also resulted in substantial daytime PaCO2 reduction (group 2). Compared with group 1, these patients had higher baseline PtcCO2 (7.4±0.7 vs 8.2±1.9 kPa, p=0.012) and better NIV usage (6.2±2.8 vs 8.3±2.4 hours, p=0.010). Despite comparable NIV settings, the forced expiratory volume in 1 s and 6MWT improved only in group 2, and only these participants reached a clinically relevant improvement on the SRI and experienced improved survival.

CONCLUSION

Patients with COPD who can maintain improved ventilation by nocturnal NIV during daytime spontaneous breathing are most likely to experience relevant benefits on HRQL, exercise capacity, lung function and survival.

Developing an Evidence-Based Interprofessional Algorithm to Apply Noninvasive Ventilation in Acute Exacerbation of COPD

BACKGROUND

When administered as first-line intervention to patients admitted with acute hypercapnic respiratory failure secondary to COPD exacerbation in conjunction with guideline-recommended therapies, noninvasive ventilation (NIV) has been shown to reduce mortality and endotracheal intubation. Opportunities to increase uptake of NIV continue to exist despite inclusion of this therapy in clinical guidelines. Prior studies suggest that efforts to increase NIV use in acute exacerbation of COPD (AECOPD) need to account for the complex and interprofessional nature of NIV delivery and the need for interprofessional team coordination.

RESEARCH QUESTION

We sought to develop an evidence-based interprofessional algorithm to apply NIV in AECOPD to improve the appropriate utilization of NIV in AECOPD.

STUDY DESIGN AND METHODS

In this prospective qualitative descriptive study, subject matter expert physicians, nurses, and respiratory therapists practicing in a variety of clinical settings caring for patients with AECOPD were recruited for semistructured interviews. The Consolidated Criteria for Reporting Qualitative Research checklist was followed for interview development. Interview themes applicable to interprofessional collaborative practice were identified using deductive thematic analysis. An NIV algorithm based on recent society guidelines was constructed. Interprofessional team tasks appropriate for each phase of the NIV process were integrated into the algorithm.

RESULTS

We present an interprofessional team-based algorithm for delivery of NIV in AECOPD inclusive of patient selection and initiation, titration, monitoring, and weaning of NIV. The goal is to increase appropriate uptake of NIV in the AECOPD population.

INTERPRETATION

The identified roles and responsibilities of an interprofessional team could be integrated into an interprofessional education program pertaining to use and management of NIV for patients with AECOPD emphasizing collaborative best practice, interprofessional team communication, and support of professional autonomy when appropriate.

Deventilation Syndrome in Patients with Chronic Obstructive Pulmonary Disease Using Nocturnal Noninvasive Ventilation: What Are the Underlying Mechanisms?

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) commonly experience severe dyspnea after discontinuation of nocturnal noninvasive ventilation (NIV), known as deventilation syndrome (DVS), which negatively affects quality of life. Despite various hypotheses, the precise mechanisms of DVS remain unknown.

METHODS

An observational pilot study was performed monitoring 16 stable COPD patients before, during, and after an afternoon nap on NIV. Seven patients experienced DVS (Borg Dyspnea Scale ≥5), while nine served as controls (Borg Dyspnea Scale ≤2). Hyperinflation was evaluated through inspiratory capacity (IC) measurements and end-expiratory lung impedance (EELI) via electrical impedance tomography. Respiratory muscle activity was assessed by diaphragmatic surface electromyography (sEMG).

RESULTS

Post-NIV dyspnea scores were significantly higher in the DVS group (5 [3-7] vs. 0 [0-1.5], p < 0.001). IC values were lower in the DVS group compared to controls, both pre-NIV (54 [41-63] vs. 88 [72-94] %pred., p = 0.006) and post-NIV (45 [40-59] vs. 76 [65-82] %pred., p = 0.005), while no intergroup difference was seen in IC changes pre- and post-NIV. EELI values after NIV indicated a tendency towards lower values in controls and higher values in DVS patients. sEMG amplitudes were higher in the DVS group within the first 5-min post-NIV (221 [112-294] vs. 100 [58-177]% of baseline, p = 0.030).

CONCLUSION

This study suggests that it is unlikely that DVS originates from the inability to create diaphragmatic muscle activity after NIV. Instead, NIV-induced hyperinflation in individuals with static hyperinflation may play a significant role. Addressing hyperinflation holds promise in preventing DVS symptoms in COPD patients.

Clinical evidence and technical aspects of innovative technology and monitoring of chronic NIV in COPD: a narrative review

INTRODUCTION

Chronic nocturnal noninvasive ventilation (NIV) improves outcomes in COPD patients with chronic hypercapnic respiratory failure. The aim of chronic NIV in COPD is to control chronic hypercapnic respiratory insufficiency and reduce symptoms of nocturnal hypoventilation, thereby improving quality of life. Chronic NIV care is more and more offered exclusively at home, enabling promising outcomes in terms of patient and caregiver satisfaction, hospital care consumption and cost reduction. Yet, to achieve and maintain optimal ventilation, during adaptation and follow-up, effective feasible (home) monitoring poses a significant challenge.

AREAS COVERED

Comprehensive monitoring of COPD patients receiving chronic NIV requires integrating data from ventilators and assessment of the patient's status including gas exchange, sleep quality, and patient-reported outcomes. The present article describes the physiological background of monitoring during NIV and aims to provide an overview of existing methods for monitoring, assessing their reliability and clinical relevance.

EXPERT OPINION

Patients on chronic NIV are 'ideal' candidates for home monitoring; the advantages of transforming hospital to home care are huge for patients and caregivers and for healthcare systems facing increasing patient numbers. Despite the multitude of available monitoring methods, identifying and characterizing the most relevant parameters associated with optimal patient well-being remains unclear.

Home Noninvasive Ventilation in COPD

Evidence is increasing that long-term noninvasive ventilation (LTNIV) can improve outcomes in individuals with severe, hypercapnic COPD. Although the evidence remains unclear in some aspects, LTNIV seems to be able to improve patient-related and physiologic outcomes like dyspnea, FEV1 and partial pressure of carbon dioxide (Pco2) and also to reduce rehospitalizations and mortality. Efficacy generally is associated with reduction in Pco2. To achieve this, an adequate interface (mask) is essential, as are appropriate ventilation settings that target the specific respiratory physiologic features of COPD. This will ensure comfort, synchrony, and adherence that will result in physiologic improvements. This article briefly reviews the newest evidence and current guidelines on LTNIV in severe COPD. It describes an actual patient who benefitted from the therapy. Finally, it provides strategies for initiating and optimizing this LTNIV in COPD, discussing high-pressure noninvasive ventilation, optimization of triggering, and control of inspiratory time. As demand increases, clinicians will need to be familiar with this therapy to reap its benefits, because inadequately adjusted LTNIV will not be tolerated or effective.

Application of Acupoint Catgut Embedding Therapy Combined with Liuzijue Breathing Exercise in the Treatment of Patients with Stable Chronic Obstructive Pulmonary Disease

Objective

To evaluate the application value of acupoint catgut embedding therapy combined with Liuzijue breathing exercise in the treatment of patients with stable chronic obstructive pulmonary disease (COPD) and its impact on immune function and quality of life.

Methods

A total of 100 patients with stable COPD admitted to our hospital from February 2020 to February 2021 were included and assigned to the experimental group (n = 50) and the control group (n = 50) according to the order of admission. Both groups of patients received conventional treatment. The control group was given daily inhalation of budesonide and formoterol fumarate powder for inhalation (320 ug/bottle), and the experimental group received additional acupoint catgut embedding therapy combined with Liuzijue breathing exercise. The clinical efficacy, pulmonary function indexes, activities of daily living (ADL) scores, quality of life (QOL) scores, traditional Chinese medicine (TCM) syndrome scores, the number of acute exacerbations, medical expenses, the incidence of adverse reactions, and immune indicators were compared between the two groups of patients.

Results

The experimental group yielded a significantly higher effective rate of treatment than the control group (P < 0.05). After the treatment, the experimental group obtained a superior outcome in terms of lung function indexes, immune function indexes, ADL and QOL scores, and the TCM syndrome scores when compared with the control group (P < 0.05). The number of acute exacerbations in the experimental group was remarkably lower than that in the control group (P < 0.05). No serious adverse reactions were observed in the two groups of patients, and no significant difference in the incidence of adverse reactions was found (P > 0.05).

Conclusion

Acupoint catgut embedding therapy combined with Liuzijue breathing exercise, with high safety, can improve the treatment effect and the quality of life of patients with stable COPD, which merits clinical promotion.

Transnasal High-Flow Oxygen Therapy versus Noninvasive Positive Pressure Ventilation in the Treatment of COPD with Type II Respiratory Failure: A Meta-Analysis

Objective

To compare the safety and efficacy of transnasal high-flow oxygen therapy (HFNT) and noninvasive positive pressure ventilation (NIV) in the treatment of chronic obstructive pulmonary disease (COPD) with type II respiratory failure.

Methods

PubMed, the Cochrane Library, Embase, CBM, CNKI, and other databases were searched for randomized controlled trials (RCTS) on the efficacy of HFNT and NIV in the treatment of COPD. Meta-analysis was conducted using RevMan 5.3 software after two researchers screened literatures, extracted data, and evaluated the methodological quality of the included studies according to inclusion and exclusion criteria.

Results

A total of 948 patients were included in 12 RCTS. Comprehensive analysis results showed that the HFNC group had higher levels of 12 h-PAO2, 48 h-PACO2 and, 48 h-pH than the NIV group, and the differences were statistically significant (P < 0.05). There were no significant differences in 24 h-PAO2 and 72 h-PAO2, 12 h-PACO2, 24 h-PACO2 and 72 h-PACO2, 24 h-pH, 48 h-pH, and 72 h-pH between the two groups after treatment (P > 0.05).

Conclusions

Compared with NIV, HFNC does not increase the treatment failure rate in COPD patients with type II respiratory failure, and HFNC has better comfort and tolerance, which is a new potential respiratory support treatment for COPD patients with type II respiratory failure.

Baseline Level and Reduction in PaCO2 are Associated with the Treatment Effect of Long-Term Home Noninvasive Positive Pressure Ventilation in Stable Hypercapnic Patients with COPD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose

Patients and Methods

Results

Conclusion

The Relationship of Partial Pressure of Carbon Dioxide (PaCO2) with Disease Severity Indicators Such as BODE and GOLD in Hospitalized COPD Patients

Purpose

This study aimed to investigate the relationship of partial pressure of carbon dioxide (PaCO2) with BODE and GOLD in stable COPD subjects and to explore the predictive value of PaCO2 for severe COPD (BODE index score ≥5 or GOLD index score ≥3). Patients and Methods. In total, 80 participants with COPD and free from other conditions affecting PaCO2 were recruited. Arterial blood gases, BODE, GOLD, SGRQ, lung function, and other data were collected. The BODE index was calculated, and patients were divided into two groups according to the BODE index and PaCO2 median, respectively. We used Pearson's correlation test and the receiver operating characteristic curves to evaluate the utility of PaCO2. Besides, the univariate and multivariate logistic regression analyses were conducted to verify whether PaCO2 was an independent factor associated with BODE grades.

Results

COPD subjects with BODE ≥5 and GOLD ≥3 had significantly higher levels of PaCO2 (p = 0.004, p = 0.001, respectively). In the high PaCO2 group, patients underwent poorer outcomes than the low PaCO2 group. PaCO2 was negatively correlated with forced expiratory volume in 1 second in percent of the predicted value (FEV1%) (r = -0.612, p < 0.001). The performance of PaCO2 levels in predicting BODE ≥5 and GOLD ≥3 was 0.748 and 0.755, respectively. The logistic regression analyses proved that PaCO2 was associated with BODE ≥5 in COPD patients (odds ratio = 1.160, 95% CI: 1.025-1.313, p = 0.019).

Conclusions

A higher level of PaCO2 was associated with a higher index for BODE or GOLD in COPD and had the predictive value for severe COPD.

Portable NIV for patients with moderate to severe COPD: two randomized crossover trials

BACKGROUND

Long-term non-invasive ventilation (NIV) is as an established treatment option for chronic hypercapnic COPD patients. Beneficial effects have also been shown during exercise, but this is restricted to rehabilitation programs. New portable NIV (pNIV) devices may now enable NIV application during walking at home.

STUDY DESIGN AND METHODS

In two randomized crossover trials, the impact of pNIV on dyspnea and endurance capacity was investigated in patients with moderate to severe COPD. Participants performed a standardized 6-min walking test, with and without pNIV, using a pre-set inspiratory/expiratory positive airway pressure of 18/8 cmH₂O. The first study was performed in NIV-naïve patients (Study I), while the second study was performed in those already established on long-term NIV (Study II).

RESULTS

38 patients (66.9 ± 7.4 years, mean FEV₁: 30.3 ± 8%pred) and 23 patients (67.6 ± 8.7 years, mean FEV₁: 29.8 ± 10.4%pred) participated in Study I and II, respectively. In Study I, the mean difference in the Borg Dyspnea Scale (BDS, primary outcome) score following walking was 3.2 (IQR 2-4) without pNIV, compared to 2.6 (IQR 1-4) with pNIV (ΔBDS 0.65, P = 0.04), while walking distance increased from 311.8 m (95%CI 276.9-346.6 m) to 326.3 m (95%CI 291.5-361.2 m) (P = 0.044) when pNIV was used. Accordingly, in Study II, the mean difference in BDS was 4.4 (IQR 3-6) without pNIV, compared to 4.5 (IQR 3-6) with pNIV (ΔBDS 0.09, P = 0.54), while walking distance decreased from 291.5 m (95%CI 246.1-336.9 m) to 258.4 m (95%CI 213-303.8 m) (P ≤ 0.001).

INTERPRETATION

The use of a pNIV device during walking can improve dyspnea and walking distance in patients with moderate to severe COPD. Patients who do not already receive long-term NIV therapy are more likely to benefit compared to those undergoing long-term NIV. Careful patient selection is mandatory. Clinical Trial Register: DRKS00013203; DRKS00012913 registered October 20th 2017 and October 16th 2017; https://www.drks.de/drks_web/.

Titration and follow-up for home noninvasive positive pressure ventilation in chronic obstructive pulmonary disease: The potential role of tele-monitoring and the Internet of things

INTRODUCTION

Home noninvasive positive pressure ventilation (NIPPV) has become a well-established treatment for stable hypercapnic chronic obstructive pulmonary disease (COPD) patients. There are still other challenges including appropriate titration of ventilator parameters, adequacy of follow-up, monitoring, and management at home to ensure effectiveness and security, and to improve quality of life. The Internet of Things (IoT) is the name given to the network of devices and other "things" with built-in sensors, software, electronics, and network connectivity, which can communicate these objects over wireless networks and then send data to a cloud platform. Reliable tele-monitoring and transmission of clinical parameters from home to hospitals have prompted the development of IoT-based home NIPPV.

OBJECTIVES

This review provides an overview of titration and follow-up of home NIPPV and focuses on different technologies, modalities, managements, and cost-effectiveness used in IoT-based tele-monitoring of home mechanical ventilation.

DATA SOURCE

Literature search of Web of Science, PubMed, and EMBASE was made to find relevant articles about tele-monitoring and the IoT in home mechanical ventilation over the last 15 years. We used the following search terms: NIPPV, COPD, home mechanical ventilation, telemedicine, tele-monitoring, and management.

CONCLUSION

IoT-based management of home NIPPV, such as home titration and follow-up with the use of tele-monitoring, are emerging and yielding positive findings. However, clear conclusions based on RCT of tele-monitoring in COPD patients with NIPPV at home are only a few and large-scale multicenter studies are required for replication and further validation.

Management of Chronic Respiratory Failure in Chronic Obstructive Pulmonary Disease: High-Intensity and Low-Intensity Ventilation

A significant body of literature supports the benefit of noninvasive ventilation (NIV) for acute hypercapnia in the setting of exacerbations of chronic obstructive pulmonary disease (COPD). In those with severe COPD with chronic hypercapnic respiratory failure, however, the role of NIV has been more controversial. This article reviews the physiologic basis for considering NIV in patients with COPD, summarizes existing evidence supporting the role of NIV in COPD, highlights the patient population and ventilatory approach most likely to offer benefit, and suggests a potential clinical pathway for managing patients.

A new mode of mechanical ventilation: positive + negative synchronized ventilation

Supporting patients suffering from severe respiratory diseases with mechanical ventilation, obstacles are often encountered due to pulmonary and/or thoracic alterations, reductions in the ventilable lung parenchyma, increases in airway resistance, alterations in thoraco-pulmonary compliance, advanced age of the subjects. All this involves difficulties in finding the right ventilation parameters and an adequate driving pressure to guarantee sufficient ventilation. Therefrom, new mechanical ventilation techniques were sought that could help overcome the aforementioned obstacles. A new mode of mechanical ventilation is being presented, i.e., a Positive + Negative Synchronized Ventilation (PNSV), characterized by the association and integration of two pulmonary ventilators; one acting inside the chest with positive pressures and one externally with negative pressure. The peculiarity of this combination is the complete synchronization, which takes place with specific electronic modifications. The PNSV can be applied both in a completely non-invasive and invasive way and, therefore, be used both in acute care wards and in ICU. The most relevant effect found, due to the compensation of opposing pressures acting on the chest, is that, during the entire inspiratory act created by the ventilators, the pressure at the alveolar level is equal to zero even if adding together the two ventilators' pressures; thus, the transpulmonary pressure is doubled. The application of this pressure for 1 hour on elderly patients suffering from severe acute respiratory failure, resulted in a significant improvement in blood gas analytical and clinical parameters without any side effects. An increased pulmonary recruitment, including posterior lung areas, and a reduction in spontaneous ventilatory rate have also been demonstrated with PNSV. This also paves the way to the search for the best ventilatory treatment in critically ill or ARDS patients. The compensation of intrathoracic pressures should also lead, although not yet proven, to an improvement in venous return, systolic and cardiac output. In the analysis of the study in which this method was applied, the total transpulmonary pressure delivered was the sum of the individual pressures applied by the two ventilators. However, this does not exclude the possibility of reducing the pressures of the two machines to modulate a lower but balanced total transpulmonary pressure within the chest.

Treatment of severe stable COPD: the multidimensional approach of treatable traits

Now that additional treatment options for severe chronic obstructive pulmonary disease (COPD) have emerged in recent years, patients with severe COPD should not be left in the rather hopeless situation of "there is nothing to improve" any more. Inertia or fatalism is a disservice to our patients. Ranging from advanced care planning to quite intense and demanding therapies such as multidisciplinary pulmonary rehabilitation, (endoscopic) lung volume reduction, chronic noninvasive ventilation and lung transplantation, caregivers should try to provide a personalised treatment for every severe COPD patient. In this review, we aim to describe the multidimensional approach to these patients at our centre along the lines of treatable traits leading to specific additional treatment modalities on top of standard care.

CUL1-Mediated Organelle Fission Pathway Inhibits the Development of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a global high-incidence chronic airway inflammation disease. Its deterioration will lead to more serious lung lesions and even lung cancer. Therefore, it is urgent to determine the pathogenesis of COPD and find potential therapeutic targets. The purpose of this study is to reveal the molecular mechanism of COPD disease development through in-depth analysis of transcription factors and ncRNA-driven pathogenic modules of COPD. We obtained the expression profile of COPD-related microRNAs from the NCBI-GEO database and analyzed the differences among groups to identify the microRNAs significantly associated with COPD. Then, their target genes are predicted and mapped to a protein-protein interaction (PPI) network. Finally, key transcription factors and the ncRNA of the regulatory module were identified based on the hypergeometric test. The results showed that CUL1 was the most interactive gene in the highly interactive module, so it was recognized as a dysfunctional molecule of COPD. Enrichment analysis also showed that it was much involved in the biological process of organelle fission, the highest number of regulatory modules. In addition, ncRNAs, mainly composed of miR-590-3p, miR-495-3p, miR-186-5p, and transcription factors such as MYC, BRCA1, and CDX2, significantly regulate COPD dysfunction blocks. In summary, we revealed that the COPD-related target gene CUL1 plays a key role in the potential dysfunction of the disease. It promotes the proliferation of fibroblast cells in COPD patients by mediating functional signals of organelle fission and thus participates in the progress of the disease. Our research helps biologists to further understand the etiology and development trend of COPD.

Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial

INTRODUCTION

Chronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic COPD patients. While the number of patients increases, home initiation of NIV would greatly alleviate the healthcare burden. We hypothesise that home initiation of NIV with the use of telemedicine in stable hypercapnic COPD is non-inferior to in-hospital NIV initiation.

METHODS

Sixty-seven stable hypercapnic COPD patients were randomised to initiation of NIV in the hospital or at home using telemedicine. Primary outcome was daytime arterial carbon dioxide pressure (PaCO₂) reduction after 6 months NIV, with a non-inferiority margin of 0.4 kPa. Secondary outcomes were health-related quality of life (HRQoL) and costs.

RESULTS

Home NIV initiation was non-inferior to in-hospital initiation (adjusted mean difference in PaCO₂ change home vs in-hospital: 0.04 kPa (95% CI -0.31 to 0.38 kPa), with both groups showing a PaCO₂ reduction at 6 months compared with baseline (home: from 7.3±0.9 to 6.4±0.8 kPa (p<0.001) and in-hospital: from 7.4±1.0 to 6.4±0.6 kPa (p<0.001)). In both groups, HRQoL improved without a difference in change between groups (Clinical COPD Questionnaire total score-adjusted mean difference 0.0 (95% CI -0.4 to 0.5)). Furthermore, home NIV initiation was significantly cheaper (home: median €3768 (IQR €3546-€4163) vs in-hospital: median €8537 (IQR €7540-€9175); p<0.001).

DISCUSSION

This is the first study showing that home initiation of chronic NIV in stable hypercapnic COPD patients, with the use of telemedicine, is non-inferior to in-hospital initiation, safe and reduces costs by over 50%.

TRIAL REGISTRATION NUMBER

NCT02652559.