Nocturnal non-invasive nasal ventilation in stable hypercapnic COPD: a randomised controlled trial
- R D McEvoy1,
- R J Pierce2,
- D Hillman3,
- A Esterman4,
- E E Ellis5,
- P G Catcheside1,
- F J O’Donoghue1,2,
- D J Barnes6,
- R R Grunstein6
- 1Adelaide Institute for Sleep Health, Repatriation General Hospital and Flinders University, Australia
- 2Institute for Breathing and Sleep, Austin Hospital, Heidelberg, Victoria, Australia
- 3WA Sleep Disorders Research Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia
- 4School of Nursing and Midwifery, University of South Australia, Adelaide, Australia
- 5School of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
- 6Sleep Research Group, Woolcock Institute, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
- Professor D McEvoy, Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, South Australia, Australia 5000; doug.mcevoy{at}health.sa.gov.au
- Received 22 September 2008
- Accepted 21 January 2009
- Published Online First 12 February 2009
Abstract
Background: Sleep hypoventilation has been proposed as a cause of progressive hypercapnic respiratory failure and death in patients with severe chronic obstructive pulmonary disease (COPD). A study was undertaken to determine the effects of nocturnal non-invasive bi-level pressure support ventilation (NIV) on survival, lung function and quality of life in patients with severe hypercapnic COPD.
Method: A multicentre, open-label, randomised controlled trial of NIV plus long-term oxygen therapy (LTOT) versus LTOT alone was performed in four Australian University Hospital sleep/respiratory medicine departments in patients with severe stable smoking-related COPD (forced expiratory volume in 1 s (FEV1.0) <1.5 litres or <50% predicted and ratio of FEV1.0 to forced vital capacity (FVC) <60% with awake arterial carbon dioxide tension (Paco2) >46 mm Hg and on LTOT for at least 3 months) and age <80 years. Patients with sleep apnoea (apnoea-hypopnoea index >20/h) or morbid obesity (body mass index >40) were excluded. Outcome measures were survival, spirometry, arterial blood gases, polysomnography, general and disease-specific quality of life and mood.
Results: 144 patients were randomised (72 to NIV + LTOT and 72 to LTOT alone). NIV improved sleep quality and sleep-related hypercapnia acutely, and patients complied well with therapy (mean (SD) nightly use 4.5 (3.2) h). Compared with LTOT alone, NIV (mean follow-up 2.21 years, range 0.01–5.59) showed an improvement in survival with the adjusted but not the unadjusted Cox model (adjusted hazard ratio (HR) 0.63, 95% CI 0.40 to 0.99, p = 0.045; unadjusted HR 0.82, 95% CI 0.53 to 1.25, p = NS). FEV1.0 and Paco2 measured at 6 and 12 months were not different between groups. Patients assigned to NIV + LTOT had reduced general and mental health and vigour.
Conclusions: Nocturnal NIV in stable oxygen-dependent patients with hypercapnic COPD may improve survival, but this appears to be at the cost of worsening quality of life.
Trial registration number: ACTRN12605000205639
Footnotes
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See Editorial, p 553
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Funding: Australian National Health and Medical Research Council, Air Liquide Healthcare, Australian Lung Foundation.
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Competing interests: None.
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Ethics approval: The ethics committee of each participating centre approved the protocol and patients gave written informed consent.
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Complete list of AVCAL investigators. Adelaide: R D McEvoy, F J O’Donoghue, P G Catcheside, L S Rowland, R Antic, H W Greville, A M Southcott; Sydney: R R Grunstein, D J Barnes, I H Young, E E Ellis, E R Collins, A J Piper; Melbourne: R J Pierce, F J O’Donoghue, K Detering, L B Irving, C F McDonald, C J Worsnop, L M Schachter, S E Rochford; Perth: D Hillman, P Eastwood.
