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The Role of Noninvasive Ventilation in the Management and Mitigation of Exacerbations and Hospital Admissions/Readmissions for the Patient With Moderate to Severe COPD (Multimedia Activity)CME Resource Center FREE TO VIEW

David P. White, MD; Gerard J. Criner, MD; Michael Dreher, MD; Nicholas Hart, MD; Fred W. Peyerl, PhD, MBA; Lisa F. Wolfe, MD; Suzette A. Chin, MD, FCCP
Author and Funding Information

From the Division of Sleep Medicine (Dr White), Sleep Disorders Research Program, Brigham and Women’s Hospital, Boston, MA; Division of Pulmonary & Critical Care Medicine (Dr Criner), Temple University School of Medicine, Philadelphia, PA; Department of Cardiology, Pneumology, Vascular Medicine, and Intensive Care Medicine (Dr Dreher), University Hospital Aachen, Aachen, Germany; Clinical and Academic Direct Lane Fox Respiratory Unit (Dr Hart), St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, England; Boston Strategic Partners (Dr Peyerl), Boston, MA; Division of Pulmonary and Critical Care Medicine (Dr Wolfe), Northwestern University, Chicago, IL; and Pulmonary & Critical Care (Dr Chin), Respiratory Consultants of Georgia, Cartersville, GA.

CORRESPONDENCE TO: David P. White, MD, 4340 E Cedar Ave, Denver, CO 80246; e-mail: dpwhite@partners.org

Editor’s Note: With this article, CHEST is offering the first in an occasional series of peer-reviewed official journal CME (and non-CME) Multimedia Activities. These activities will permit readers to view video and other interactive online material and then claim CME. To access the online CME activity, go to http://journal.cme.chestnet.org/home-nivcopd.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Release date: May 11, 2015; expiration date: May 11, 2016.

Chest. 2015;147(6):1704-1705. doi:10.1378/chest.15-0394
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Published online

As seen in this CME online activity (available at http://journal.cme.chestnet.org/home-niv-copd), COPD is a common and debilitating disease and is currently the third leading cause of death in the United States. The role of noninvasive ventilation (NIV) in the management of severe, hypercapnic COPD has been controversial. However, it was concluded that current data would support the following recommendations. Patients with COPD with a waking Paco2 > 50 to 52 mm Hg, an overnight Paco2 > 55 mm Hg, or both who are symptomatic and compliant with other therapies should be eligible for NIV. In addition, multiple previous hospital admissions for COPD exacerbation, requiring noninvasive/invasive mechanical ventilation, strongly suggest a need for chronic NIV. Patients with COPD with a BMI > 30 kg/m2 respond particularly well to this therapy. When the decision is made to start NIV, this treatment is probably best initiated during a short hospitalization, although this can be accomplished in the clinic, home, or sleep laboratory if well-trained clinicians are available. Newer modes of NIV such as volume-assured pressure support, particularly with autotitrating expiratory positive airway pressure (EPAP), may create the opportunity for home NIV initiation easier for less experienced physicians. Regardless of the mode selected, inspiratory pressures must be in the 20 to 25 cm H2O range to meaningfully increase tidal volume, reduce work of breathing, and, importantly, reduce waking arterial Paco2. EPAP is currently set at 4 to 5 cm H2O, although future technologies may allow this to be individualized to maximally reduce auto-positive end expiratory pressure. The NIV device should have a backup rate although it is controversial as to whether this should be set at a high (18-20 breaths/min) vs a low (8-10 breaths/min) rate. The proper use of NIV in appropriately chosen patients with COPD can improve quality of life and increase survival. Ongoing studies are assessing if the frequency of future hospitalizations can be reduced with NIV. Thus, NIV should be strongly considered in any patients with COPD meeting the criteria described here.

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Global Education Group (Global) requires instructors, planners, managers, and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations. The faculty who participated in this multimedia activity have disclosed the following industry relationships: David P. White, MD, is a consultant/independent contractor and stock holder for Philips Respironics and ApniCure, Inc; Gerard J. Criner, MD, has nothing to disclose; Michael Dreher, MD, has received grant/research support from ResMed and honoraria from ResMed, Philips Respironics, Linde, Weinmann, and Breas Medical; Nicholas Hart, MD, has received unrestricted research grants and honoraria from ResMed, Philips Respironics, Philips, B&D Electromedical, and Fisher-Paykel; Fred W. Peyerl, PhD, MBA, has nothing to disclose; Lisa F. Wolfe, MD, is a consultant/independent contractor for Hill-Rom and Philips Respicare and has received grant/research support from ResMed; and Suzette A. Chin, MD, FCCP, has served on the Speaker’s Bureau for GlaxoSmithKline PLC.

The educational design of this activity addresses the needs of pulmonologists, primary care physicians and advanced practitioners, and other healthcare professionals caring for patients with COPD.

After completing this activity, the participant should be better able to:

  • • Describe the stages of COPD and the symptoms, causes, and presentations of COPD exacerbations.

  • • Explain the economic and quality-of-life impact of COPD exacerbations and hospital readmissions in Europe, the United States, and globally.

  • • Compare and explain the differences between the European approaches to home noninvasive ventilation (NIV) therapy in COPD to that in the United States.

  • • Inform and describe the nonpharmacologic therapies, other than NIV, to manage the patient with chronic COPD in the home.

  • • Explain and evaluate the faculty panel conclusions on the impact of home NIV on exacerbations and hospital readmissions, and on healthcare costs.

Global Education Group is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

*This CME/CE activity complies with all requirements of the federal Physician Payment Sunshine Act. If a reportable event is associated with this activity, the accredited provider managing the program will provide the appropriate physician data to the Open Payments database.

Global Education Group designates this enduring material for a maximum of 2.0 AMA PRA category 1 credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Global Education Group is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA. This educational activity for 2.0 contact hours is provided by Global Education Group. Nurses should claim only the credit commensurate with the extent of their participation in the activity.

Application for AARC credit is pending approval. For information about the accreditation of this program, please contact Global at 303-395-1782 or inquire@globaleducationgroup.com

This activity is provided by Global Education Group.

This activity is supported by an educational grant from Philips Respironics.



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