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University Medical Centre Groningen The Netherlands

Oxygen / ventilatory support in COPD. University Medical Centre Groningen The Netherlands. OXYGEN. MEDICATION. LTX. Severe COPD. LVRS. VENTILATORY SUPPORT. REHABILITATION. OXYGEN. MEDICATION. LTX. Severe COPD. LVRS. VENTILATORY SUPPORT. REHABILITATION. 100. 90.

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University Medical Centre Groningen The Netherlands

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  1. Oxygen / ventilatory support in COPD University Medical Centre Groningen The Netherlands

  2. OXYGEN MEDICATION LTX Severe COPD LVRS VENTILATORY SUPPORT REHABILITATION

  3. OXYGEN MEDICATION LTX Severe COPD LVRS VENTILATORY SUPPORT REHABILITATION

  4. 100 90 NOTT 80 19 hrs 70 MRC 60 Cumulative Survival % 50 15 hrs 12 hrs 40 No Oxygen 30 20 10 0 0 10 20 30 40 50 60 70 80 Time (months) 203 subjects randomized to continuous or 12 hours of oxygen for at least 12 months 87 subjects randomized to oxygen 15 hours/day or none Composite slide NOTT and MRC studies

  5. Dynamic Hyperinflation in COPD • Increases work of breathing from added elastic loads • Respiratory muscles at a mechanical disadvantage • Contributes to the sensation of dyspnea with increasing inspiratory pressures

  6. 3 32 14 30 12 2.5 28 10 2 26 Inspiratory capacity (L) Respiratory rate (breath/min) Endurance time (min) 8 24 1.5 6 22 1 4 20 0.5 2 18 0.2 0.3 0.5 0.75 1.0 0.2 0.3 0.5 0.75 1.0 0.2 0.3 0.5 0.75 1.0 FiO2 FiO2 FiO2 Effect of Oxygen in 10 Non-hypoxemic Patients with Severe COPD, During Constant Work Modified from Somfay A, ERJ 2001;18:77

  7. Reduces ventilation Reduces air trapping Reduces hyperinflation Relieves dyspnea Increases exercise Improves health-related quality of life Medical Volume Reduction with Oxygen

  8. -50 0 50 Favours placebo Favours oxygen Systematic Review of RCT’s of Short Term Benefit of Ambulatory Oxygen in COPD Exercise capacity – Endurance distance

  9. Supplementary Oxygen and Exercise • Strong laboratory support for oxygen improving exercise, by decreasing ventilation • Funding criteria vary among jurisdictions • Few controlled trials of oxygen during exercise training

  10. 700 600 500 400 6MWD (m) 300 200 100 0 Air Oxygen Supplemental Oxygenin hypoxemic COPD Rooyackers J, ERJ 1997;10:1278

  11. Supplemental Oxygen in hypoxemic COPD Garrod et al Thorax 2000;55:543

  12. 70 60 Work Rate (Watt) B 50 A 40 30 20 0 5 10 15 20 Training Sessions Supplemental Oxygen in Non-hypoxemic COPD Emtner M, AJRCCM 2003;168

  13. Supplemental Oxygen in Non-hypoxemic COPD • Oxygen room air Emnter. AJRCCM 2003;168:1034

  14. Supplemental Oxygen in Non-hypoxemic COPD Emnter. AJRCCM 2003;168:1034

  15. Conclusion • LTOT is life saving for those with resting hypoxaemia • Ambulatory oxygen should increase mobility for those who require LTOT, but the evidence to support this is incomplete • Oxygen for exercise training reduces ventilation and may enable training at a higher load.

  16. OXYGEN MEDICATION LTX Severe COPD LVRS VENTILATORY SUPPORT REHABILITATION

  17. Chronic ventilatory support in COPD • Why should we start NIPPV in COPD ? • What is the evidence ? • New studies

  18. Sleep hypothesis Meecham Jones et al.1995:152:538-544

  19. Hyperinflationhypothesis Diaz et al. ERJ 2002;20:1490

  20. Study FEV1 PaCO2 BIpap Effects Strumpf 1991 0.54 49 15/2 Psych.  Meecham Jones 1995 0.86 56 18/2 QOL Gasex.  Sleep  Gay 1996 0.68 55 10/2 = Casanova2000 0.85 51 12/4 Psych. Dysp.  Short term randomised controlled trials

  21. Wijkstra et al. Chest 2003 ;124:337

  22. Study FEV1 PaCO2 BIpap Monitoring Strumpf 1991 0.54 6.5 15/2 no Meecham Jones 1995 0.86 7.4 18/2 ETCO2 Gay 1996 0.68 7.3 10/2 no Casanova2000 0.85 6.7 12/4 No Randomised controlled trials

  23. Chronic ventilatory support in COPD • Why should we start NIPPV in COPD ? • What is the evidence ? • New studies

  24. OXYGEN LTX NUTRITION COPD LVRS NIPPV + REHABILITATION

  25. Ventilatory support during exercise Oxygen Ventilation Dreher ERJ 2007;29:930

  26. Ventilatory support during exercise Dreher ERJ 2007;29:930

  27. OXYGEN LTX NUTRITION COPD LVRS NIPPV + REHABILITATION

  28. Nocturnal NIPPV in stable COPD Randomisation NIPPV 12 weeks 12 weeks NIPPV + PR 3 months Baseline Measurements PR Measurements Measurements Duiverman ATS 2008 abstract

  29. Assessed for eligibility (n= 87) Not meeting inclusioncriteria (n= 15) Randomised (n =72) Allocated to rehabilitation (n=35) Allocated to NIPPV + rehabilitation (n= 37) Early drop-outs (n=6) - 2 died - 2 withdrew - 2 other diseases Run in Baseline Baseline measurements (n = 35) Baseline measurements (n = 31) Drop-outs (n=7) - 5 intolerance to NIPPV - 1 noncompliant rehab - 1 died Drop-outs (n=3) noncompliant 3 months Analysed (n= 32) Analysed (n = 24)

  30. Patient characteristics

  31. Daytime blood gases

  32. Health related quality of lifeCRQ

  33. Health related quality of lifeMRF-28

  34. 15000 * 12500 10000 Daily step count (steps/day) 7500 5000 2500 0 Baseline After 3 months Rehabilitation NIPPV + Rehabilitation Activities in daily livingSteps/day

  35. Chronic ventilatory support in COPD • No strong evidence to provide ventilatory to patients with COPD routinely. • Ventilatory support during exercise might improve its effects, although more studies are needed • Nocturnal ventilatory support improves the effects of rehabilitation in hypercapnic COPD patients.

  36. Nocturnal blood gases * *

  37. Muscle resting hypothesis Diaz et al. ERJ 2002;20:1490

  38. Nocturnal NIPPV and daytime exercise training <-------- P <0.009 -------- > < P<0.01> Garrod et al.AJRCCM 2000:162:1335

  39. Noninvasive ventilation in stable COPDLung function

  40. Noninvasive ventilation in stable COPDBreathing pattern

  41. Shuttle walk test <-------- P <0.009 -------- > < P<0.01> Garrod et al.AJRCCM 2000:162:1335

  42. OXYGEN LTX NUTRITION COPD and hypercapnia LVRS NIPPV + REHABILITATION

  43. Inclusion criteria • COPD • FEV1< 50% pred. • symptoms : dyspnoea on exertion / impaired exercise tolerance • Age < 75 years • PaCO2> 45 mmHg

  44. Exclusion criteria • Any diagnosis interfering with a successfull rehabilitation • OSAS : AHI > 10 • Currently on NIPPV • Within last 2 years started a rehabilitation programma

  45. Design (1) • Randomised open trial • 2 arms : NIPPV + rehabilitation (A) rehabilitation alone (B) • Duration : 24 months

  46. Design (2) 0 inclusion / randomisation 3 m control period 3 m A : start NIPPV and after 2 weeks rehab B : start rehabilitation 6 m end of clinical / outpatient rehab 6m start follow-up rehabilitation community

  47. Effect-parameters • Primary health related quality of life • Secundary dyspnoea ADL activities PSG gasexchange EMG respiratory muscles freq./duur opnames exacerbations freq. exercise tolerance

  48. MEASUREMENTS CONTROL CLINICAL COMMUNITY 0 3 6 12 24 HRQL dyspneu ADL PSG BGA EMG SWT LF HRQL dyspneu ADL BGA EMG SWT LF HRQL dyspneu ADL BGA EMG SWT LF HRQL dyspneu ADL PSG BGA EMG SWT LF HRQL dyspneu ADL PSG BGA EMG SWT LF

  49. Discussion • No clear evidence for rationale of NIPPV • Effect of NIPPV still controversial • What did we learn ? • Level of hypercapnia • Adequate ventilatory support / monitoring • What kind of research is needed in COPD ?

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