Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, California.
Respir Care. 2023 Jul;68(7):1013-1022. doi: 10.4187/respcare.10788.
Patients with hypercapnic COPD appear to represent a phenotype driven by specific physiology including air trapping and mechanical disadvantage, sleep hypoventilation, and sleep apnea. Such individuals appear to be at high risk for adverse health outcomes. Home noninvasive ventilation (NIV) has been shown to have the potential to help compensate for physiological issues underlying hypercapnia. In contrast to older literature, contemporary clinical trials of home NIV have been shown to improve patient-oriented outcomes including quality of life, hospitalizations, and mortality. Advancements in the use of NIV, including the use of higher inspiratory pressures, may account for recent success. Successful practical application of home NIV thus requires an adequate understanding of patient selection, devices and modes, and strategies for titration. The emergence of telemonitoring holds promise for further improvements in patient care by facilitating titration, promoting adherence, troubleshooting issues, and possibly predicting exacerbations. Given the complexity of home NIV, clinicians and health systems might consider establishment of dedicated home ventilation programs to provide such care. In addition, incorporation of respiratory therapist expertise is likely to improve success. Traditional fee-for-service structures have been a challenge for financing such programs, but ongoing changes toward value-based care are likely to make home NIV programs more feasible.
伴有高碳酸血症的 COPD 患者似乎代表了一种由特定生理学特征驱动的表型，包括空气潴留和机械劣势、睡眠通气不足和睡眠呼吸暂停。这些人似乎有发生不良健康结局的高风险。家庭无创通气（NIV）已被证明有潜力帮助代偿高碳酸血症的潜在生理问题。与旧的文献相比，家庭 NIV 的当代临床试验已被证明可改善以患者为导向的结局，包括生活质量、住院和死亡率。NIV 使用的进步，包括更高的吸气压力的使用，可能是最近成功的原因。因此，家庭 NIV 的成功实际应用需要对患者选择、设备和模式以及滴定策略有足够的了解。远程监测的出现有望通过促进滴定、提高依从性、解决问题以及可能预测恶化，进一步改善患者护理。鉴于家庭 NIV 的复杂性，临床医生和医疗系统可能会考虑建立专门的家庭通气计划来提供此类护理。此外，纳入呼吸治疗师的专业知识可能会提高成功率。传统的按服务收费结构一直是为这些项目提供资金的挑战，但向基于价值的护理的持续转变可能会使家庭 NIV 项目更可行。
