Published in the July 2013 issue of Today’s Hospitalist
IT’S CHEAPER, it produces better outcomes and it’s been recommended by multiple guidelines. But noninvasive ventilation (NIV) in COPD patients with respiratory failure is still underutilized, according to a recent study. The solution, says the lead author, is for hospitalists and emergency physicians to lead the way by embracing noninvasive ventilation for their patients.
Chiu-Lin Tsai, MD, ScD, lead author of the study, says that when researchers examined more than 100,000 ED visits, they found that the upsides of NIV were impressive. Length of stay (LOS) fell 3.2 days compared to invasive ventilation, mortality dropped 46% (from 16% to 8%), and hospital charges per visit fell from $53,400 to $26,000.
Given that COPD accounts for 1.5 million ED visits and 726,000 hospitalizations every year in the U.S., overall savings could be significant. “These COPD patients are usually very sick and in the ICU, which is very costly,” says Dr. Tsai.
While invasive ventilation can put too much air into
patients’ lungs, Dr. Tsai says, NIV “if done well “delivers air through the nose and mouth, producing less pressure and leading to fewer complications. The study, which was published in the April issue of the Journal of Hospital Medicine, also found NIV use associated with a lower rate of iatrogenic pneumothorax than ventilator use: 0.05% vs. 0.5%.
“It produces shorter LOS with less money spent,” says Dr. Tsai, assistant professor of epidemiology, division of epidemiology, human genetics and environmental sciences at University of Texas School of Public Health, Houston. “And it’s safer because the patient isn’t in the hospital as long.”
Underutilized in the U.S.
The findings add power to guidelines, which already support using NIV in these patients. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) states that “in all but a few situations there is nothing to be lost by a trial of non-invasive ventilation.” The American Thoracic Society guidelines also support NIV for COPD patients.
Nonetheless, NIV use is “surprisingly underutilized in this country,” Dr. Tsai notes. Researchers found that NIV use ranged from 0% to 100%. Geography was a factor, with hospitals in the Northeast the heaviest users, but the median use in COPD patients with acute exacerbations was only 11%.
Overall, the study found that NIV use in the U.S. increased from 14% to 16% between 2006 and 2008, with the use of invasive ventilation decreasing from 28% to 19% over that time period. While the study notes that it didn’t have the data to determine the optimal rate of NIV use, the authors stated that “the low rate of NIV use is concerning and suggests room for improvement.”
In Europe, by contrast, 40% of hospitalized COPD patients receive NIV. Dr. Tsai attributes that difference to the fact that European pulmonologists were pioneers in using NIV and that the first randomized trial on NIV was conducted in France.
Despite the underwhelming results, Dr. Tsai sees some progress. “Our results did not show a big increase,” Dr. Tsai says. “But we have hope.”
What’s holding physicians back? Dr. Tsai offers several explanations. Although the technology is a decade old, people still may not be familiar with the benefits of NIV.
Then there’s the fact that some areas of the country lack NIV training. Parts of the country also lack personnel to do the job, which requires the expertise and time to set up the NIV machines.
And physicians have concerns about the therapy, some of which can be valid if training is subpar. Dr. Tsai notes, for example, that if you put a patient on NIV for too long without monitoring the condition, the patient will deteriorate.
The cost of using NIV is a non-issue, he says. Whatever those costs may be, they’re a bargain compared to having a patient on invasive ventilation.
According to Dr. Tsai, previous studies have found that only between 10% and 25% of ED physicians use NIV. Some survey results found that hospitalists fare no better.
“They’re probably not using it as much as they should, given that NIV use in all locations isn’t that high,” he says. But it’s a hospitalist-related issue, he adds, because NIV can be used on the general ward, in addition to in the ICU.
“Hospitalists, among other specialists, need to be more aware of the guideline recommendations and best situations to use this treatment for this patient population,” Dr. Tsai says.
When to use it
Study results show certain patient characteristics associated with NIV use: Medicare insurance, older age and high-income neighborhoods. NIV use was also associated with pulmonary circulatory disorders and liver disease.
The study found the mean patient age of those visiting the ED with acute COPD exacerbations was 68 years. Dr. Tsai explains that older patients are more likely to have NIV because it’s less invasive and less painful. The key, he says, is making sure patients know they have a choice. “It’s better if the patient knows his options,” he says, “because for this age group, our finding is that NIV can be appropriate.”
On the other hand, certain factors were negatively associated with NIV use. For example, patients with pneumonia were less likely to get NIV. Having a lot of secretions from the mouth and nose can create barriers that can decrease NIV’s efficiency and effectiveness, Dr. Tsai explains.
Additionally, his study found that alcohol and drug abuse were negatively associated with NIV use. “This reflects the physician’s decision because those patients are less compliant with therapies and it takes additional effort to monitor them,” he says.
The study also looked at patients who used both invasive and noninvasive therapies, what Dr. Tsai calls a “problematic subgroup.” He points out that this was a very heterogeneous group that included patients who transferred from NIV to invasive ventilation because their condition worsened. In those cases, the physician had to intubate the patient and likely transfer him or her to the ICU as well. The study data were not able to differentiate which came first, only the final placement.
“They may have used invasive ventilation, then extubated and transferred the patient to NIV as a weaning strategy,” he says. “We can’t tell if the patient was going from one to the other.”
Practice makes perfect
The study did find that patients receiving both NIV and invasive ventilation had more comorbidities such as congestive heart failure than those receiving just one mode of therapy. These patients also had the highest inpatient mortality (18%), longest LOS (seven-16 days) and highest hospital charges ($64,585).
As use of NIV slowly inches up, Dr. Tsai says it’s no surprise that his study found that hospitals with a higher case volume were heavier users.
He attributes that finding to the “practice-makes-perfect” concept: As physicians become more familiar with treatment options, they’re more likely to use NIV and get better at it. “This is the most important predictor of NIV use,” he says.
And that’s a lesson for those reluctant to move forward. “NIV is highly effective and proven by randomized controlled trials,” says Dr. Tsai. “It should be used more often.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.