Modafinil: a novel alternative to non-invasive ventilation in hypercapnic respiratory failure?

Abstract

Dear editor Nowadays non-invasive ventilation (NIV) is a common therapeutic option in chronic hypercapnic respiratory failure, especially in chronic obstructive pulmonary disease (COPD).1 Even though there is not robust data showing mortality or morbidity benefits, it appears to improve quality of life and reduce admissions for exacerbation.1,2 However, there will always be a group of patients where NIV is not an option, because of poor compliance or side effects. Parnell et al used modafinil, out of label, in a very small heterogeneous group of hypercapnic respiratory failure patients unwilling to carry out NIV, with good results (benefic effects in blood gases, exacerbation admissions, with no adverse effects).3 This pilot study open a new door to control hypercapnic respiratory failure in noncompliance patients with NIV. We understand limitations of this brief study, but consider, however, some key aspects need to take into account to a proper clinical extrapolation. First, mechanism of acute and chronic hypercapnic are numerous and complex interaction, not only during daytime and night time period, muscular weakness play a central role in this pathways and respiratory central breathing could be influenced to chemical and mechanical properties of lung and upper airways.1,2 Second, regarding limits of hypercapnic and how monitoring response to modafinil therapy is a key cornerstone. Third, other co morbidity as chronic renal failure or neurologic conditions influence by hypercapnic could difficult interaction of modafinil as coincident psychiatric drugs like antidepressive or anxiolytic, that in some cases are associated in chronic respiratory insufficiency.4–6 Additionally, coexistence of COPD and sleep breathing disorders determinate more complexity in this prescription.7,8 In our opinion, the good results shown in these six patients justify the conduct of extended studies on the action of modafinil in hypercapnic respiratory failure. However, if this drug may improve the quality of life, reduce health costs and safe alternative to non-invasive mechanical ventilation are still open questions.