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      Long-Term Noninvasive Ventilation in Chronic Stable Hypercapnic Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline

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          Abstract

          Background: Noninvasive ventilation (NIV) is used for patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnia. However, evidence for clinical efficacy and optimal management of therapy is limited.

          Target Audience: Patients with COPD, clinicians who care for them, and policy makers.

          Methods: We summarized evidence addressing five PICO (patients, intervention, comparator, and outcome) questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to evaluate the certainty in evidence and generate actionable recommendations. Recommendations were formulated by a panel of pulmonary and sleep physicians, respiratory therapists, and methodologists using the Evidence-to-Decision framework.

          Recommendations: 1) We suggest the use of nocturnal NIV in addition to usual care for patients with chronic stable hypercapnic COPD (conditional recommendation, moderate certainty); 2) we suggest that patients with chronic stable hypercapnic COPD undergo screening for obstructive sleep apnea before initiation of long-term NIV (conditional recommendation, very low certainty); 3) we suggest not initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure, favoring instead reassessment for NIV at 2–4 weeks after resolution (conditional recommendation, low certainty); 4) we suggest not using an in-laboratory overnight polysomnogram to titrate NIV in patients with chronic stable hypercapnic COPD who are initiating NIV (conditional recommendation, very low certainty); and 5) we suggest NIV with targeted normalization of Pa CO 2 in patients with hypercapnic COPD on long-term NIV (conditional recommendation, low certainty) .

          Conclusions: This expert panel provides evidence-based recommendations addressing the use of NIV in patients with COPD and chronic stable hypercapnic respiratory failure.

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          Most cited references55

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          Deaths: Leading Causes for 2017.

          Objectives-This report presents final 2017 data on the 10 leading causes of death in the United States by age, sex, race, and Hispanic origin. Leading causes of infant, neonatal, and postneonatal death are also presented. This report supplements "Deaths: Final Data for 2017," the National Center for Health Statistics' annual report of final mortality statistics. Methods-Data in this report are based on information from all death certificates filed in the 50 states and the District of Columbia in 2017. Causes of death classified by the International Classification of Diseases, 10th Revision (ICD-10) are ranked according to the number of deaths assigned to rankable causes. Cause-of-death statistics are based on the underlying cause of death. Results-In 2017, the 10 leading causes of death were, in rank order: Diseases of heart; Malignant neoplasms; Accidents (unintentional injuries); Chronic lower respiratory diseases; Cerebrovascular diseases; Alzheimer disease; Diabetes mellitus; Influenza and pneumonia; Nephritis, nephrotic syndrome and nephrosis; and Intentional self-harm (suicide). They accounted for 74% of all deaths occurring in the United States. Differences in the rankings are evident by age, sex, race, and Hispanic origin. Leading causes of infant death for 2017 were, in rank order: Congenital malformations, deformations and chromosomal abnormalities; Disorders related to short gestation and low birth weight, not elsewhere classified; Newborn affected by maternal complications of pregnancy; Sudden infant death syndrome; Accidents (unintentional injuries); Newborn affected by complications of placenta, cord and membranes; Bacterial sepsis of newborn; Diseases of the circulatory system; Respiratory distress of newborn; and Neonatal hemorrhage. Important variations in the leading causes of infant death are noted for the neonatal and postneonatal periods.
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            Outcomes in patients with chronic obstructive pulmonary disease and obstructive sleep apnea: the overlap syndrome.

            Patients with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) (overlap syndrome) are more likely to develop pulmonary hypertension than patients with either condition alone. To assess the relation of overlap syndrome to mortality and first-time hospitalization because of COPD exacerbation and the effect of continuous positive airway pressure (CPAP) on these major outcomes. We included 228 patients with overlap syndrome treated with CPAP, 213 patients with overlap syndrome not treated with CPAP, and 210 patients with COPD without OSA. All were free of heart failure, myocardial infarction, or stroke. Median follow-up was 9.4 years (range, 3.3-12.7). End points were all-cause mortality and first-time COPD exacerbation leading to hospitalization. After adjustment for age, sex, body mass index, smoking status, alcohol consumption, comorbidities, severity of COPD, apnea-hypopnea index, and daytime sleepiness, patients with overlap syndrome not treated with CPAP had a higher mortality (relative risk, 1.79; 95% confidence interval, 1.16-2.77) and were more likely to suffer a severe COPD exacerbation leading to hospitalization (relative risk, 1.70; 95% confidence interval, 1.21-2.38) versus the COPD-only group. Patients with overlap syndrome treated with CPAP had no increased risk for either outcome compared with patients with COPD-only. The overlap syndrome is associated with an increased risk of death and hospitalization because of COPD exacerbation. CPAP treatment was associated with improved survival and decreased hospitalizations in patients with overlap syndrome.
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              Effect of Home Noninvasive Ventilation With Oxygen Therapy vs Oxygen Therapy Alone on Hospital Readmission or Death After an Acute COPD Exacerbation : A Randomized Clinical Trial

              Outcomes after exacerbations of chronic obstructive pulmonary disease (COPD) requiring acute noninvasive ventilation (NIV) are poor and there are few treatments to prevent hospital readmission and death.
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                Author and article information

                Journal
                Am J Respir Crit Care Med
                Am. J. Respir. Crit. Care Med
                ajrccm
                American Journal of Respiratory and Critical Care Medicine
                American Thoracic Society
                1073-449X
                1535-4970
                15 August 2020
                15 August 2020
                15 August 2020
                15 August 2020
                : 202
                : 4
                : e74-e87
                Author notes
                Correspondence and requests for reprints should be addressed to Robert L. Owens, M.D., Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, 9444 Campus Point Drive ECOB 2-045, La Jolla, CA 92037. E-mail: rowens@ 123456health.ucsd.edu .
                Author information
                http://orcid.org/0000-0002-5352-9587
                http://orcid.org/0000-0002-2874-8948
                http://orcid.org/0000-0002-8293-7061
                http://orcid.org/0000-0002-0912-3360
                http://orcid.org/0000-0002-7266-8371
                http://orcid.org/0000-0003-1246-3814
                http://orcid.org/0000-0002-4404-3833
                http://orcid.org/0000-0002-2757-6806
                http://orcid.org/0000-0002-4498-5337
                http://orcid.org/0000-0003-3824-6172
                http://orcid.org/0000-0002-6968-4610
                Article
                202006-2382ST
                10.1164/rccm.202006-2382ST
                7427384
                32795139
                bdd4f519-9848-4cd6-8f5d-846cf098f862
                Copyright © 2020 by the American Thoracic Society

                You may print one copy of this document at no charge. However, if you require more than one copy, you must place a reprint order. Domestic reprint orders: amy.schriver@ 123456sheridan.com ; international reprint orders: louisa.mott@ 123456springer.com .

                History
                Page count
                Figures: 0, Tables: 1, Pages: 14
                Categories
                American Thoracic Society Documents

                chronic obstructive pulmonary disease,hypercapnic respiratory failure,noninvasive ventilation

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