Noninvasive Ventilation and Lung Volume Reduction

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Key points

  • •

    Noninvasive ventilation given to patients with acute hypercapnic exacerbation of chronic obstructive pulmonary disease reduces mortality and morbidity.

  • •

    Lung volume reduction surgery is effective in patients with heterogeneous upper zone emphysema and reduced exercise tolerance, and is probably underused.

  • •

    Rapid progress is being made in nonsurgical approaches to lung volume reduction, but use outside specialized centers cannot be recommended presently.

NIV

NIV provides ventilatory support without the need for endotracheal intubation and thus supports the respiratory muscle pump both by reducing the work of breathing and by improving tidal volume.2 The ability to provide ventilatory support without the need for invasive mechanical ventilation has been one of the major advances in the management of acute respiratory failure complicating exacerbations of COPD. The use of NIV during decompensated hypercapnic respiratory failure secondary to acute

Indications

Acute exacerbations of COPD represent a dynamic shift in the load-capacity-drive relationship of the respiratory system caused by an increased load exerted on it.6 The increased load is mediated principally via changes in both inspiratory resistance and dynamic chest wall elastance, as well as a threshold load exerted by intrinsic PEEP.7 This acute increase in load on the respiratory system causes a significant increase in the work of breathing, with transdiaphragmatic pressure changes in

Physiologic Basis

The development of hypercapnic respiratory failure in COPD occurs because of an imbalance in the load-capacity-drive relationship of the respiratory system and confers a poor prognosis, with significant morbidity and mortality.26, 27 The use of ventilatory support to correct respiratory failure in this context has empirical appeal and is suggested to work via 3 main hypotheses:

  • 1.

    Resetting central respiratory drive

  • 2.

    Improving pulmonary mechanics

  • 3.

    Resting chronically fatigued respiratory muscles

The

Physiologic Basis

Emphysema is characterized by damage and destruction of the alveoli and airspaces distal to the terminal bronchioles diminishing the alveolar surface area available for gas exchange. This loss of the alveolar wall, structural elements, and pulmonary vasculature leads to reduced elastic recoil, as well as narrowing of the airways caused by the loss of the outward tension that maintains their patency. Airways are thus compressed and can collapse under the positive intrathoracic pressure of

Summary

At the time of writing, the only established therapy is surgical LVR, which is indicated for hyperinflated patients with heterogeneous upper zone disease who exceed the NETT safety criteria and who experience symptoms despite rehabilitation. Pivotal trials of several nonsurgical techniques are underway and should inform on efficacy, safety, and optimal patient selection within the next 3 to 5 years. Long-term safety and efficacy data for these novel bronchoscopic techniques are lacking but will

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    • This work was supported in part by the NIHR Respiratory Biomedical Research Unit, which part funds the salary of M.I. Polkey and wholly funds the salary of Z. Zoumot. Z. Zoumot’s institution has received reimbursement for trial expenses from PneumRx, Spiration, and Broncus. P. Murphy was previously supported by a grant for a study cofounded by ResMed and Respironics. M.I. Polkey receives fees for consulting from Respironics, Broncus, and PortAero, and his institution held on his behalf an award from PortAero for clinical research.

    1

    Drs P. Murphy and Z. Zoumot contributed equally to this article.

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