Jake Woodrow

[Jake Woodrow @JakeWoodrow3]

IPAP should be started at 15-18 and then increased to at least > 18 and ideally to reduced PaCO2 by 20% (or even to normal if possible) #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

I find it easier to titrate BiPAP (pressure targeted) . There is no evidence that volume targeted modes are superior #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

I recommend NIV for patients with COPD and HyperCO2. I use PaCO2 of 52 as a cutoff based on CMS criteria and this review. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

All patients treated with NIV should have IPAP increased to at least 18mmHg and higher as tolerated to achieve a 20% reduction or even normalization of PaCO2. Whether or not volume targeted vent modes are superior to pressure targeted mode (BiPAP) is not clear #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

This review and prior studies support the use of NIV for patients with stable COPD and chronic hypercapnia (PaCO2 > 52). Patients post hospitalization for COPD exacerbation should also be treated with NIV if PaCO2 remains elevated 2-4 weeks after discharge. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

Post exacerbation patients treated with NIV also had a significantly reduced PaCO2 at 3/12 mo (3.0/3.9 mmHg mean reduction). Admission free survival was reduced but not overall exacerbation rate or all cause mortality, suggesting a delayed time to readmission. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

Stable COPD patients treated with NIV had a significantly lower PaCO2 at 3 / 12mo (4.5 / 3.5mmHg mean reduction). All cause mortality was also reduced in the NIV group (HR 0.78, 95% CI 0.58-0.97). Effect was limited to high IPAP and high baseline PaCO2 groups #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

This Cochrane Analysis included RCTs that enrolled patients with COPD and hypercapnia and compared NIV (min 5 hr/night) to standard of care. Studies were divided by patients with stable COPD and patients post COPD exacerbation requiring hospitalization. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

COPD pathophysiology predisposes to retention of CO2. Morbidity/mortality is high for this subset of patients. Non-invasive ventilation (NIV) is often used in this setting but data regarding efficacy is conflicting and practice patterns are variable. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

First, I will touch on the high points of the article and then @NJHealthMedEd will pose some discussion questions about clinical implications of the article #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

Thank you so much for the introduction! I'm excited to chat tonight about discussing Chronic Non-invasive Ventilation for Chronic Obstructive Pulmonary Disease. DOI: 10.1002/14651858.CD002878.pub3. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

@NJHealthMedEd I wonder if bacterial infections are infrequent and so most studies will be underpowered to detect a difference. Would flipping a coin yield similar results? #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

@NJHealthMedEd A5 Not sure but maybe patients in UK have better access to care and lower threshold to present? If so maybe lower % severe bacterial infections? #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

@NJHealthMedEd A4 I would use POC testing acutely but I’m not sure CRP is the right lab #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

@NJHealthMedEd A2 I don’t know that we have POC CRP or any other labs available in clinic. I would use it #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

@NJHealthMedEd A1 I still use change in sputum character/volume along with other signs of infection (wbc , fever , etc)

[Jake Woodrow @JakeWoodrow3]

@PGeorgeMD @NJHealthMedEd I have had patients like this and I don't think we should be afraid to diagnose people with Asthma + Emphysema. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

@NJHealthMedEd A5 I struggle with patients who have airflow limitation based on other measures (residual volume, air trapping on CT) but have a normal FEV1/FVC ratio. Also patients with a long history of asthma complicate the diagnosis. #COPDTwitterJC

[Jake Woodrow @JakeWoodrow3]

@NJHealthMedEd A4 There is controversy here but in my opinion emphysema by itself without demonstrable airflow limitation is not COPD. Important because these patients are not enrolled in COPD trials so I don't know if they benefit from therapies or not. #COPDTwitterJC