Nichtinvasive Beatmung und körperliche Belastung bei Patienten mit COPD

 

 Buy Article Permissions and Reprints

Zusammenfassung

Der Einsatz einer nichtinvasiven Beatmung (noninvasive ventilation = NIV) zur Verbesserung der körperlichen Belastung bei Patienten mit COPD wurde in der Vergangenheit in einer Vielzahl von Studien untersucht. Grundsätzlich muss unterschieden werden, ob die NIV während der körperlichen Belastung appliziert wird und somit direkt die Belastbarkeit beeinflusst oder ob eine intermittierende, meist nächtliche NIV indirekt zu einem Anstieg der körperlichen Leistungsfähigkeit führt. Mehrere Arbeiten zeigten, dass der direkte Einsatz einer NIV während körperlicher Belastung zu einer Steigerung der Belastbarkeit bei gleichzeitiger Reduktion der belastungsinduzierten Dyspnoe führt. Des Weiteren konnten gute Trainingsergebnisse erzielt werden, wenn das körperliche Training mit NIV unterstützt wurde. Allerdings gibt es interindividuelle Unterschiede, was die Toleranz und die positive Beeinflussung der Belastbarkeit und der Dyspnoe betrifft. In den meisten Studien der direkten Anwendung wurden COPD-Patienten ohne Indikation zur Langzeitanwendung der NIV mit meist niedrigen Beatmungsdrücken ventiliert, was zu unterschiedlichen Ergebnissen führte. Dagegen war bei hyperkapnischen COPD-Patienten der Einsatz einer NIV mit hohen Inspirationsdrücken im Hinblick auf eine Belastungssteigerung meist effektiver. Die intermittierende NIV führte nach Studienergebnissen ebenfalls zu einer positiven Beeinflussung der Belastbarkeit bei COPD-Patienten, wenngleich auch hier unterschiedliche Ergebnisse bei sehr verschiedenen Beatmungsstrategien mit einer großen Varianz der angewandten Beatmungsdrücke erzielt wurden. Sowohl bei der direkten als auch bei der intermittierenden Applikation der NIV kamen mehrere Formen zum Einsatz: CPAP, pressure support ventilation, proportional assist ventilation und zuletzt eine kontrollierte NIV. Dies erschwert eine konklusive Aussage darüber, ob und wie eine NIV die Belastbarkeit bei COPD-Patienten beeinflusst. Somit gilt es in der Zukunft genau zu definieren, welche Untergruppen von COPD-Patienten von einer NIV in welchem Modus und mit welcher Einstellung profitieren.

Abstract

The use of non-invasive ventilation (NIV) to improve physical activity in COPD patients has been addressed in several clinical investigations in the past. In general, NIV can be applied directly during exercise, but also intermittently when used for long-term treatment thereby aiming at improving physical activity during spontaneous breathing. There is increasing evidence that NIV enhances exercise capacity in COPD patients with a reduction of exercise-induced dyspnea when applied during exertion. Furthermore, physical training has been shown to produce positive results when training was performed under NIV-aided conditions. However, the results regarding tolerance of NIV, exercise ability and dyspnea are individually different. In most studies where NIV was applied during exercise, patients had no indication for long-term NIV, and patients were ventilated with low inspiratory pressures, which produced varying results. In contrast, the use of higher inspiratory pressures in hypercapnic COPD patients was more effective in enhancing exercise capacity. The intermittent application of NIV also positively affects exercise capacity in COPD patients, although different results were achieved with different ventilator strategies, mainly with a variety of inspiratory pressure levels. Different ventilation modes were used for NIV to aid exercise and for the intermittent approach in addition to different settings: CPAP, pressure support ventilation, proportional assist ventilation and controlled NIV. Therefore, it is still unclear how to define the best technique for NIV to be used in order to enhance exercise capability in COPD patients. Future studies are needed to define which subgroup of patients benefit from NIV in view of its effects on exercise. Further studies should also be aimed at clarifying which mode and which ventilator settings are most beneficial in improving exercise capability in COPD patients.

Literatur

• 1 Rabe K F, Hurd S, Anzueto A. et al . Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.  Am J Respir Crit Care Med. 2007;  176 532-555
  Google Scholar
• 2 Lopez A D, Shibuya K, Rao C. et al . Chronic obstructive pulmonary disease: current burden and future projections.  Eur Respir J. 2006;  27 397-412
  Google Scholar
• 3 Ambrosino N, Strambi S. New strategies to improve exercise tolerance in chronic obstructive pulmonary disease.  Eur Respir J. 2004;  24 313-322
  Google Scholar
• 4 Nici L, Donner C, Wouters E. et al . American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation.  Am J Respir Crit Care Med. 2006;  173 1390-1413
  Google Scholar
• 5 Agusti A GN, Noguera A, Sauleda J. et al . Systemic effects of chronic obstructive pulmonary disease.  Eur Respir J. 2003;  21 347-360
  Google Scholar
• 6 Gan W Q, Man S FP, Senthilselvan A. et al . Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis.  Thorax. 2004;  59 574-580
  Google Scholar
• 7 Similowski T, Agusti A, MacNee W. et al . The potential impact of anaemia of chronic disease in COPD.  Eur Respir J. 2006;  27 390-396
  Google Scholar
• 8 Vrieze A, de Greef M HG, Wijkstra P J. et al . Low bone mineral density in COPD patients related to worse lung function, low weight and decreased fat-free mass.  Osteoporos Int. 2007;  18 1197-1202
  Google Scholar
• 9 Sin D D, Man S FP. Chronic obstructive pulmonary disease as a risk factor for cardiovascular morbidity and mortality.  Proc Am Thorac Soc. 2005;  2 8-11
  Google Scholar
• 10 Buch P, Friberg J, Scharling H. et al . Reduced lung function and risk of atrial fibrillation in the Copenhagen City Heart Study.  Eur Respir J. 2003;  21 1012-1016
  Google Scholar
• 11 Mador M J, Bozkanat E. Skeletal muscle dysfunction in chronic obstructive pulmonary disease.  Respir Res. 2001;  2 216-224
  Google Scholar
• 12 Saey D, Michaud A, Couillard A. et al . Contractile fatigue, muscle morphometry, and blood lactate in chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2005;  171 1109-1115
  Google Scholar
• 13 Casaburi R, Porszasz J, Burns M R. et al . Physiologic benefits of exercise training in rehabilitation of patients with severe chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 1997;  155 1541-1551
  Google Scholar
• 14 Anonymous . International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure.  Am J Respir Crit Care Med. 2001;  163 283-291
  Google Scholar
• 15 Mehta S, Hill N S. Noninvasive ventilation.  Am J Respir Crit Care Med. 2001;  163 540-577
  Google Scholar
• 16 Simonds A K. Home ventilation.  Eur Respir J Suppl. 2003;  47 38s-46s
  Google Scholar
• 17 Simonds A K, Elliott M W. Outcome of domiciliary nasal intermittent positive pressure ventilation in restrictive and obstructive disorders.  Thorax. 1995;  50 604-609
  Google Scholar
• 18 Simonds A K, Muntoni F, Heather S. et al . Impact of nasal ventilation on survival in hypercapnic Duchenne muscular dystrophy.  Thorax. 1998;  53 949-952
  Google Scholar
• 19 Bourke S C, Williams T L, Bullock R E. et al . Non-invasive ventilation in motor neuron disease: current UK practice.  Amyotroph Lateral Scler Other Motor Neuron Disord. 2002;  3 145-149
  Google Scholar
• 20 Bach J R. Amyotrophic lateral sclerosis: prolongation of life by noninvasive respiratory AIDS.  Chest. 2002;  122 92-98
  Google Scholar
• 21 Dreher M, Rauter I, Storre J H. et al . When should home mechanical ventilation be started in patients with different neuromuscular disorders?.  Respirology. 2007;  12 749-753
  Google Scholar
• 22 Kolodziej M A, Jensen L, Rowe B. et al . Systematic review of noninvasive positive pressure ventilation in severe stable COPD.  Eur Respir J. 2007;  30 293-306
  Google Scholar
• 23 Clini E, Sturani C, Rossi A. et al . The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients.  Eur Respir J. 2002;  20 529-538
  Google Scholar
• 24 Casanova C, Celli B R, Tost L. et al . Long-term controlled trial of nocturnal nasal positive pressure ventilation in patients with severe COPD.  Chest. 2000;  118 1582-1590
  Google Scholar
• 25 Wijkstra P J, Lacasse Y, Guyatt G H. et al . A meta-analysis of nocturnal noninvasive positive pressure ventilation in patients with stable COPD.  Chest. 2003;  124 337-343
  Google Scholar
• 26 Windisch W, Vogel M, Sorichter S. et al . Normocapnia during nIPPV in chronic hypercapnic COPD reduces subsequent spontaneous PaCO₂.  Respir Med. 2002;  96 572-579
  Google Scholar
• 27 Windisch W, Kostic S, Dreher M. et al . Outcome of patients with stable COPD receiving controlled noninvasive positive pressure ventilation aimed at a maximal reduction of Pa(CO₂).  Chest. 2005;  128 657-662
  Google Scholar
• 28 Windisch W, Dreher M, Storre J H. et al . Nocturnal non-invasive positive pressure ventilation: Physiological effects on spontaneous breathing.  Respir Physiol Neurobiol. 2006;  150 251-260
  Google Scholar
• 29 Budweiser S, Jorres R A, Riedl T. et al . Predictors of survival in COPD patients with chronic hypercapnic respiratory failure receiving noninvasive home ventilation.  Chest. 2007;  131 1650-1658
  Google Scholar
• 30 Kenn K, Schoenheit-Kenn U, Bösl T. et al . Effects of Pulmonary Rehabilitation Including Exercise Training in Patients With Indication For Noninvasive Ventilation Therapy.  AJRCCM. 2002;  Vol 165, Nr. 8 A735
  Google Scholar
• 31 Schönhofer B, Zimmermann C, Abramek P. et al . Non-invasive mechanical ventilation improves walking distance but not quadriceps strength in chronic respiratory failure.  Respir Med. 2003;  97 818-824
  Google Scholar
• 32 Diaz O, Begin P, Andresen M. et al . Physiological and clinical effects of diurnal noninvasive ventilation in hypercapnic COPD.  Eur Respir J. 2005;  26 1016-1023
  Google Scholar
• 33 Hul A van’t, Kwakkel G, Gosselink R. The acute effects of noninvasive ventilatory support during exercise on exercise endurance and dyspnea in patients with chronic obstructive pulmonary disease: a systematic review.  J Cardiopulm Rehabil. 2002;  22 290-297
  Google Scholar
• 34 Kakkar R K, Berry R B. Positive airway pressure treatment for obstructive sleep apnea.  Chest. 2007;  132 1057-1072
  Google Scholar
• 35 Winck J C, Azevedo L F, Costa-Pereira A. et al . Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema - a systematic review and meta-analysis.  Crit Care. 2006;  10 R69
  Google Scholar
• 36 O'Donnell D E, Sanii R, Younes M. Improvement in exercise endurance in patients with chronic airflow limitation using continuous positive airway pressure.  Am Rev Respir Dis. 1988;  138 1510-1514
  Google Scholar
• 37 Petrof B J, Calderini E, Gottfried S B. Effect of CPAP on respiratory effort and dyspnea during exercise in severe COPD.  J Appl Physiol. 1990;  69 179-188
  Google Scholar
• 38 O'Donnell D E, Sanii R, Giesbrecht G. et al . Effect of continuous positive airway pressure on respiratory sensation in patients with chronic obstructive pulmonary disease during submaximal exercise.  Am Rev Respir Dis. 1988;  138 1185-1191
  Google Scholar
• 39 Bianchi L, Foglio K, Pagani M. et al . Effects of proportional assist ventilation on exercise tolerance in COPD patients with chronic hypercapnia.  Eur Respir J. 1998;  11 422-427
  Google Scholar
• 40 Dolmage T E, Goldstein R S. Proportional assist ventilation and exercise tolerance in subjects with COPD.  Chest. 1997;  111 948-994
  Google Scholar
• 41 Keilty S E, Ponte J, Fleming T A. et al . Effect of inspiratory pressure support on exercise tolerance and breathlessness in patients with severe stable chronic obstructive pulmonary disease.  Thorax. 1994;  49 990-994
  Google Scholar
• 42 Maltais F, Reissmann H, Gottfried S B. Pressure support reduces inspiratory effort and dyspnea during exercise in chronic airflow obstruction.  Am J Respir Crit Care Med. 1995;  151 1027-1033
  Google Scholar
• 43 Polkey M I, Kyroussis D, Mills G H. et al . Inspiratory pressure support reduces slowing of inspiratory muscle relaxation rate during exhaustive treadmill walking in severe COPD.  Am J Respir Crit Care Med. 1996;  154 1146-1150
  Google Scholar
• 44 Kyroussis D, Polkey M I, Hamnegard C H. et al . Respiratory muscle activity in patients with COPD walking to exhaustion with and without pressure support.  Eur Respir J. 2000;  15 649-655
  Google Scholar
• 45 Polkey M I, Hawkins P, Kyroussis D. et al . Inspiratory pressure support prolongs exercise induced lactataemia in severe COPD.  Thorax. 2000;  55 547-549
  Google Scholar
• 46 Costes F, Agresti A, Court-Fortune I. et al . Noninvasive ventilation during exercise training improves exercise tolerance in patients with chronic obstructive pulmonary disease.  J Cardiopulm Rehabil. 2003;  23 307-313
  Google Scholar
• 47 Hul A van’t, Gosselink R, Hollander P. et al . Training with inspiratory pressure support in patients with severe COPD.  Eur Respir J. 2006;  27 65-72
  Google Scholar
• 48 Hul A van’t, Gosselink R, Hollander P. et al . Acute effects of inspiratory pressure support during exercise in patients with COPD.  Eur Respir J. 2004;  23 34-40
  Google Scholar
• 49 Toledo A, Borghi-Silva A, Sampaio L MM. et al . The impact of noninvasive ventilation during the physical training in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD).  Clinics. 2007;  62 113-120
  Google Scholar
• 50 Highcock M P, Shneerson J M, Smith I E. Increased ventilation with NiIPPV does not necessarily improve exercise capacity in COPD.  Eur Respir J. 2003;  22 100-105
  Google Scholar
• 51 Hernandez P, Maltais F, Gursahaney A. et al . Proportional assist ventilation may improve exercise performance in severe chronic obstructive pulmonary disease.  J Cardiopulm Rehabil. 2001;  21 135-142
  Google Scholar
• 52 Hawkins P, Johnson L C, Nikoletou D. et al . Proportional assist ventilation as an aid to exercise training in severe chronic obstructive pulmonary disease.  Thorax. 2002;  57 853-859
  Google Scholar
• 53 Bianchi L, Foglio K, Porta R. et al . Lack of additional effect of adjunct of assisted ventilation to pulmonary rehabilitation in mild COPD patients.  Respir Med. 2002;  96 359-367
  Google Scholar
• 54 Tsuboi T, Ohi M, Chin K. et al . Ventilatory support during exercise in patients with pulmonary tuberculosis sequelae.  Chest. 1997;  112 1000-1007
  Google Scholar
• 55 Dreher M, Storre J H, Windisch W. Noninvasive ventilation during walking in patients with severe COPD: a randomised cross-over trial.  Eur Respir J. 2007;  29 930-936
  Google Scholar
• 56 Garrod R, Mikelsons C, Paul E A. et al . Randomized controlled trial of domiciliary noninvasive positive pressure ventilation and physical training in severe chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2000;  162 1335-1341
  Google Scholar
• 57 Schönhofer B, Dellweg D, Suchi S. et al . Exercise Endurance before and after Long-Term Noninvasive Ventilation in Patients with Chronic Respiratory Failure.  Respiration. 2007, Jul 12; [Epub ahead of print]; 
  Google Scholar

PD. Dr. med. Wolfram Windisch

Abteilung Pneumologie Universitätsklinik Freiburg

Killianstrasse 5

79106 Freiburg

Email: wolfram.windisch@uniklinik-freiburg.de