Optimal NIV Medicare Access Promotion: Patients With COPD: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society

Abstract

This document summarizes the work of the COPD Technical Expert Panel working group. For patients with COPD, the most pressing current coverage barriers identified were onerous diagnostic requirements focused on oxygenation (rather than ventilation) and difficulty obtaining bilevel devices with backup rate capabilities. Because of these difficulties, many patients with COPD were instead sometimes prescribed home mechanical ventilators. Critical evidence supports changes to current policies, including randomized controlled trial evidence suggesting a mortality benefit from bilevel positive airway pressure with backup rate and updated clinical practice guidelines from the American Thoracic Society as well as the European Respiratory Society. To achieve optimal access to noninvasive ventilation for patients with COPD, we make the following key recommendations: (1) removal of the need for overnight oximetry testing; (2) the ability to initiate therapy using bilevel devices with backup rate capability; and (3) increased duration of time to meet adherence criteria (ie, a second 90-day trial period) in those patients actively engaged in their care. Clear guidelines based on medical necessity are also included for patients who require initiation of or switch to a home mechanical ventilator. Adoption of these proposed recommendations would result in the right device, for the right type of patient with COPD, at the right time. Finally, we emphasize the need for adequate clinical support during initiation and maintenance of home noninvasive ventilation in such patients.

Keywords: COPD; hypercapnic respiratory failure; mechanical ventilation; noninvasive ventilation.

Figure 1

Severe nocturnal hypercapnia despite normoxia in hospitalized patients with COPD receiving supplemental nasal oxygen at 2 L/min. EtCO₂ = end-tidal CO₂; Spo₂ = oxygen saturation by pulse oximetry; Pvco₂ = venous Pco₂.

Figure 2

Effect of noninvasive ventilation with backup rate vs oxygen therapy alone on survival in stable severe hypercapnic COPD. (From Kohnlein et al.⁷).

Figure 3

Suggested management of patients with COPD who require noninvasive ventilation. ABG = arterial blood gas; BPAP = bilevel positive airway pressure; HMV = home mechanical ventilator.