High-velocity nasal insufflation versus noninvasive positive pressure ventilation for moderate acute exacerbation of chronic obstructive pulmonary disease in the emergency department: A randomized clinical trial

Abstract

Background: Acute exacerbations of chronic obstructive pulmonary disease (COPD) in the emergency department (ED) involve dyspnea, cough, and chest discomfort; frequent exacerbations are associated with increased mortality and reduced quality of life. Noninvasive positive pressure ventilation (NiPPV) is commonly used to help relieve symptoms but is limited due to patient intolerance. We aimed to determine whether high-velocity nasal insufflation (HVNI) is noninferior to NiPPV in relieving dyspnea within 4 h in ED patients with acute hypercapnic respiratory failure.

Methods: This randomized control trial was conducted in seven EDs in the United States. Symptomatic patients with suspected COPD, partial pressure of carbon dioxide (pCO₂) ≥ 60 mm Hg, and venous pH 7.0-7.35 were randomized to receive HVNI (n = 36) or NiPPV (n = 32). The primary outcome was dyspnea severity 4 h after the initiation of study intervention, as measured by the Borg score. Secondary outcomes included vital signs, oxygen saturation, venous pCO₂, venous pH, patient discomfort level, and need for endotracheal intubation.

Results: Sixty-eight patients were randomized between November 5, 2020, and May 10, 2023 (mean age 65.6 years; 47% women). The initial pCO₂ was 77.7 ± 13.6 mm Hg versus 76.5 ± 13.6 mm Hg and the initial venous pH was 7.27 ± 0.063 versus 7.27 ± 0.043 in the HVNI and NiPPV groups, respectively. Dyspnea was similar in the HVNI and NiPPV groups at baseline (dyspnea scale score 5.4 ± 2.93 and 5.6 ± 2.41) and HVNI was noninferior to NiPPV at the following time points: 30 min (3.97 ± 2.82 and 4.54 ± 1.65, p = 0.006), 60 min (3.09 ± 2.70 and 4.07 ± 1.77, p < 0.001), and 4 h (3.17 ± 2.59 and 3.34 ± 2.04, p = 0.03). At 4 h, there was no difference between the groups in the pCO₂ mm Hg (68.76 and 67.29, p = 0.63). Patients reported better overall comfort levels in the HVNI group at 30 min, 60 min, and 4 h (p = 0.003).

Conclusions: In participants with symptomatic COPD, HVNI was noninferior to NiPPV in relieving dyspnea 4 h after therapy initiation. HVNI may be a reasonable treatment option for some patients experiencing moderate acute exacerbations of COPD in the ED.

FIGURE 1

CONSORT diagram showing the flow of participants. *Reasons for exclusion (n = 185): CHF without COPD (n = 96), pneumonia without COPD (n = 23), non–English‐speaking (n = 22), major medical complications including active cancer (n = 11), DVT/PE (n = 8), AMS/unable to consent (n = 8), respiratory or cardiac arrest prior to enrollment (n = 5), seizure (n = 3), renal failure (n = 3), pulmonary hypertension (n = 3), metabolic derangement (n = 2), anaphylaxis (n = 1), patient declined study and/or refused care (n = 56). Other reasons (n = 90): no respiratory support needed (n = 37), no research staff available (n = 34), treated prior to randomizing (n = 12), clinician declined to agree to enrollment (n = 3), police custody (n = 2), inability to draw blood (n = 1), previously enrolled (n = 1). AMS, altered mental status; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; HVNI, high‐velocity nasal insufflation; NIPPV, noninvasive positive pressure ventilation; PE, pulmonary embolism.

FIGURE 2

(A) pCO₂ over time. (B) pH over time. (C) Modified dyspnea score over time dyspnea scale. (D) Patient reported level of discomfort. HVNI, high‐velocity nasal insufflation; NIPPV, noninvasive positive pressure ventilation; pCO₂, partial pressure of carbon dioxide.