European guidelines on noninvasive long-term ventilation for chronic obstructive pulmonary disease

Long-term noninvasive ventilation (NIV) is an established therapy for patients with end-stage chronic obstructive pulmonary disease (COPD) suffering from chronic hypercapnic respiratory failure (CHRF). This is reflected by its prominent position within national and international guidelines. The NIV can be initiated in order to restore the balance between load and capacity of the respiratory pump and to increase alveolar ventilation. Positive results augmenting alveolar ventilation in COPD patients have been achieved by means of high-intensity NIV (HI-NIV). This was first described for chronic hypercapnic COPD patients in 2009 and refers to a specific ventilatory approach whereby NIV settings are aimed at maximum reduction of the partial pressure of carbon dioxide in order to reach normocapnia by increasing inspiratory pressure and back-up frequency. Previous years were predominated by establishing correct therapy modalities and proving their benefits. Long-term NIV remains an active field of research as the European guidelines published last year illustrate by raising questions for the future that need to be answered. They present important future topics that will be assessed in large trials, such as the role of outpatient care, telemonitoring and a clearer pathophysiological phenotyping of the patient collective benefitting from the therapy. This article portrays the development of noninvasive long-term ventilation in COPD patients and the contents of national and European guidelines in this respect.