Skip to main content

Noninvasive ventilation in hypercapnic chronic obstructive pulmonary disease

Recently, Murphy and colleagues [1] reported findings from a clinical trial designed to evaluate the effect of home noninvasive ventilation (NIV) with oxygen on time to readmission or death in patients with persistent hypercapnia after an acute chronic obstructive pulmonary disease (COPD) exacerbation. The authors concluded that the addition of home NIV to home oxygen therapy may improve outcomes in patients with severe COPD and persistent hypercapnia following hospital admission.

I would like to make the following observations in relation to the use of NIV in patients with COPD:

  1. 1.

    In COPD patients, NIV may be beneficial when used overnight or during the day at home [2]. When using pressure-targeted ventilation, beginning in the spontaneously triggered mode with a backup rate is recommended. The pressure limit should be set to 8 to 12 cm H2O inspiratory and 3 to 5 cm H2O expiratory, and the inspiratory pressure (10 to 20 cm H2O) should be gradually increased, as tolerated, in order to alleviate dyspnea, decrease respiratory rate, increase tidal volume (if being monitored), and promote good patient–ventilator synchrony [3].

  2. 2.

    The transdiaphragmatic pressure (Pdi; calculated as the difference between the gastric and esophageal pressures), ranged from 10.87 to 14.95 cm H2O during spontaneous inspirations. The Pdi represents the gastroesophageal pressure gradient, and it can be considered a driving force for the gastric content to reflux into the esophagus [4]. There is a strong linear correlation between the lower esophageal sphincter (LES) pressure and Pdi. Inspirations made with a closed mouth and nose or a closed glottis (effort levels of 75 to100 %) can cause an increase in the LES pressure of between 127.8 and 179.5 cmH2O [4]. NIV may have some problems related to air pressure and flow, such as gastric insufflation (30 to 40%) and aspiration (5%) [5]. Murphy and colleagues [1] did not report on the side effects of the high pressure strategy.

  3. 3.

    One of the long-term objectives of NIV is to prolong survival [3]. However, Murphy and colleagues [1] reported that 12-month mortality results were not different between the groups (28.1% in the home oxygen plus home NIV group and 32.2% in home oxygen alone group [difference of 4.13%, p = 0.777]) [1].

  4. 4.

    Finally, the estimated cost of providing a domiciliary NIV service is $3022 in the first year and $1956 in subsequent years [2], which is a high cost for those with low and lower middle incomes.



Chronic obstructive pulmonary disease


Lower esophageal sphincter


Noninvasive ventilation


Transdiaphragmatic pressure


  1. Murphy PB, Rehal S, Arbane G, et al. Effect of home noninvasive ventilation with oxygen therapy vs oxygen therapy alone on hospital readmission or death after an acute COPD exacerbation: a randomized clinical trial. JAMA. 2017;317:2177–86.

    Article  PubMed  Google Scholar 

  2. Dretzke J, Blissett D, Dave CS, et al. The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation. Health Technol Assess. 2015;19:1–246.

    Google Scholar 

  3. Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163:540–77.

    CAS  Article  PubMed  Google Scholar 

  4. Mittal RK, Rochester DF, McCallum RW. Electrical and mechanical activity in the human lower esophageal sphincter during diaphragmatic contraction. J Clin Invest. 1988;81(4):1182–9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. Gay PC. Complications of noninvasive ventilation in acute care. Respir Care. 2009;54:246–57.

    PubMed  Google Scholar 

Download references


None to report.


No funding to report.

Availability of data and materials

Not applicable.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Silvio A. Ñamendys-Silva.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The author declares that he has no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ñamendys-Silva, S.A. Noninvasive ventilation in hypercapnic chronic obstructive pulmonary disease. Crit Care 21, 266 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: