Deniz ÇELİK, Murat YILDIZ, Hasret Gizem KURT, Zeynep Tilbe SAYMAZ

Hastaneden taburculuk sırasında yüksek PaCO2 seviyeleri, evde non-invaziv mekanik ventilatörü olmayan kronik solunum yetmezliği hastalarında orta vadeli mortaliteyi öngörüyor mu?

Amaç: Uzun süreli evde NIV kullanımı, kompanse ılımlı hiperkapnik KOAH olan hastalar için tartışmalı bir tedavi şeklidir. Çalışmamızın amacı kliniğimizden taburcu edilen kompanse fakat ılımlı hiperkapnik hastalardan evde non-invaziv mekanik ventilatörü olmayan hasta grubunun taburculuk sonrası hastaneye başvuru sayıları, hastaneye yatış sayıları ve orta vadeli (6-8 ay) mortalite durumlarını incelemektir. Gereç ve Yöntem: Çalışma grubunu oluşturan hastalar 01.01.2019 ve 31.12.2020 tarihleri arasında Göğüs Hastalıkları Yoğun Bakım Kliniğinde yatarak tetkik edilip taburcu edilmiş kompanse hiperkapnik olgulardan oluşmaktadır. Araştırmamız retrospektif gözleme dayalı kohort çalışma olarak planlanmıştır. Bulgular: Çalışmaya 01.01.2019 ve 31.12.2020 tarihleri arasında yüksek PaCO2 düzeyiyle taburcu edilmiş toplam 245 hasta dahil edildi. Olguların %58’i erkek (n=142) cinsiyette idi. Hastaların yaş ortalaması 71,89±12,63 idi. Her iki grup arasında cinsiyet, yatışları sırasında NIV kullanımı, yatışları sırasında NIV kullanım gün sayısı, evde USOT veya Oksijen tüpü kullanımı ve GYBÜ yatışı öncesinde entübasyon öyküsü bulunması açılarından istatistiksel olarak anlamlı farklılık bulunmamaktadır (p>0,05). Mortalite grubunda konjestif kalp yetmezliği, koroner arter hastalığı ve atriyal fibrilasyon bulunma oranları istatistiksel olarak anlamlı düzeyde daha yüksektir (sırasıyla p=0,017, p=0,032 ve p=0,002). Her iki grup arasında yatış, taburcu ve kontrol sonuçları açısından istatistiksel olarak anlamlı farklı izlenmemiştir. Yüksek PaCO2 düzeyiyle taburcu olmuş olguların 1, 3, 6, 8, 12 aylık ve takip süresinin tamamındaki mortalite oranlarına karşılık taburculuk PaCO2 düzeyleri ROC analizine tabi tutulmuştur. ROC analizi sonucunda, taburculuk PaCO2 düzeyleri için 8. ay mortaliteyi belirlemede cut-off değeri 50,25 mmHg sınır değer kabul edildiğinde, duyarlılık %78,6 özgüllük %43 olarak hesaplanmıştır. Sonuç: Taburculukta ılımlı hiperkapnisi (PaCO2>50 mmHg) olan, kalp ilişkili hastalığı bulunan hasta grubunda evde NIV tedavisinin dikkatle değerlendirilmesi gerektiğini düşünüyoruz.

Anahtar Kelimeler:

Solunum yetmezliği, hiperkapni, mortalite, ventilasyon

Do high PaCO2 levels during discharge from the hospital predict medium-term mortality in chronic respiratory failure patients without domiciliary non-invasive mechanical ventilator?

Aim: Long-term domiciliary use of a non-invasive mechanical ventilator (NIV) is a controversial form of therapy for patients with chronic obstructive pulmonary disease (COPD) and moderate hypercapnia. The present research attempted to examine hospital admissions, hospitalizations, and medium-term (6-8 months) mortality in a group of patients with compensated but moderate hypercapnia who were discharged from our clinic without a domiciliary NIV. Material and Method: The sample of this retrospective, observation-based cohort study consisted of compensated hypercapnic cases that were hospitalized in our Pulmonology Intensive Care Unit (ICU) between 01.01.2019 and 12.31.2020. Results: A total of 245 patients discharged with high partial pressure of carbon dioxide (PaCO2) levels between 01.01.2019 and 12.31.2020 were included in the study. While 58% of the cases were males (n=142), we found the mean age of the patients to be 71.89±12.63 years. The findings yielded no significant differences between the groups by sex, use of NIV during hospitalization, number of days of NIV use during hospitalization, use of LTOT or Oxygen tube at home, and intubation history before ICU admission (p>0.05). Similarly, we could not conclude significant differences between the groups by hospitalization, discharge, and follow-up arterial blood gas (ABG) parameters. Yet, the rates of congestive heart failure, coronary artery disease, and atrial fibrillation were significantly higher in the mortality group (p=0.017, p=0.032, and p=0.002, respectively). Besides, high PaCO2 levels versus mortality rates at 1, 3, 6, 8, and 12 months and in the entire follow-up period were subjected to the ROC analysis. Accordingly, when accepting 50.25 mmHg as the cut-off value for determining the 8-month mortality for discharge PaCO2 levels, we calculated the sensitivity to be 78.6% and the specificity to be 43%. Conclusion: Overall, it is highly convenient to consider the possible positive effects of NIV therapy on mortality among patients with heart-related diseases and with moderate hypercapnia (PaCO2>50 mmHg) at discharge.

Keywords:

Respiratory failure, hypercapnia, mortality, ventilation,

PDF

___

Eui-Sik S, Hart N. Respiratory failure. Medicine 2012; 40: 293-7.
Estenne M, Yernault J-C. The mechanism of CO2 retantion in cardiac pulmonary edema. Chest 1984; 86: 936-8.
Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; 7: CD004104
McEvoy RD, Pierce RJ, Hillman D, et al. Australian trial of non-invasive Ventilation in Chronic Airflow Limitation (AVCAL) Study Group. Nocturnal non-invasive nasal ventilation in stable hypercapnic COPD: a randomised controlled trial. Thorax 2009; 64: 561–6.
Dreher M, Storre JH, Schmoor C, Windisch W. High-intensity versus low-intensity non-invasive ventilation in patients with stable hypercapnic COPD: a randomised crossover trial. Thorax 2010; 65: 303–8.
Windisch W, Haenel M, Storre JH, Dreher M. High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD. Int J Med Sci 2009; 6: 72–6
Bourke SC, Tomlinson M, Williams TL, et al. Effects of non-invasive ventilation on survival and quality of life in patients with amyotrophic lateral sclerosis: a randomised controlled trial. Lancet Neurol 2006; 5: 140-7.
Leger P, Bedicam JM, Cornette A, et al. Nasal intermittent positive pressure ventilation. Long-term follow-up in patients with severe chronic respiratory insufficiency. Chest 1994; 105: 100–5.
Casanova C, Celli BR, Tost L, et al. Long-term controlled trial of nocturnal nasal positive pressure ventilation in patients with severe COPD. Chest 2000; 118: 1582-90.
Garrod R, Mikelsons C, Paul EA, et al. Randomized controlled trial of domiciliary non-invasive positive pressure ventilation and physical training in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 162: 1335–41.
Crimi C, Noto A, Princi P, et al. Domiciliary non-invasive ventilation in COPD: an international survey of indications and practices. COPD 2016; 13: 483–90.
Hill NS, Spoletini G, Schumaker G, Garpestad E. Noninvasive ventilatory support for acute hypercapnic respiratory failure. Respir Care 2019; 64: 647-57.
Chawla R, Dixit SB, Zirpe KG, et al. ISCCM Guidelines for the use of non-invasive ventilation in acute respiratory failure in adult ICUs. Indian J Crit CareMed 2020; 24: 61–81.
Arpağ H, Karakurt Z, Kuyucu T, Kansu A, Atilla N. Akut hiperkapnik solunum yetmezliğinde noninvaziv mekanik ventilasyon yanıtı sonrasında erken dönem geri dönüşümlü respiratuvar asidoz gelişen hastaların analizi. J Med Palliat Care 2020; 1: 103-8.
Meservey AJ, Burton MC, Priest J, Teneback CC, Dixon AE. Risk of readmission and mortality following hospitalization with hypercapnic respiratory failure. Lung 2020; 198: 121-34.
Baykal H, Bulcun E. Relationship of clinical parameters and inflammation markers with pulmonary hypertension in patients with stable chronic obstructive pulmonary disease. Sağlık Bilimlerinde Değer 2022; 12: 6-14.
Borel JC, Burel B, Tamisier R, et al. Comorbidities and mortality in hypercapnic obese under domiciliary non-invasive ventilation. PLoS One 2013; 8: e52006.
Şahan E, Bulut S. Relationship between disease severity and atrial fibrillation in chronic obstructive pulmonary disease. Turk Kardiyol Dern Ars 2021; 49: 517-21.
Goedemans L, Bax JJ, Delgado V. COPD and acute myocardial infarction. Eur Respir Rev 2020; 29: 190139.
Dretzke J, Moore D, Dave C, et al. The effect of domiciliary non-invasive ventilation on clinical outcomes in stable and recently hospitalized patients with COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2016; 11: 2269-86.
Köhnlein T, Schwarz SB, Nagel S, Windisch W. Home non-invasive positive pressure ventilation in chronic obstructive pulmonary disease: why, who, and how? Respiration 2022: 1-8.
Chu CM, Chan VL, Lin AW, Wong IW, Leung WS, Lai CK. Readmission rates and life threatening events in COPD survivors treated with non-invasive ventilation for acute hypercapnic respiratory failure. Thorax 2004; 59: 1020–5.
Wilson MW, Labaki WW, Choi PJ. Mortality and healthcare use of patients with compensated hypercapnia. Ann Am Thorac Soc 2021; 18: 2027-32.
Suraj KP, Jyothi E, Rakhi R. Role of domiciliary noninvasive ventilation in chronic obstructive pulmonary disease patients requiring repeated admissions with acute type ii respiratory failure: a prospective cohort study. Indian J Crit Care Med 2018; 22: 397-401.
He X, Luo L, Ma Y, Chen Y. Efficacy of domiciliary non-invasive ventilation on clinical outcomes in posthospital chronic obstructive pulmonary disease patients: a meta-analysis of randomized controlled trials. Ann Palliat Med 2021; 10: 5137-45.