Impact of Non-invasive Ventilation in Hypercapnic COPD
Study Details
Study Description
Brief Summary
Chronic obstructive pulmonary disease (COPD) is a highly prevalent condition worldwide and is a cause of substantial morbidity and mortality. Unfortunately, few therapies have been shown to improve survival. The importance of systemic effects and co-morbidities in COPD has garnered attention based on the observation that many patients with COPD die from causes other than respiratory failure, including a large proportion from cardiovascular causes. Recently, two high profile randomized trials have shown substantial improvements in morbidity and mortality with use of nocturnal non-invasive ventilation (NIV) in COPD patients with hypercapnia. Although the mechanisms by which NIV improves outcomes remain unclear, the important benefits of NIV might be cardiovascular via a number of mechanisms. In contrast to prior trials of NIV in COPD that did not show substantial benefit, a distinguishing feature of these encouraging recent NIV clinical trials was a prominent reduction of hypercapnia, which might be a maker or mediator of effective therapy. Alternatively, improvements might be best achieved by targeting a different physiological measure. Additional mechanistic data are therefore needed to inform future trials and achieve maximal benefit of NIV. Recent work in cardiovascular biomarkers has identified high-sensitivity troponin to have substantial ability to determine cardiovascular stress in a variety of conditions - even with only small changes. In COPD, a number of observational studies have shown that high-sensitivity troponin increases with worsening disease severity, and that levels increase overnight during sleep. This biomarker therefore presents a promising means to study causal pathways regarding the effect of NIV in patients with COPD. With this background, the investigator's overall goals are: 1) To determine whether the beneficial effect of non-invasive ventilation might be due to a reduction in cardiovascular stress, using established cardiovascular biomarkers, and 2) To define whether a reduction in PaCO2 (or alternative mechanism) is associated with such an effect.
Condition or Disease | Intervention/Treatment | Phase |
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N/A |
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Experimental: Non-invasive ventilation Subjects will undergo a baseline night with standard polysomnography, followed by a treatment night using non-invasive ventilation under polysomnography |
Device: High-intensity non-invasive ventilation
Single night of high-intensity non-invasive ventilation
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Outcome Measures
Primary Outcome Measures
- Paired difference in morning level of high sensitivity troponin between baseline and NIV nights [1 day]
Comparing morning levels of high sensitivity troponin between baseline and NIV nights
Secondary Outcome Measures
- Paired difference in overnight increase in high sensitivity troponin between baseline and NIV night [1 day]
Troponin assay: Minimum 0, no maximum, with higher values worse.
- Paired difference in sleep quality by Richards-Campbell Sleep Questionnaire between baseline and NIV night [1 day]
Questionnaire: 5 questions, 0 to 100 on visual analog scale, with higher scores indicating better sleep. Total score reported as mean of 5 components.
- Paired difference in sleep quality by arousal index between baseline and NIV night [1 day]
Arousal index: Index reported as events/hour. Minimum 0, no maximum, with higher scores indicating worse sleep.
- Paired difference in heart rate variability during sleep between baseline and NIV night [1 day]
Comparing difference in heart rate variability during sleep between baseline and NIV night
- Paired difference between Morning psychomotor vigilance testing score between baseline and NIV night [1 day]
Psychomotor vigilance score: Reported as number of lapses. Minimum 0, no maximum, with higher values worse.
- Paired difference in morning exhaled nitric oxide level between baseline and NIV night [1 day]
Exhaled nitric oxide assay: Minimum 0, no maximumm with higher values worse.
Eligibility Criteria
Criteria
Inclusion Criteria:
- Subjects with previously diagnosed severe COPD (FEV1 <50% predicted) and daytime hypercapnia (PaCO2 or TcCO2 > 45 mmHg)
Exclusion Criteria:
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Lung disease besides COPD (e.g., pulmonary fibrosis, bronchiectasis, pulmonary arterial hypertension) other than well controlled asthma
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Unrevascularized coronary artery disease, angina, prior heart attack or stroke, congestive heart failure
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Uncontrolled hypertension (SBP >160, DBP >95)
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Unwilling or unable to withhold CPAP during polysomnography
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Presence of tracheostomy
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Hospitalization within the past 90 days
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Prior peptic ulcer disease, esophageal varicies, or gastrointestinal bleeding (< 5 years)
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Prior gastric bypass surgery
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Anticoagulant use (other than aspirin) or bleeding diathesis (only for esophageal catheter placement)
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Chronic liver disease or end-stage kidney disease
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Allergy to any of the study medications
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Regular use of medications known to affect control of breathing (opioids, benzodiazepines, theophylline)
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Insomnia or circadian rhythm disorder
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Active illicit substance use or >3 oz nightly alcohol use
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Psychiatric disease, other than controlled depression
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Pregnancy
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Prisoners
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Cognitive impairment, unable to provide consent, or unable to carry out research procedures
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
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1 | University of California San Diego | San Diego | California | United States | 92037 |
Sponsors and Collaborators
- University of California, San Diego
Investigators
- Principal Investigator: Jeremy E Orr, MD, UCSD
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- 161873