ATS Releases Guideline on NIV in Chronic Stable Hypercapnic COPD

The American Thoracic Society has developed a guideline for the use of noninvasive ventilation (NIV) among patients with chronic obstructive pulmonary disease (COPD) and chronic stable hypercapnic respiratory failure. Included are 5 recommendations on the optimal management of these patients.

“Since the development of NIV, there has been interest in its use for the treatment of patients with COPD and chronic stable hypercapnia. During acute exacerbations with ventilatory failure, NIV is frequently used because it has been shown to improve survival,” the authors wrote. “However, there have been fewer studies addressing the use of chronic domiciliary, nocturnal NIV for stable hypercapnic COPD.”

Now that there have been studies on “high-intensity” NIV, interest has grown around the use of NIV among patients with chronic hypercapnic COPD. The new guideline summarizes the available evidence and provides guidance on the optimal management of stable patients with COPD and chronic hypercapnia (defined as FEV1/FVC < 0.70; resting PaCO2 > 45 mm Hg; not during exacerbation).

The panel—which comprised pulmonary and sleep physicians, respiratory therapists, and methodologists—made the following conditional recommendations:

  1. Use NIV in addition to usual care for patients with chronic stable hypercapnic COPD.
  2. Before initiating long-term NIV, screen for obstructive sleep apnea among patients with chronic stable hypercapnic COPD.
  3. Avoid initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure. Instead, reassess for NIV at 2 to 4 weeks after resolution.
  4. Avoid using an in-laboratory overnight polysomnogram to titrate NIV among patients with chronic stable hypercapnic COPD who are initiating NIV.
  5. Use NIV with targeted normalization of PaCO2 among patients with hypercapnic COPD on long-term NIV.


“Few interventions have been shown to improve morbidity and mortality in COPD. Thus, it is exciting to consider NIV as additional therapy for those with hypercapnic COPD,” the authors wrote.

However, the authors highlight key considerations that still exist, including appropriate patient selection, implementation barriers, and gaps in therapy-related data. 

—Colleen Murphy


Macrea M, Oczkowski S, Rochwerg B, et al; American Thoracic Society Assembly on Sleep and Respiratory Neurobiology. Long-term noninvasive ventilation in chronic stable hypercapnic chronic obstructive pulmonary disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;202(4):e74-e87. doi:10.1164/rccm.202006-2382ST