Workstation 3: The addition of non-invasive ventilation during exercise
training in COPD patients
Dr. Michelle Chatwin
Department of Sleep and Ventilation
Royal Brompton Hospital
Sydney Street
SW3 6NP London
UNITED KINGDOM
[email protected]
Prof. Enrico Maria Clini
Università di Modena
Ospedale Villa Pineta
Via Gaiato, 127
(MO)
41026 Pavullo
ITALY
[email protected]
AIMS
Exercise intolerance in lung diseases is the consequence of a complex interplay of different
factors. While several of these factors are susceptible of improvement by specific interventions, we
will to focus in this Workshop on the potential role of non-invasive ventilation as one of the so called
ergogenic aids to usual training, specifically related to the population of COPD. In particular, the
potential benefits of non-invasive ventilation during a rehabilitation course including training will be
reviewed.
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Discuss the role of non-invasive ventilation as a potential ergogenic aid to exercise in COPD
Report the clinical available evidence to train severe COPD patients assisted by non-invasive
techniques during a rehabilitation course
Discuss the actual limitations of such a strategy in this population
To identify patients that may benefit from NIV during pulmonary rehabilitation
To practically initiate NIV in the clinical context of the “COPD” patient with regard to
optimal interface, mode of ventilation and settings for exercise and nocturnal use
To identify equipment options that facilitate the use of NIV for pulmonary rehabilitation
SUMMARY
Severe COPD individuals experience limitation during exercise due to several factors involving
ventilation and gas exchange.
Recent research has pointed out potential ergogenic aids to improve exercise performance in such
patients. These may act at different pathophysiological mechanisms i.e. unloading the respiratory
system, reducing the ventilatory demand [1], and increasing the arterial oxygen content [2].
Training peripheral muscles by adding non-invasive ventilatory aid may potentially help to prolong
exercise time and to increase exercise intensity [3]. Indeed, the intensity of training is crucial to
achieve a true physiologic effect. However, in severe severe COPD, exertional dyspnea and leg
fatigue could impede to maintain intensity of training for enough time to yield such effect [2].
However, there has also been speculation that the addition of non-invasive ventilation applied at night
in addition to pulmonary rehabilitation alone improves outcome. In this situation non-invasive
ventilation is applied via a nasal mask or pillow or full face mask with the aims of decreasing
breathlessness, correcting ABG’s and improving sleep quality. Garrod et al., [4] showed an increase
in walking distance in COPD patients who underwent a pulmonary rehabilitation program. However,
this was not reproduced by Schonhofer and co-workers[5] when measured by cycle ergonometry.
Indicating the non-invasive ventilation alone may not have a drastic effect on cycle endurance. A later
study following patients up for 2 years showed that the addition of non-invasive ventilation in this
situation improved HRQOL, dyspnoea, gas exchange, exercise tolerance and decreased the lung
function decline [6].
Non-invasive ventilation can be applied during exercise via a nasal pillows, nasal mask, full face
mask or mouthpiece with the aim of providing enough pressure to match the patients peak inspiratory
flow. Using non-invasive ventilation during exercise has been shown to unload the respiratory
muscles [7, 8], improve gas exchange [9], potentially improve dyspnea perception [1, 9] and prolong
exercise duration [10-13].
Clinical studies in COPD patients have clarified a potential role for this ergogenic aid during training
course, especially for the most severe and symptomatic individuals, unable to maintain exercise
intensity. Notwithstanding, results are still contradictory (See table below). Three meta-analysis, two
on physical training with non-invasive ventilation [14, 15] and the one on nocturnal non-invasive
ventilation in stable COPD [16], using exercise performance as an outcome. All have concluded that
larger randomised controlled trials are warranted as this area requires more in-depth analysis.
However, the joint ATS/ERS key concepts and advances in pulmonary rehabilitation statement [17]
identifies non-invasive ventilation used as an adjunct to PR augments the effects of the exercise
program. The effect is more pronounced in severe COPD and that the greatest benefit appears when
higher pressures are used. They also conclude that as non-invasive ventilation is “difficult and labour
intensive” it may only be feasible in specialist units.
Major barriers to using non-invasive ventilation as an adjunct to pulmonary rehabilitation include,
lack of confidence around the ventilator along with what pressures to use, portability of the
ventilators, battery length time and weight of the equipment. Simple things like walking aid trolleys
and file carriers can help to overcome the issue of weight and portability (see pictures below) or
exercising on a treadmill or exercise bike. With regard to what pressures to use it would seem that
high pressures [9, 10] produce a more favourable outcome and that supplementary oxygen therapy is
warranted[18]
Subjects
(n)
COPD
Severity
Training /
exercise
test
Johnson
2002[19]
39
Severe
Bianchi
2002[13]
33
Hawkins
2002[11]
Study details
Mask
Ventilator
mode
Treadmill
RCT: NIV vs. heliox
vs. usual training
Nasal
Mild to
moderate
Cycling
RCT: PAV vs. usual
training
19
Severe
Cycling
Reuveny
2005[20]
24
Moderate
to severe
Van ‘t Hul
2006[3]
29
Toledo
2007[20]
Pressure cmH2O
Major outcomes
Bilevel
IPAP 8-12
EPAP 2
>↑ in exercise training time in NIV
group
Nasal and face
mask
PAV
6.6 (VA 2.2L)
3.5 (FA 1.6L per s)
Improvements in peak work rate,
dyspnoea
In both groups
RCT: PAV vs. usual
training
Face mask
PAV
12.7 (VA 1.5L)
3.6 (FA 0.7L per s)
↑ mean training time in NIV group
Treadmill
RCT: NIV vs. usual
training
Face mask
Bilevel
IPAP 7-10
EPAP 2
Greater ↑ in training intensity in
NIV group
Moderate
to severe
Cycling
RCT: NIV vs. sham
NIV
Mouthpiece
and nose clip
IPS
10
↑ SWT distance and cycle
endurance
18
Moderate
to severe
Treadmill
RCT: NIV vs. usual
training
Nasal
Bilevel
IPAP 10-15
EPAP 4-6
↑ VO2 max at peak in NIV group
Cotes
2003[12]
14
Moderate
to severe
Cycling
Alternate allocation
NIV vs. usual training
Bilevel
IPAP ?
EPAP 4-8
Peak VO2 max higher in NIV group
Kyroussis
2000[8]
5
Severe
Exhaustive
treadmill
With and without
NIV
Face mask
PS
?
NIV led to substantial unloading of
the respiratory muscle pump
Dreher
2007[9]
20
Very severe
6 min
walking
distance
Nasal
PS and
bilevel
Average PS = 29 and
PEEP 4
(high intensity NIV)
NIV led to  walking distance, 
oxygen levels and dyspnoea
Dolmage
1997[21]
10
Moderate
to severe
Cycling 6070%
maximum
Randomized
crossover: with and
without NIV and
supplementary O2
Randomized
crossover:
PAV
VA 6cm H2O/L)
3.6 (FA 3cmH2O/L
per s)
CPAP 5cmH2O
PAV + CPAP increased cycle
endurance time
Training /
exercise
test
Study details
Mask
Severe
Cycling 75%
maximum
Randomized
crossover:
Mouthpiece
and nose clip
45
Moderate
to severe
PR
ISWT
35 COPD
24
respiratory
failure
15
Moderate
Cycling 75%
maximum
Severe to
very severe
Moderate
to severe
Subjects
(n)
COPD
Severity
Van ‘t Hul
2004[10]
45
Garrod
2000[4]
Schonhofer
2008[5]
Walker
2015[18]
Duiverman
2011[6]
66
Ventilator
mode
Pressure cmH2O
Major outcomes
PS
IPS of 5 and IPS of
10
IPS of 10 cmH2O led to a 
exercise endurance
RCT: usual training
and NIV at night +
usual training
NI
Bilevel
IPAP 13-24
EPAP 4-6
NIV and PR led to  ISWT distance
Bilevel
?
No improvement seen in COPD
group
6 minute
walking
distance
Randomised
crossover:
supplementary
oxygen vs. NIV
Bilevel
High intensity
NIV without supplementry O2 in
hypoxic, hypercapnic COPD
patients led to  distance walked
and a  PaO2 compared to oxygen
therapy alone
PR: cycling,
walking and
IMT
Outcomes:6
minute
walking
distance
RCT: NIV + PR vs. PR
alone
Bilevel
MeanSD
Non invasive ventilation and PR
IPAP 234
HRQOL, mood, gas exchange,
exercise tolerance,  dyspnoea,
and a decreased decline in lung
function rate
Nasal or full
Face mask
EPAP 62
BPM 183
Adapted from: Piper and Menadue, Breathe, 2009 [22]. This table summarises some but not all of the studies in this area.
Practicalities of NIV and Walking
From: Dreher M, Storre JH, Windisch W. ERJ. 2007 [9].
From: Dr Miguel Gonclaves, Porto.
Case Study
John is a 72 year old male with a clinical diagnosis of COPD, has a FEV1 15% predicted. John lives
with his wife and is totally reliant on her in his activities of daily living. He uses non invasive
ventilation (NIV) at night due to severe hypercapnia with a daytime PaCO2 of 8.9kPa and a PaO2 of
6.7kPa. He uses NIV via a nasal pillows system. His current setting is IPAP 32 cmH2O, EPAP
8cmH2O, BPM 15 and a target volume 650mls. He also requires 3L O2 to be entrained.
John attended clinic with his wife and his main complaint was the fact that he had lost all
independence.
John underwent exercise testing (6 minute walking distance) in 3 conditions on liquid oxygen, on NIV
and NIV in conjunction with oxygen. The results are tabulated below.
Distance walked
(m)
Initial SpO2
(%)
Final SpO2
(%)
Liquid O2
110
91
62
NIV
140
97
73
NIV+O2
190
94
92
Due to the increased walking distance and preserved oxygen saturation it was recommended that
John walk with NIV and oxygen therapy (See picture 1 below)
Picture 1
John and his wife, John is mobilizing with his ventilator and oxygen
However, Due to the weight of of the ventilator and oxygen and relatively low battery life of the
ventilator he was unable to mobilise far. John also found that wearing nasal pillow the whole time
made his face sore and he also found that the pressures delivered on the ventilator were not always
enough to off load the work of breathing.
Johns ventilator was changed to one that had a longer battery life. The mode of ventilation was
changed to mouthpiece ventilation. Most importantly all the equipment was secured onto a trolley
which enabled him to mobilise independently (See picture 2 and 3).
Picture 2
Picture 3
Johns initial use of his ventilator went from night time use and a short period in the middle of the day
to 24/7 use (See figure 1). But, as Johns ventilator dependence increase his exercise tolerance and
distance that he was able to walk increased. He also was able to achieve social independence and was
back out meeting his friends.
Figure 1
This figure shows a ventilator download for hours of use. Note initially the nocturnal use and short
periods in the day to near 24/7 usage. Ventilator usage is shown by the green bars.
Acknowledgement: Photos and ventilator download were provided by Miguel Gonclaves, Porto.
REFERENCES
1. Maltais, F., H. Reissmann, and S.B. Gottfried, Pressure support reduces inspiratory effort and
dyspnea during exercise in chronic airflow obstruction. Am J Respir Crit Care Med, 1995.
151(4): p. 1027-33.
2. Borghi-Silva, A., et al., Respiratory muscle unloading improves leg muscle oxygenation during
exercise in patients with COPD. Thorax, 2008. 63(10): p. 910-5.
3. van 't Hul, A., et al., Training with inspiratory pressure support in patients with severe COPD.
European Respiratory Journal, 2006. 27(1): p. 65-72.
4. Garrod, R., et al., Randomized controlled trial of domiciliary noninvasive positive pressure
ventilation and physical training in severe chronic obstructive pulmonary disease. Am J Respir
Crit Care Med, 2000. 162(4 Pt 1): p. 1335-41.
5. Schonhofer, B., et al., Exercise endurance before and after long-term noninvasive ventilation in
patients with chronic respiratory failure. Respiration, 2008. 75(3): p. 296-303.
6. Duiverman, M.L., et al., Two-year home-based nocturnal noninvasive ventilation added to
rehabilitation in chronic obstructive pulmonary disease patients: A randomized controlled trial.
Respiratory Research, 2011. 12(1): p. 112-112.
7. Dayer, M.J., et al., Exercise-induced depression of the diaphragm motor evoked potential is not
affected by non-invasive ventilation. Respiratory Physiology & Neurobiology, 2007. 155(3): p.
243-254.
8. Kyroussis, D., et al., Respiratory muscle activity in patients with COPD walking to exhaustion
with and without pressure support. Eur Respir J, 2000. 15(4): p. 649-55.
9. Dreher, M., J.H. Storre, and W. Windisch, Noninvasive ventilation during walking in patients
with severe COPD: a randomised cross-over trial. European Respiratory Journal, 2007. 29(5): p.
930-936.
10. van 't Hul, A., et al., Acute effects of inspiratory pressure support during exercise in patients with
COPD. European Respiratory Journal, 2004. 23(1): p. 34-40.
11. Hawkins, P., et al., Proportional assist ventilation as an aid to exercise training in severe chronic
obstructive pulmonary disease. Thorax, 2002. 57(10): p. 853-9.
12. Costes, F., et al., Noninvasive Ventilation During Exercise Training Improves Exercise
Tolerance in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary
Rehabilitation and Prevention, 2003. 23(4): p. 307-313.
13. Bianchi, L., et al., Effects of proportional assist ventilation on exercise tolerance in COPD
patients with chronic hypercapnia. European Respiratory Journal, 1998. 11(2): p. 422-427.
14. Ricci, C., et al., Physical training and noninvasive ventilation in COPD patients: a meta-analysis.
Respir Care, 2014. 59(5): p. 709-17.
15. Menadue, C., et al., Non-invasive ventilation during exercise training for people with chronic
obstructive pulmonary disease. Cochrane Database Syst Rev, 2014(5): p. Cd007714.
16. Struik, F.M., et al., Nocturnal noninvasive positive pressure ventilation in stable COPD: a
systematic review and individual patient data meta-analysis. Respir Med, 2014. 108(2): p. 32937.
17. Spruit, M.A., et al., An official American Thoracic Society/European Respiratory Society
statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med,
2013. 188(8): p. e13-64.
18. Walker, D.J., et al., Walking with Non-Invasive Ventilation Does Not Prevent Exercise-Induced
Hypoxaemia in Stable Hypercapnic COPD Patients. Copd, 2015. 12(5): p. 546-51.
19. Johnson, J.E., D.J. Gavin, and S. Adams-Dramiga, Effects of training with heliox and
noninvasive positive pressure ventilation on exercise ability in patients with severe COPD.
Chest, 2002. 122(2): p. 464-72.
20. Toledo, A., et al., The impact of noninvasive ventilation during the physical training in patients
with moderate-to-severe chronic obstructive pulmonary disease (COPD). Clinics (Sao Paulo),
2007. 62(2): p. 113-20.
21. Dolmage, T.E. and R.S. Goldstein, Proportional assist ventilation and exercise tolerance in
subjects with COPD. Chest, 1997. 111(4): p. 948-54.
22. Piper, A.J. and C. Menadue, Noninvasive ventilation as an adjunct to exercise training in patients
with chronic respiratory disease. Breathe, 2009. 5(4): p. 334-345.
SUGGESTED READING
1. To ensure a basic understanding of the principles of NIV and how to initiate and modify settings:
ERS Practical Handbook of Noninvasive Ventilation. Simonds AK, editor: European Respiratory
Society; 2015 2015-09-01 00:00:00. 320
2. Dreher M, Storre JH, Windisch W. Noninvasive ventilation during walking in patients with
severe COPD: a randomised cross-over trial. European Respiratory Journal. 2007;29(5):930-6.
3. Kleinsasser A, Loeckinger A. Brief report: pressure support ventilation during an ascent and on
the summit of Mt. Everest? A theoretical approach. High Alt Med Biol. 2002;3(1):65-8.
4. Menadue C, Piper AJ, van 't Hul AJ, Wong KK. Non-invasive ventilation during exercise
training for people with chronic obstructive pulmonary disease. The Cochrane database of
systematic reviews. 2014(5):Cd007714.
5. Piper AJ, Menadue C. Noninvasive ventilation as an adjunct to exercise training in patients with
chronic respiratory disease. Breathe. 2009;5(4):334-45.
6. Ricci C, et al. Physical training and Noninvasive ventilation in COPD patients: a meta-analysis.
Respir Care 2014; 59(5): 709-714.
7. Struik FM, Lacasse Y, Goldstein R, Kerstjens HM, Wijkstra PJ. Nocturnal non-invasive positive
pressure ventilation for stable chronic obstructive pulmonary disease. The Cochrane database of
systematic reviews. 2013(6):Cd002878.
8. Struik FM, Lacasse Y, Goldstein RS, Kerstjens HA, Wijkstra PJ. Nocturnal noninvasive positive
pressure ventilation in stable COPD: a systematic review and individual patient data metaanalysis. Respiratory medicine. 2014;108(2):329-37.
9. Walker DJ, Walterspacher S, Ekkernkamp E, Storre JH, Windisch W, Dreher M. Walking with
Non-Invasive Ventilation Does Not Prevent Exercise-Induced Hypoxaemia in Stable
Hypercapnic COPD Patients. Copd. 2015;12(5):546-51.
Online Resources
1. To ensure a basic understanding of the principles of NIV and how to initiate and modify settings:
ERS NIV Simulation Program,
http://www.ers-education.org/e-learning/simulators.aspx
Online congress and ERS School presentations
1.
2.
3.
4.
The use of NIV during rehabilitation, P. Wijkstra (Groningen, The Netherlands)
Annual Congress 2013 –Non-invasive ventilation and airway structure and function
ERS School Course on Noninvasive Positive Pressure Ventilation, Hanover 2012
NIV in rehabilitation, T. Kohnlein (Hannover, Germany)
EVALUATION
1. Non-invasive ventilation during training in the COPD population should be indicated
a. Almost never
b. Always
c. On a individual basis in the most severe and disabled individuals
d. None of the previous
2. Main mechanisms by which non-invasive ventilation may increase the exercise load are:
a. Reduction of mechanical load of respiratory system
b. Improvement of gas exchange
c. Reduction of respiratory muscles activity
d. All of the previous
3. Quality of life following a training course with supplemental non-invasive ventilation in COPD
may turn
a. Always better
b. Never better
c. Potentially better
d. Better in the best performing patients
4. What interface should be used when exercising on NIV?
I.
Nasal mask
II.
Full face mask
III.
Mouthpiece ventilation
IV.
Nasal pillows
Answer one choice from below
a. All of the above
b. None of the above
c. I, III and IV
d. I, II and IV
5. You decide initiate your patient on NIV to enhance their exercise capacity. You decide to use a
ventilator with a good battery life. You initiate your patient on a bilevel ventilator with a IPAP 15
cmH2O, EPAP 4 cmH2O a respiratory rate of 15bpm with 2L O2 entrained. You start walking
them and they complain of breathlessness. What do you do?
a. Increase EPAP to 6 cmH2O
b. Increase the IPAP to 20 cmH2O
c. Decrease the respiratory rate to 10bpm
d. Increase the inspiratory trigger
6. What equipment is required when preparing to perform rehabilitation with NIV for a COPD
patient for the first time?
I.
Portable ventilator with good battery life
II.
Supplementary oxygen therapy
III.
High IPAP
IV.
Walking aid trolley
V.
Pulse oximeter
Answer one choice from below:
a. I, II, III, V
b. I, II, IV, V
c. II, III, IV, V
d. ALL OF THE ABOVE