HOT-HMV Pathway for COPD

This pathway has been developed for patients who have had a hospital admission requiring appropriate acute non-invasive ventilation (ANIV) for hypercapnic respiratory failure, secondary to an exacerbation of COPD, who are not already established on HMV.

• Some patients will be unable to wean from ANIV and they should be referred to a specialist HMV centre for assessment and consideration of HMV before discharge. For patients who were hypercapnic pre-admission, HMV should also be considered prior to hospital discharge.
• All patients who have had an admission requiring ANIV need to be referred and assessed post-discharge with either a specialist COPD team or HMV centre depending on pre-discharge CO2 (please refer to pathway).
• All patients requiring ANIV should have a pre-discharge blood gas analysis when medically stable and weaned from ANIV.
• If the patient has a primary diagnosis of non-COPD (eg neuromuscular or muscular skeletal diagnosis – including chest wall/restrictive deficits) and required ANIV, they should be discussed with a specialist HMV team prior to discharge. These patients frequently benefit from long-term ventilatory support.
• If the patient has a presumed or definitive diagnosis of COPD, the aim should be for them to have been seen and established on HMV 2-4 weeks of discharge if it is indicated and appropriate. This can be delivered in various ways depending upon local practice and care pathways.

1. If the pre-discharge pCO2 is below 6kPa the patient should be followed up as per local COPD pathways

2. If the pre-discharge pCO2 is between 6-7 kPa, the patient should be reviewed by an appropriate specialist clinician who can provide a full respiratory assessment and optimisation of the patient’s COPD management. This may include discussion and triage with a specialist HMV service.

3. If the pre-discharge pCO2 is 7kPa or above and the patient would be accepting of non-invasive ventilation they should have a post discharge specialist review, ideally within 2 weeks. This should include the following as a minimum:

• • Blood gas analysis
  • Spirometry (if not done previously)
  • Pharmacological optimisation
  • Advance care planning
  • Pulmonary rehabilitation referral if appropriate

N.B. Some patients decline HMV based on a misunderstanding of what is involved. Unless it is very clear that they fully understand what HMV involves and still decline, they should enter the HMV pathway.

If the post-discharge pCO2 remains above 7kPa then there needs to be a pathway where the patient is assessed and established on HMV within 2-4 weeks of hospital discharge.

A post-set-up review should take place within 8 weeks by a member of the HMV team to optimise ventilation.

If the patient is readmitted requiring ANIV secondary to hypercapnic respiratory failure within this period, they should be considered a candidate for in-patient set up and discussed with an HMV specialist team.

Additional notes:

Case examples of HMV set up:

1. HMV set up in HMV clinic when reviewed post-discharge at 2 weeks
2. Speciality respiratory team locality review referred onto specialist HMV team for set up for a 2-week post-discharge review
3. Locality review at another hospital by HMV team and set up in-patient in locality hospital
4. Home set up for those unable to attend clinic
5. In-patient transfer following referral into HMV pathway

We recommend that all patients on HMV are reviewed by a member of the HMV service at least annually. HMV titration should be aimed at improving chronic respiratory failure and this should be the measure of efficacy.