Comparison of mathematically arterialised venous blood gas sampling with arterial, capillary, and venous sampling in adult patients with hypercapnic respiratory failure: a single-centre longitudinal cohort study.

BACKGROUND: Accurate arterial blood gas (ABG) analysis is essential in the management of patients with hypercapnic respiratory failure, but repeated sampling requires technical expertise and is painful. Missed sampling is common and has a negative impact on patient care. A newer venous to arterial conversion method (v-TAC, Roche) uses mathematical models of acid-base chemistry, a venous blood gas sample and peripheral blood oxygen saturation to calculate arterial acid-base status. It has the potential to replace routine ABG sampling for selected patient cohorts. The aim of this study was to compare v-TAC with ABG, capillary and venous sampling in a patient cohort referred to start non-invasive ventilation (NIV). METHODS: Recruited patients underwent near simultaneous ABG, capillary blood gas (CBG) and venous blood gas (VBG) sampling at day 0, and up to two further occasions (day 1 NIV and discharge). The primary outcome was the reliability of v-TAC sampling compared with ABG, via Bland-Altman analysis, to identify respiratory failure (via PaCO2) and to detect changes in PaCO2 in response to NIV. Secondary outcomes included agreements with pH, sampling success rates and pain. RESULTS: The agreement between ABG and v-TAC/venous PaCO2 was assessed for 119 matched sampling episodes and 105 between ABG and CBG. Close agreement was shown for v-TAC (mean difference (SD) 0.01 (0.5) kPa), but not for CBG (-0.75 (0.69) kPa) or VBG (+1.00 (0.90) kPa). Longitudinal data for 32 patients started on NIV showed the closest agreement for ABG and v-TAC (R2=0.61). v-TAC sampling had the highest first-time success rate (88%) and was less painful than arterial (p<0.0001). CONCLUSION: Mathematical arterialisation of venous samples was easier to obtain and less painful than ABG sampling. Results showed close agreement for PaCO2 and pH and tracked well longitudinally such that the v-TAC method could replace routine ABG testing to recognise and monitor patients with hypercapnic respiratory failure. TRIAL REGISTRATION NUMBER: NCT04072848; www. CLINICALTRIALS: gov.

A randomised crossover trial comparing volume assured and pressure preset noninvasive ventilation in stable hypercapnic COPD.

Recent randomised controlled trials suggest non-invasive ventilation may offer benefit in the long-term management of ventilatory failure in stable COPD. The best mode of ventilation is unknown and newer volume assured modes may offer advantages by optimising ventilation overnight when treatment is delivered. This study compares volume assured with pressure preset non-invasive ventilation. Randomised crossover trial including twenty five subjects previously established on long-term non-invasive ventilation to manage COPD with chronic ventilatory failure. Two 8-week treatment periods of volume assured and pressure preset non-invasive ventilation. The primary outcomes were daytime arterial blood gas tensions and mean nocturnal oxygen saturation. Secondary outcomes included lung function, exercise capacity, mean nocturnal transcutaneous carbon dioxide, health status and compliance. No significant differences were seen in primary or secondary outcomes following 8 weeks of treatment when comparing volume assured and pressure preset ventilation. Primary outcomes assessed: mean (standard deviation) PaO(2) 7.8 (1.2) vs 8.1(1) kPa, PaCO(2) 6.7 (1.1) vs 6.3 (1.2) kPa and mean nocturnal oxygenation 90 (4) vs 91 (3)% volume assured versus pressure preset, respectively. Volume assured and pressure preset non-invasive ventilation appear equally effective in the long-term management of ventilatory failure associated with stable COPD.

The effects of withdrawing long-term nocturnal non-invasive ventilation in COPD patients.

Patients with ventilatory failure due to chronic obstructive pulmonary disease (COPD) are increasingly managed with long-term non-invasive positive pressure ventilation (NIPPV) and this may improve survival. NIPPV can frequently be interrupted but there are few data detailing the short-term effects and none on the longer-term consequences of treatment withdrawal. Ten patients withdrew from NIPPV for 1 week and were randomised to restart NIPPV or to continued withdrawal for up to 6 months. Outcomes assessed included daytime blood gases, nocturnal ventilation, lung function, exercise capacity and health status. After 1 week of withdrawal PaO(2), PaCO(2), nocturnal oximetry, lung function and exercise capacity did not change, but mean nocturnal transcutaneous CO(2) (6.3 (1) vs. 7.6 (1.1) kPa p = 0.04) and daytime blood gas bicarbonate (30.3 (4.5) vs. 31.2 (3.9) mmol/L p = 0.04) rose. During a 6-month period of withdrawal of nocturnal NIPPV, daytime PaCO(2) (6 (1.1) vs. 7.5 (1.3) kPa p = 0.002) increased and health status (total St George's Respiratory Questionnaire score 55.5 (6.3) vs. 65.6 (10) p = 0.006) worsened. Three out of five patients met a priori criteria to restart NIPPV in the continued withdrawal group. Short interruptions to domiciliary NIPPV used to manage chronic ventilatory failure as a consequence of COPD do not cause a rapid clinical deterioration but nocturnal ventilation worsens and daytime bicarbonate levels increase following 1 week's cessation. Thereafter, daytime PaCO(2) rises and health status worsens, supporting the role of long-term NIPPV in the management of such patients.