Clinical Characteristics,Status And Compliance Of Noninvasive Ventilator Treatment In Patients With Chronic Obstructive Pulmonary Disease And Obstructive Sleep Apnea Overlap Syndrome

Part one Analysis of clinical characteristics of overlap syndrome inpatients treated with non-invasive ventilatorObjective:The coexistence of chronic obstructive pulmonary disease（COPD）and obstructive sleep apnea（OSA）in one individual is called overlap syndrome（OS）.This chapter aims at exploring the risk factors of OS patients combined with non-invasive ventilator treatment by comparing the clinical characteristics of inpatients with OS combined with non-invasive ventilator treatment or not,so as to provide reliable early warning indicators for clinical practice.Methods:Select all patients hospitalized in the Department of Respiratory and Critical Care Medicine of our hospital due to acute exacerbation of COPD from 2018.10 to 2022.9.Except for patients who need tracheal intubation and invasive assisted ventilation due to illness.After admission to the hospital,after active symptomatic treatment,portable sleep apnea monitoring screening was performed after the condition was stable.Combined with the sleep apnea hypopnea index（AHI）,to determine whether OSA is complicated.Assess lung function levels.According to whether non-invasive ventilator treatment is performed or not,they are divided into OS treated with non-invasive assisted ventilation group and OS without non-invasive assisted ventilation group.Record of general clinical data of patients,such as age,gender,body mass index（BMI）,smoking history within6 months,comorbidities（cerebrovascular disease,atrial fibrillation,hypertension,etc.）and related auxiliary examination data（white blood cell count,neutrophil count,lymphocyte count,uric acid（UA）,creatinine（Cr）,whole blood C-reactive protein（CRP）,procalcitonin（PCT）,N-terminal precursor B-type natriuretic peptide（NT-pro BNP）,arterial blood gas,left ventricular ejection fraction（LVEF%）,left ventricular and right ventricular end-diastolic diameter）.SPSS 24.0 statistical software was used to analyze the collected data.Graph Pad Prism 9.0 software was used to draw relevant indicators charts according to the statistical analysis results.Results:Excluding excluded cases,1077 COPD inpatients were screened.During hospitalization,420 cases（39.0%）received non-invasive ventilator treatment,and 657 cases（61.0%）did not receive non-invasive ventilator treatment;244 cases（58.2%）of OS patients were found to be treated with non-invasive ventilator by portable sleep breathing monitoring,Among them,25 were duplicate cases.176（41.9%）were pure COPD patients.There were239 OS patients（36.4%）without non-invasive assisted ventilation.Among them,21 were duplicate cases.418（63.6%）were pure COPD patients.Statistical analysis of the clinical data of OS combined with non-invasive assisted ventilation group and OS patients showed that,in the general data of patients,there were significant differences in BMI（29.01±3.29 VS28.42±2.80,P=0.036）,previous non-invasive ventilator application rate（27%VS 17.6%,P=0.012）and ordinary diuretic application rate（15.6%VS 8.4%,P=0.015）.Significant differences in the prevalence of comorbidities in ischemic heart disease（46.3%VS 35.6%,P=0.016）,renal insufficiency（7%VS 2.9%,P=0.041）,and lower extremity venous thrombosis in intermuscular venous thrombosis（17.2%VS 9.6%,P=0.015）.In auxiliary examination data,there were significant differences in lymphocyte count（1.01±0.30×10⁹/L VS1.12±0.29×10⁹/L,P<0.001）,neutrophil count/lymphocyte count（NLR）（8.18（5.64,11.68）VS 7.36（5.35,10.03）,P=0.020）,UA（328.21±74.61VS 287.49±66.37,P<0.001）,UA/Cr（4.56（3.61,5.91）VS 4.03（3.16,5.36）,P=0.002）,CRP（62.24±20.69 VS 55.38±18.02,P<0.001）,PCT（0.43±0.14VS 0.37±0.12,P<0.001）,NT-pro BNP（345（67,972）VS 129（56,674）,P=0.005）,arterial blood gas p H（7.26±0.06 VS 7.41±0.04,P<0.001）,carbon dioxide partial pressure（PCO₂）（99.07±11.20 VS 44.56±8.50,P<0.001）,LVEF%（52.74±6.88 VS 54.91±5.97,P<0.001）and RV/LV（0.53±0.09 VS0.51±0.08,P=0.024）;Total hospital stay（12（10,14）VS 10（8,12）,P<0.001）and survival analysis of cumulative hospitalization rates showed significant differences between the two groups.（Log-rank=96.217,P<0.001）.But survival analysis of cumulative readmission rateshowed no significant difference between the two groups of patients（Log-rank=1.094,P=0.296）.According to the general condition of the patients,BMI,the previous application of non-invasive ventilator therapy,the usual application of diuretics,and the presence or absence of ischemic heart disease,renal insufficiency and intermuscular venous thrombosis were determined.Combined prediction of whether or not to combine non-invasive assisted ventilation during hospitalization（AUC 0.623,P<0.05）.Conclusion:The prevalence of OS was high among hospitalized COPD patients,reaching 44.8%,OS patients with higher BMI and previous non-invasive ventilator treatment were more inclined to combine non-invasive ventilator treatment during hospitalization.Among OS patients,patients with ischemic heart disease,renal insufficiency and ordinary oral diuretics are more likely to treated with non-invasive assisted ventilation.During hospitalization,patients with OS treated with non-invasive ventilator treatment are more likely to be have decreased lymphocyte count,increased UA,increased CRP,increased PCT,decreased p H,increased PCO₂,increased NT-pro BNP,decreased LVEF%and increased RV/LV,and the total hospitalization rate relatively long time.The rehospitalization of OS patients with poor treatment effect during hospitalization is mostly concentrated within two weeks after discharge.Part two Analysis of the current situation of overlap syndrome inpatients treated with non-invasive ventilatorObjective: To observe the application of non-invasive ventilator after hospitalization in patients with pure COPD and OS,to evaluate the current status of non-invasive ventilator treatment in OS patients.Methods: All patients who were hospitalized in the Department of Respiratory and Critical Care Medicine of our hospital due to acute exacerbation of chronic obstructive pulmonary disease from 2018.10 to 2020.10 and treated with non-invasive ventilators were selected.Except for those who received tracheal intubation and invasive ventilator treatment on admission.Portable sleep breathing monitoring was performed within 1 week after active treatment and the condition was relatively stable.Combined with AHI,they were divided into COPD group and OS group.The general information of patients in each group was tracked and recorded,such as age,BMI,smoking history within 6 months,CAT（COPD assessment test）score,blood gas analysis,pulmonary function and comorbidities.As well as the duration of non-invasive ventilator application and the conversion of tracheal intubation to invasive ventilation in each group.SPSS 24.0 statistical software was used to analyze the collected data.Graph Pad Prism 9.0 software was used to draw relevant indicators charts according to the statistical analysis results.Results: Excluding excluded cases,a total of 206 COPD patients were screened from 2018.10 to 2020.10.There were 86 cases（male,64 cases,73.3%）in the COPD group,120 cases（male,88 cases,74.4%）in the OS group.A summary analysis of the general information of the patients showed that,In COPD and OS groups BMI（23.84±4.06 vs 28.95±2.96,P=0.001）.The ROC curve analysis showed that the area under the curve of BMI was 0.835（P<0.001）.BMI can be used as an indicator to predict whether patients with COPD who are hospitalized and treated with non-invasive ventilator have OSA,with a sensitivity of 77.5% and a specificity of 89.4%.The rate of endotracheal intubation within 48 hours after admission in the COPD group and the OS group（20.93% vs 9.17%,P=0.017）.There was no significant difference in the interval time between the two groups of patients with tracheal intubation from admission to tracheal intubation and invasive mechanical ventilation（Log-rank=0.708,P=0.400）,while there was a statistically significant difference in the application time of non-invasive assisted ventilation between the two groups of patients who had always been treated with non-invasive ventilators（Log-rank=30.856,P<0.001）.Conclusion: A large proportion of AECOPD patients are combined with OSA,and BMI can be used as one of the indicators to predict combined OSA or not.During acute exacerbation,OS patients are more tolerant to hypercapnia than pure COPD patients,and the success rate of non-invasive mechanical ventilation is higher than that of pure COPD patients.but the non-invasive ventilation time is longer than that of pure COPD patients.Part three Influence of non-invasive ventilator treatment compliance on prognosis of patients with overlap syndromeObjective: Out-of-hospital non-invasive ventilator therapy is an important means of maintenance treatment for overlap syndrome.To further explore the influence of non-invasive ventilator treatment adherence on the prognosis of patients with overlap syndrome.Methods: Out-of-hospital non-invasive ventilator maintenance treatment education was given to inpatient OS patients before discharge.The OS who agreed to the non-invasive ventilator maintenance treatment outside the hospital were selected and followed up for 12 months.Use the electronic We Chat software platform to report and record the daily application time of the non-invasive ventilator.More than 70% of the daily application time of non-invasive ventilator was ≥4 hours,recorded as T≥4 hours group（good compliance group）,On the contrary,it was recorded as T<4 hours group（poor compliance group）.The general conditions,annual frequency of acute exacerbations,first acute exacerbations（time and degree）,and quarterly SGRQ scores of the two groups of patients were recorded respectively.SPSS 24.0 statistical software was used to analyze the collected data.Graph Pad Prism 9.0 software was used to draw relevant indicators charts according to the statistical analysis results.Results: Excluding excluded cases,a total of 49 OS patients were screened from 2018.10 to 2021.5.The acceptance rate of non-invasive ventilator maintenance treatment outside the hospital was 22.97%（34/148）in hospitalized patients with OS combined with non-invasive ventilator treatment,while the acceptance rate of hospitalized patients with pure OS was 11.36%（15/132）.The use of non-invasive ventilator treatment during hospitalization significantly affected the acceptance of non-invasive ventilator maintenance treatment outside the hospital（χ2=6.513,P=0.011）.Continuous follow-up for 12 months.Among them,8 were lost to follow-up,with a loss-to-follow-up rate of 16.33%,mostly within 6 months after the start of follow-up.There were 25 cases in the good compliance group and 16 cases in the poor compliance group.There were no significant differences between the two groups in age,gender,pulmonary function classification,OSA classification,previous smoking history,and history of non-invasive ventilator therapy.In terms of BMI,OS patients with good compliance had significantly higher BMI（31.75±1.58 VS 28.64±1.39,P<0.001）.In terms of time to first exacerbation,OS patients with good compliance were significantly longer（Log rank=11.216,P=0.001）.In terms of annual exacerbation frequency,OS patients with good compliance also significantly decreased（1.04±0.935 VS 1.63±0.806,P=0.046）.However,there was no significant difference between the two groups in terms of the degree of first acute exacerbation.Quarterly SGRQ scores showed significant differences in total SGRQ scores between the two groups only at month 12.Conclusion: Out-of-hospital non-invasive ventilator therapy should become an important part of maintenance therapy for OS patients.At present,the overall acceptance of non-invasive ventilator maintenance treatment outside the hospital is low.Relatively high acceptance of patients who have received non-invasive ventilator therapy in the past.The overall compliance rate of non-invasive ventilator maintenance treatment outside the hospital was 83.67%,and most of the patients lost to follow-up were within 6 months from the start of follow-up.BMI may be a predictor of good adherence to noninvasive ventilator therapy.Maintaining good non-invasive ventilator treatment compliance（at least 12 months）can prolong the time to first exacerbation,reduce the annual exacerbation frequency,and improve the quality of life in OS patients.