Impact of long-term non-invasive ventilation on severe exacerbations and survival in COPD: a French nationwide cohort study using multistate models

RATIONALE: Chronic obstructive pulmonary disease (COPD) is the most common indication for domiciliary non-invasive ventilation (NIV), but long-term outcomes data are limited. OBJECTIVE: This multistate model analysis estimated the impact of NIV therapy continuation versus cessation on transitions between three different disease states. METHODS: Model data came from the French national health insurance reimbursement system database for individuals aged ≥40 years with COPD and ≥1 NIV reimbursement in 2015-2019. MEASUREMENT AND MAIN RESULTS: Data from 49 503 patients started on NIV were included (median age 70 years, 51.2% male, median 1 exacerbation in the previous year). There were 80 361 severe exacerbations and 18 125 deaths (including 7805 in severe exacerbation). In multistate models, NIV continuation was associated with a significant reduction in transition to death, from severe exacerbation (HR 0.84, 95% CI 0.79 to 0.91) and without exacerbation (HR 0.88, 95% CI 0.83 to 0.93). NIV continuation versus cessation had no significant effect on transition between without exacerbation to severe exacerbation (HR 0.98, 95% CI 0.95 to 1.00) but was significantly associated with slower transition from severe exacerbation to without exacerbation (HR 0.87, 95% CI 0.84 to 0.89). CONCLUSION: This multistate model analysis found that the long-term use of domiciliary NIV was associated with a lower risk of transitions to death, but was not associated with a reduction in recovery time after severe exacerbation. These data highlight the potential mortality benefits of long-term domiciliary NIV in COPD and can be used as one piece of evidence to support evidence-based guideline recommendations.