This Figure lists the factors from my clinical experience with my patient population that I have determined are likely to identify patients who may fail NIV treatment in the outpatient setting, with increased NIV failure leading to readmissions:

• A key feature is poor selection of candidates to start NIV in the first place;
• Lack of a disease management component, breathing technique education, and an action plan of when and who to call in case of disease exacerbation is important;
• Ongoing tobacco abuse;
• Lack of management of the comorbid medical problems, especially anxiety, depression, and additionally cardiac disease.

These conditions have in common the fact that they affect breathing, and if a person is not managed well with those conditions, the result may lead to hospitalizations that are perceived as a COPD exacerbation when, in fact, they may not be.

I have also found the importance of a trained respiratory specialist, specifically the respiratory therapist, who can be responsible for frequent visits with patients to reinforce their disease management, keeping up-to-date with their compliance with therapy, downloads, education, etc.  I found that if you do not have this component in place, the patients who have less contact with this component of their care have more hospitalizations compared to patients who have frequent communication with a therapist who knows what is going on with their equipment and who therefore tend to have fewer hospitalizations.

Finally, one of the things that I have found in my practice is that patients are more likely to fail NIV if they are not patients who follow up very well.  When patients have poor physician follow-up, they tend to be patients who do not take their medications; they are more likely to do poorly and their NIV therapy appears to be failing, when, in fact, the treatment failure may be associated with other components of their health and their compliance.