Clinician-Perceived Barriers and Facilitators for Initiation and Management of Noninvasive Ventilation Among Patients With Chronic Hypercapnia From COPD: A Qualitative Study.

Abstract

Background Long-term non-invasive ventilation (NIV) improves survival and re-admission risk for patients with chronic hypercapnia from chronic obstructive pulmonary disease (COPD). However, outpatient NIV prescription remains low. Methods We conducted a qualitative study using semi-structured interviews with pulmonary physicians. We identified a convenience sample of community-affiliated outpatient pulmonologists who were recruited via email. Deductive and inductive thematic content analysis were used to identify how physicians screen and manage patients with COPD at risk for chronic hypercapnia and what barriers hinder their ability to care for this population. Results Among 15 physicians interviewed, 13 were general pulmonologists. Two were sleep certified. They spent 52.5 + 21.3% of clinical time on average in outpatient care. While physicians identified FEV1 and serum bicarbonate (HCO3-) as parameters that would prompt a hypercapnia evaluation, there was no consistent threshold identified. Physicians initiated NIV themselves but varied in initial device selection and settings. Arterial blood gas (ABG) testing was infrequently used to monitor improvement and opinions differed on why and how initial NIV settings needed to be changed. Barriers to management included patient factors (e.g. NIV disinterest), physician discomfort (e.g. NIV troubleshooting), poor access to testing, lack of clinical support, and insurance and durable medical equipment (DME) company logistics. Conclusion Pulmonary physicians face multiple barriers in caring for this population, leading to variation in screening and management practices for chronic hypercapnia in COPD. Areas for improvement include standardized screening guidance, better clinical support and testing access, improved clinical education, and a streamlined approach to insurance approval.