EzPAP device bests noninvasive ventilation for hypercapnic COPD exacerbations

In the treatment of patients with mild-to-moderate hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD), the EzPAP positive airway pressure device works better than noninvasive ventilation at improving oxygen saturation levels and correcting respiratory acidosis, as shown in a study.

At 24 h following initiation of therapy, the primary outcome of arterial oxygen saturation (SaO2) significantly increased from baseline in both the EzPAP (from 80.44 percent to 92.10 percent) and the noninvasive ventilation (from 80.55 percent to 89.63 percent) arms, although the improvement was more pronounced in the EzPAP arm. [Respir Med 2025;248:108383]

Similarly, the pH levels improved by a greater magnitude in the EzPAP arm, from 7.30 at baseline to 7.36 at 24 h, as opposed to the increase from 7.30 to 7.35 in the noninvasive ventilation arm. Of note was that significant increases in pH levels in the EzPAP arm occurred at the 1- and 4-h mark.

Partial pressure of oxygen (PaO2) values increased substantially at 24 h only in the EzPAP arm (from 56.33 to 63.23 mm Hg). Other outcomes such as lactate and bicarbonate levels, as well as 90-day readmission and mortality rates did not significantly differ between the EzPAP and noninvasive ventilation arms.

“These results indicate that EzPAP [exerts] beneficial short-term effects and may represent a promising alternative to noninvasive ventilation in treating COPD exacerbations,” according to the investigators.

Practical advantage

EzPAP is a noninvasive, portable respiratory therapy device that mixes atmospheric air with oxygen from a gas cylinder to enhance positive end-expiratory pressure (PEEP) while improving oxygenation. [Rev Bras Pesqui Ciênc Saúde 2022;8:97-102; Respir Care 2019;64:1181-1192]

“The device harnesses Bernoulli’s effects to increase expiratory pressure by generating resistance during exhalation. This mechanism is crucial, as it allows for higher expiratory and positive inspiratory pressures, which can effectively recruit collapsed lung alveoli and enhance respiratory function,” the investigators explained. [Multidiscip Cardio Annal 2018;10:e82822]

EzPAP treatment is administered through a mouthpiece and can be applied intermittently, allowing patients to take breaks for eating, clearing respiratory secretions, and general comfort, they added.

In contrast, noninvasive ventilation support, which is critically important for patients facing hypercapnic respiratory failure from COPD exacerbations, can fail. Common causes of treatment failure with noninvasive ventilation include mask discomfort, challenges in clearing excessive respiratory secretions, agitation, and anxiety. These factors demonstrate why a simpler, less restrictive device such as the EzPAP is a compelling alternative, as the investigators pointed out.

“Additionally, the device is relatively inexpensive and requires minimal training, which could make it a suitable option in resource-limited healthcare settings,” they said. [Anaesthesist 2012;61:867-874; Thorax 2011;66:A96]

Study details

For the study, 39 patients with a diagnosis of hypercapnic COPD exacerbation were randomly assigned to receive treatment with either EzPAP therapy (n=19) or noninvasive ventilation support (n=20).

In the EzPAP arm, therapy was administered at a flow rate of 5 L/min, targeting SpO2 of between 88 percent and 92 percent, every hour for 40 min. During treatment interruptions, a nasal cannula oxygen was administered to maintain SpO2 at the target range.

In the noninvasive ventilation arm, treatment was administered with a standard oral nasal mask, with baseline inspiratory positive airway pressure of 8–10 cmH20 and expiratory positive airway pressure of 4–6 cmH2O. Both pressures were gradually increased according to the patient’s tolerable level.

Treatments were administered for up 24 h, contingent on patient tolerance. Interruptions were allowed in cases where patients needed to relieve their needs, such as eating or clearing of secretions. Nasal cannula oxygen was administered during interruptions to maintain SpO2 at the target range. All patients were monitored with continuous SaO2, electrocardiogram, and noninvasive blood pressure throughout the intervention.