Effect of ventilatory support pressure during exercise on endurance time in patients with chronic obstructive pulmonary disease: a systematic review

Rationale Non-invasive ventilation (NIV) during exercise has been proposed to improve exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). However, the influence of fixed pressure support intensity on endurance performance and exercise-related physiological responses remains insufficiently clarified. Materials and Methods A systematic review and meta-analysis were conducted according to PRISMA guidelines (PROSPERO CRD420251018584). Randomized controlled and crossover trials evaluating NIV delivered in fixed pressure support mode during exercise were included. Random-effects models were applied to pool standardized mean differences (SMD). Mixed-effects meta-regression analyses assessed the association between pressure support level and outcomes. Primary outcome was endurance time. Secondary outcomes included dyspnea (modified Borg scale) and capnia. Results Sixteen studies (299 participants) were included. NIV significantly improved endurance time compared with control conditions (SMD 0.47; 95% CI 0.20 to 0.73). Pressure support intensity was not significantly associated with endurance time (β=0.0345 per cmH 2 O; p=0.25). Dyspnea was significantly reduced in pooled analysis (SMD −0.50; 95% CI −0.92 to −0.08) and showed a significant dose–response relationship with pressure support (β=−0.0880 per cmH 2 O; p=0.019). Capnia was significantly reduced with NIV (SMD −0.48; 95% CI −0.92 to −0.04; I 2 =68.2%), with a pressure-dependent reduction observed when post-exercise measurements were excluded (β=−0.1055 per cmH 2 O; p=0.033). Conclusion NIV during exercise improves endurance and dyspnea in COPD. Pressure support intensity influences ventilatory unloading, but endurance performance appears multifactorial. Further standardized studies are needed to optimize pressure titration during exercise.