Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease

Non-invasive positive pressure ventilation (NPPV) used in patients with acute exacerbations of COPD substantially improves recovery. Invasive mechanical ventilation is undoubtedly a lifesaving procedure for patients with severe life threatening (respiratory failure) exacerbation of their COPD. However, this procedure is also associated with numerous adverse effects. NPPV that requires wearing a nasal or facial mask connected to a mechanical ventilator has been shown to be beneficial for such patients in reducing hospital deaths and also the number of patients going on to require tracheal intubation. NPPV has also been shown to reduce complications associated with treatment and length of hospital stay.

Authors' conclusions: 

Data from good quality randomised controlled trials show benefit of NPPV as first line intervention as an adjunct therapy to usual medical care in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD. NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, as a means of reducing the likelihood of endotracheal intubation, treatment failure and mortality.

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Background: 

Non-invasive positive pressure ventilation (NPPV) is being used increasingly in the management of patients admitted to hospital with acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease (COPD).

Objectives: 

To determine the efficacy of NPPV in the management of patients with respiratory failure due to an acute exacerbation of COPD.

Search strategy: 

An initial search was performed using the Cochrane Airways Group trials register and other relevant electronic databases. An updated search was conducted in September 2003 and another in April 2004.

Selection criteria: 

Randomised controlled trials comparing NPPV plus usual medical care (UMC) versus UMC alone were selected. Trials needed to recruit adult patients admitted to hospital with respiratory failure due to an exacerbation of COPD and with PaCO2 > 6 kPa (45 mmHg).

Data collection and analysis: 

Two authors independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted the data.

Main results: 

Fourteen studies were included in the review. NPPV resulted in decreased mortality (Relative Risk 0.52; 95%CI 0.35 to 0.76), decreased need for intubation (RR 0.41; 95%CI 0.33 to 0.53), reduction in treatment failure (RR 0.48; 95%CI 0.37 to 0.63), rapid improvement within the first hour in pH (Weight Mean Difference 0.03; 95%CI 0.02 to 0.04), PaCO2 (WMD -0.40 kPa; 95%CI -0.78 to -0.03) and respiratory rate (WMD -3.08 bpm; 95%CI -4.26 to -1.89). In addition, complications associated with treatment (RR 0.38; 95%CI 0.24 to 0.60) and length of hospital stay (WMD -3.24 days; 95%CI -4.42 to -2.06) was also reduced in the NPPV group.

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