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


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


METHODS
An initial search was performed using the Cochrane Airways Group trials register and other relevant electronic databases.


METHODS
Randomised controlled trials comparing NPPV plus usual medical care versus usual medical care 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).


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


RESULTS
Eight studies were included in the review. NPPV resulted in decreased mortality (Relative Risk [RR] 0.41; 95% Confidence Intervals [CI] 0.26, 0.64), decreased need for intubation (RR 0.42; 95%CI 0.31, 0.59), reduction in treatment failure (RR 0.51; 95%CI 0.39, 0.67), rapid improvement within the first hour in pH (Weight Mean Difference [WMD] 0.03; 95%CI 0.02, 0.04), PaCO2 (WMD -0.40 kPa; 95%CI -0.78, -0.03) and respiratory rate (WMD -3.08 bpm; 95%CI -4.26, -1.89). In addition, complications associated with treatment (RR 0.32; 95%CI 0.18, 0.56) and length of hospital stay (WMD -3.24 days; 95%CI -4.42, -2.06) were also reduced in the NPPV group.


CONCLUSIONS
Data from good quality randomised controlled trials permit NPPV to be recommended as the first line intervention, coupled with usual medical care, in all suitable patients with respiratory failure secondary to an acute exacerbation of COPD. A trial of NPPV should be considered early in the course of respiratory failure, and before severe acidosis ensures, as a means of avoiding endotracheal intubation, reducing mortality and treatment failure.
Ram
F S
FS
Department of Physiological Medicine, St George's Hospital Medical School, Level 0, Jenner Wing, Cranmer Terrace, London, UK, SW17 0RE. fram@sghms.ac.uk
Lightowler
J V
JV
Wedzicha
J A
JA
D000328:Adult; D006801:Humans; D011175:Positive-Pressure Respiration / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications*; D016032:Randomized Controlled Trials as Topic; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*