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 efficacy 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. An updated search was conducted in September 2003 and another in April 2004.


METHODS
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).


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


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.


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.
Ram
F S F
FS
National Collaborating Centre for Women and Children's Health, 27 Sussex Place, Regent's Park, London, UK, NW1 4RG. fsfram@yahoo.co.uk
Picot
J
J
Lightowler
J
J
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*