title: Noninvasive positive pressure ventilation in patients with acute exacerbations of COPD and varying levels of consciousness.
abstract: OBJECTIVE
  A severely altered level of consciousness (ALC) has been considered a contraindication to noninvasive positive pressure ventilation (NPPV). We compared the clinical outcome of patients with acute respiratory failure (ARF) due to COPD exacerbations and different degrees of ALC.
  
  
  METHODS
  A 5-year case-control study with a prospective data collection.
  
  
  METHODS
  Respiratory Monitoring Unit.
  
  
  METHODS
  Eighty of 153 consecutive COPD patients requiring NPPV for ARF were divided into four groups, which were carefully matched for the main physiologic variables, according to the level of consciousness assessed with the Kelly-Matthay Score, in which 1 is normal (control subjects) and 6 is severely impaired.
  
  
  RESULTS
  Changes from baseline in arterial blood gas (ABG) levels and Kelly score, the rate and causes of NPPV failure, the rate of nosocomial pneumonia, and the 90-day mortality rate were compared. NPPV significantly improved ABG levels and Kelly score in all groups after 1 to 2 h. NPPV failure (Kelly score 1 = 15%; Kelly score 2 = 25%; Kelly score 3 = 30%; Kelly score > 3 = 45%) and 90-day mortality rate (Kelly score 1 = 20%; Kelly score 2 = 35%; Kelly score 3 = 35%; Kelly score > 3 = 50%) significantly increased with the worsening of the level of consciousness. Using a multivariate analysis, the acute nonrespiratory component of the acute physiology and chronic health evaluation (APACHE) III score, and baseline pH independently predicted baseline Kelly score. After 1 to 2 h of NPPV, changes in the Kelly score were associated with those in pH. No correlation was found with Pa(CO2).
  
  
  CONCLUSIONS
  This study confirms that NPPV may be successfully applied to patients experiencing COPD exacerbations with milder ALCs, whereas the rate of failure in patients with severely ALCs (ie, Kelly score > 3) is higher, even though better than expected, so that an initial and cautious attempt with NPPV may be performed even in this latter group. Changes in the level of consciousness induced by NPPV are not correlated with those in Pa(CO2).
authors.affiliation: Unità Operativo Pneumologia, Ospedale S. Donato, ASL 8 Arezzo, Via Nenni 20, 52100 Arezzo, Italy. raffaele_scala@hotmail.com
authors.forename: Raffaele
authors.initials: R
authors.lastname: Scala
authors.forename: Mario
authors.initials: M
authors.lastname: Naldi
authors.forename: Ivano
authors.initials: I
authors.lastname: Archinucci
authors.forename: Giovanni
authors.initials: G
authors.lastname: Coniglio
authors.forename: Stefano
authors.initials: S
authors.lastname: Nava
mesh_terms: D000137:Acid-Base Imbalance / Q000150:complications; D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D003244:Consciousness Disorders / Q000209:etiology*; D005260:Female; D006801:Humans; D006935:Hypercapnia / Q000150:complications; D008297:Male; D011175:Positive-Pressure Respiration; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*