Which Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Benefit from Noninvasive Positive-Pressure Ventilation? A Systematic Review of the Literature

Royal Columbian Hospital, New Westminster, British Columbia V3L 5E7, Canada.
Annals of internal medicine (Impact Factor: 17.81). 07/2003; 138(11):861-70.
Source: PubMed


Over the past decade, noninvasive positive-pressure ventilation (NPPV) in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased in popularity. Although several trials have been published on the relative effectiveness of this treatment, apparent inconsistencies in study results remain.
To assess the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality rate in patients with an acute exacerbation of COPD and to determine the effect of exacerbation severity on these outcomes.
MEDLINE (1966 to 2002) and EMBASE (1990 to 2002). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. There were no language restrictions.
The researchers selected randomized, controlled trials that 1) examined patients with acute exacerbation of COPD; 2) compared noninvasive ventilation and standard therapy with standard therapy alone; and 3) included need for endotracheal intubation, length of hospital stay, or hospital survival as an outcome.
Methodologic quality and results were abstracted independently and in duplicate.
The addition of NPPV to standard care in patients with an acute exacerbation of COPD decreased the rate of endotracheal intubation (risk reduction, 28% [95% CI, 15% to 40%]), length of hospital stay (absolute reduction, 4.57 days [CI, 2.30 to 6.83 days]), and in-hospital mortality rate (risk reduction, 10% [CI, 5% to 15%]). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations.
Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.

5 Reads
  • Source
    • "It is now well-demonstrated that non-invasive ventilation (NIV) can reduce intubation and mortality rates in patients with severe acute exacerbation of chronic obstructive pulmonary disease [1-3] or cardiogenic pulmonary edema [4]. By contrast, the beneficial effects of NIV remain unclear in patients with de novo acute hypoxemic respiratory failure (AHRF), that is, non-hypercapnic patients having acute respiratory failure in the absence of a cardiac origin or underlying chronic pulmonary disease. "
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess rates and predictive factors of non-invasive ventilation (NIV) failure in patients admitted to the intensive care unit (ICU) for non-hypercapnic acute hypoxemic respiratory failure (AHRF). Observational cohort study using data prospectively collected over a three-year period in a medical ICU of a university hospital. Among 113 patients receiving NIV for AHRF, 82 had acute respiratory distress syndrome (ARDS) and 31 had non-ARDS. Intubation rates significantly differed between ARDS and non-ARDS patients (61% versus 35%, P = 0.015) and according to clinical severity of ARDS: 31% in mild, 62% in moderate, and 84% in severe ARDS (P = 0.0016). In-ICU mortality rates were 13% in non-ARDS, and, respectively, 19%, 32% and 32% in mild, moderate and severe ARDS (P =0.22). Among patients with moderate ARDS, NIV failure was lower among those having a PaO2/FiO2 >150 mmHg (45% vs. 74%, p=0.04). NIV failure was associated with active cancer, shock, moderate/severe ARDS, lower Glasgow coma score and lower positive end-expiratory pressure level at NIV initiation. Among intubated patients, ICU mortality rate was 46% overall and did not differ according to the time to intubation. With intubation rates below 35% in non-ARDS and mild ARDS, NIV stands as the first-line approach; NIV may be attempted in ARDS patients with a PaO2/FiO2 > 150. By contrast, 84% of severe ARDS required intubation and NIV did not appear beneficial in this subset of patients. However, the time to intubation had no influence on mortality.
    Critical care (London, England) 11/2013; 17(6):R269. DOI:10.1186/cc13103 · 4.48 Impact Factor
  • Source
    • "Noninvasive positive pressure can also be used in home care for patients with cardiovascular, respiratory, central nervous system, neuromuscular and skeletal disorders. Despite the frequent use of EPAP, the literature on this subject is scarce, especially with regard to the adverse effects [1, 2]. Respiration exerts a significant influence over autonomic cardiovascular control. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The increase in the number of studies has led to greater security in the application of this method and the determination of its effectiveness in adults.. The purpose of the present study was to evaluate heart rate variability in healthy individuals submitted to different levels of positive expiratory pressure using an expiratory positive airway pressure (EPAP) device. The study involved 27 healthy male individuals ranging in age from 20 to 35 years. Patient histories were taken and the subjects were submitted to a physical examination. The volunteers were monitored using the Polar 810s(®) and submitted to the EPAP experiment. Analyses were performed on variables of the frequency domain. Sympathetic and parasympathetic bands and their relationship with sympathovagal response were also analyzed. The mean value of this variable was 526.89 (55.50) ms(2) in the first period, 2811.0 (721.10) ms(2) in the fourth period and 726.52 (123.41) ms(2) in the fifth period. Regarding the parasympathetic area, significant differences were detected when Periods 1 and 5 (no load) were compared with periods in which the individuals were subjected to the use of the therapy. Sympathetic and parasympathetic areas together, a significant difference was detected regarding the sympathetic/parasympathetic ratio in the comparison between Periods 1 and 4 (p < 0.01) as well as Periods 2 and 4 (p < 0.05). The findings of the present study suggest that the therapeutic use of EPAP significantly alters the parameters of heart rate variability in the frequency domain, highlighting the importance of monitoring and care during the practice of EPAP.
    Archives of Medical Science 08/2013; 9(4):651-5. DOI:10.5114/aoms.2013.36902 · 2.03 Impact Factor
  • Source
    • "Noninvasive mechanical ventilation (NIV) is used in patients with acute respiratory failure for several different etiologies [1]. The heterogeneity of different patient groups leads to varying levels of success, with the best results produced in patients with infectious exacerbations of COPD and congestive heart failure [2-4]. When NIV is initiated in patients with acute respiratory failure due to infectious exacerbations of COPD, ventilatory parameters are typically determined based on clinical assessment and changes in blood gases. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Non-invasive mechanical ventilation (NIV) in patients with acute respiratory failure has been traditionally determined based on clinical assessment and changes in blood gases, with NIV support pressures manually adjusted by an operator. Bilevel positive airway pressure-spontaneous/timed (BiPAP S/T) with average volume assured pressure support (AVAPS) uses a fixed tidal volume that automatically adjusts to a patient’s needs. Our study assessed the use of BiPAP S/T with AVAPS in patients with chronic obstructive pulmonary disease (COPD) and hypercapnic encephalopathy as compared to BiPAP S/T alone, upon immediate arrival in the Emergency-ICU. We carried out a prospective interventional match-controlled study in Guayaquil, Ecuador. A total of 22 patients were analyzed. Eleven with COPD exacerbations and hypercapnic encephalopathy with a Glasgow Coma Scale (GCS) <10 and a pH of 7.25-7.35 were assigned to receive NIV via BiPAP S/T with AVAPS. Eleven patients were selected as paired controls for the initial group by physicians who were unfamiliar with our study, and these patients were administered BiPAP S/T. Arterial blood gases, GCS, vital signs, and ventilatory parameters were then measured and compared between the two groups. We observed statistically significant differences in favor of the BiPAP S/T + AVAPS group in GCS (P = .00001), pCO2 (P = .03) and maximum inspiratory positive airway pressure (IPAP) (P = .005), among others. However, no significant differences in terms of length of stay or days on NIV were observed. BiPAP S/T with AVAPS facilitates rapid recovery of consciousness when compared to traditional BiPAP S/T in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy. Trial registration Current Controlled Trials application ref is ISRCTN05135218
    BMC Pulmonary Medicine 03/2013; 13(1):12. DOI:10.1186/1471-2466-13-12 · 2.40 Impact Factor
Show more