Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature.
ABSTRACT 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.
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Chapter: HIV/AIDS in Developing Countries[Show abstract] [Hide abstract]
ABSTRACT: The HIV/AIDS epidemic in developing countries has raised unique challenges. Total health care expenditure is low in comparison to developed countries. The overwhelming effect of infectious diseases, malnutrition, and inadequate education, singularly and in combination seriously limit the capacity of such countries to deal with HIV/AIDS with effective long-term strategies. This review will focus on three aspects of the epidemic with emphasis on their impact on critically ill patients in developing countries.04/2007: pages 27-33;
Chapter: Hepatorenal Syndrome[Show abstract] [Hide abstract]
ABSTRACT: Initial reports by Frerichs (1861) and Flint (1863) , who had noted an association between advanced liver disease with ascites and acute oliguric renal failure in the absence of significant histological changes in the kidneys, led Heyd , and later Helwig and Schutz , to introduce the concept of the hepatorenal syndrome (HRS) to explain the increased frequency of acute renal failure after biliary surgery. However, because HRS could not be reproduced in animal models, pathophysiological concepts remained speculative and its clinical entity was not generally accepted. During the 1950s, HRS was more specifically characterised as a functional renal failure in patients with advanced liver disease, electrolyte disturbances and low urinary sodium concentrations . Hecker and Sherlock  showed its temporal reversibility by norepinephrine administration. Over the next few decades, haemodynamic and perfusion studies by Epstein and other investigators  identified splanchnic and systemic vasodilatation and active renal vasoconstriction as the pathophysiological hallmarks of HRS. Improved models of ascites and circulatory dysfunction contributed to therapeutic advances, including the introduction of large-volume paracentesis, vasopressin analogues, and transjugular intrahepatic stent-shunt (TIPS), which in turn have led to an improved pathophysiological understanding of HRS .04/2007: pages 9-26;
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ABSTRACT: La ventilation noninvasive (VNI) est une pierre angulaire du traitement de l’insuffisance respiratoire aiguë en réanimation. C’est donc naturellement qu’elle a été proposée pour le sevrage de la ventilation mécanique. En postextubation, trois situations correspondant à trois indications différentes doivent être clairement distinguées. La première situation est la VNI « facilitatrice », dont l’objectif est de permettre l’extubation des patients en échec de sevrage. Dans ce cas, malgré l’échec de l’épreuve de sevrage, le patient est tout de même extubé et reçoit de la VNI intensive au décours afin de prévenir la réintubation. La VNI facilitatrice peut se discuter chez certains patients porteurs d’une maladie respiratoire chronique. La seconde indication est la VNI « prophylactique », qui a pour but de prévenir la survenue d’une détresse respiratoire chez des patients ayant réuni tous les critères prérequis du sevrage, et ayant réussi l’épreuve de sevrage sans signes de mauvaise tolérance. Dans ce cas, la VNI est débutée immédiatement après l’extubation chez des patients à fort risque de détresse respiratoire aiguë comme par exemple les patients hypercapniques ayant une maladie respiratoire chronique ou cardiaque sousjacente. La troisième indication est la VNI « curative », dont l’objectif est de traiter une détresse respiratoire aiguë survenant dans les suites de l’extubation. Dans ce dernier cas, le patient est extubé mais développe secondairement une détresse respiratoire. Cette stratégie dénommée VNI « curative » est potentiellement dangereuse et risque de retarder la réintubation sans pour autant l’éviter. Abstract Non-invasive ventilation (NIV) is widely used for the treatment of acute respiratory failure in the intensive care unit and has been therefore naturally used to hasten extubation and avoid reintubation. In the post-extubation period, three different situations should be clearly distinguished: 1) The first situation is the use of NIV to hasten extubation in difficult-to-wean patients. Despite the failure of a weaning trial, the patient is extubated and treated by intensive NIV after extubation. This strategy can be discussed for some patients with chronic respiratory failure but cannot be routinely proposed as reference method in clinical practice. 2) The second situation is the use of prophylactic NIV immediately applied after planned extubation, i.e. before the occurrence of a respiratory distress in patients ready for extubation. This strategy should be systematically used in order to prevent post-extubation acute respiratory failure in hypercapnic patients with any underlying chronic lung disease. Further studies are needed to expand its use in other patients considered at high risk for extubation failure. 3) The third situation is the use of therapeutic NIV to treat patients who have already signs of respiratory distress. This strategy can be dangerous and should not be used in clinical practice, except in postoperative patients after thoracic surgery or in patients with chronic lung disease. Clinical trials on weaning are difficult because of the low number of reintubated patients. However, despite the absence of current recommendations, the literature enables to justify some propositions.Réanimation 01/2014; 24(1):11-19. DOI:10.1007/s13546-014-1006-6