Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis

doi:10.1136/bmj.326.7382.185

BMJ 2003;326:185 ( 25 January )

Papers

Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis

Josephine V Lightowler, specialist registrar in respiratory medicine, ^a Jadwiga A Wedzicha, professor of respiratory medicine, ^b Mark W Elliott, consultant respiratory and general physician, ^a Felix S F Ram, research fellow in respiratory medicine. ^c

^a Department of Respiratory Medicine, St James's University Hospital, Leeds LS9 7TF, ^b Academic Respiratory Medicine, St Bartholomew's School and the Royal London School of Medicine and Dentistry, London EC1A 7BE, ^c Department of Physiological Medicine, St George's Hospital Medical School, University of London, London SW17 0RE

Correspondence to: Felix S F Ram fram{at}sghms.ac.uk

Objectives: To determine the effectiveness of non-invasivepositive pressure ventilation (NPPV) in the management of respiratoryfailure secondary to acute exacerbation of chronic obstructivepulmonarydisease.
Design: Systematic review of randomised controlledtrials that compared NPPV and usual medical care with usual medicalcare alone in patients admitted to hospital with respiratory failureresulting from an exacerbation of chronic obstructive pulmonarydisease and with PaCO₂ >6kPa.
Results: The eight studies included in the review showedthat, compared with usual care alone, NPPV as an adjunct to usualcare was associated with a lower mortality (relative risk 0.41(95% confidence interval 0.26 to 0.64)), a lower need for intubation(relative risk 0.42 (0.31 to 0.59)), lower likelihood of treatmentfailure (relative risk 0.51 (0.38 to 0.67)), and greater improvementsat 1 hour in pH (weighted mean difference 0.03 (0.02 to 0.04)),PaCO₂ (weighted mean difference $-$ 0.40 kPa ( $-$ 0.78 to $-$ 0.03)), andrespiratory rate (weighted mean difference $-$ 3.08 breaths per minute( $-$ 4.26 to $-$ 1.89)). NPPV resulted in fewer complications associatedwith treatment (relative risk 0.32 (0.18 to 0.56)) and shorterduration of stay in hospital (weighted mean difference $-$ 3.24 days( $-$ 4.42 to $-$ 2.06)).
Conclusions: NPPV should be the first line interventionin addition to usual medical care to manage respiratory failuresecondary to an acute exacerbation of chronic obstructive pulmonarydisease in all suitable patients. NPPV should be tried early inthe course of respiratory failure and before severe acidosis,to reduce mortality, avoid endotracheal intubation, and decreasetreatmentfailure.

What is already known on this topic
Prospective studies, especially the larger studies, have shown that non-invasive positive pressure ventilation (NPPV) reduces the need for intubation, improves survival, and reduces complications in patients with respiratory failure resulting from exacerbation of chronic obstructive pulmonary disease (COPD)

A previous meta-analysis showed NPPV to be an effective intervention, including for acute exacerbations of COPD, but some studies in this meta-analysis contained mixed groups of patients and were not of good quality

What this study adds
Evidence from good quality, randomised controlled trials shows that NPPV is an effective treatment for acute exacerbations of COPD

NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, to avoid the need for endotracheal intubation and reduce mortality in patients with COPD

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

StumbleUpon Add to Technorati

Technorati What's this?

Relevant Articles

Ventilatory support: Gordon Christie, Graeme P Currie, and Paul Plant
BMJ 2006 333: 138-140. [Extract] [Full Text] [PDF]

First line treatment for COPD should be NPPV
BMJ 2003 326: 0. [Full Text] [PDF]

Non-invasive ventilation in chronic obstructive pulmonary disease: K Suresh Babu and Anoop J Chauhan
BMJ 2003 326: 177-178. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

Chakrabarti, B, Angus, R M, Agarwal, S, Lane, S, Calverley, P M A (2009). Hyperglycaemia as a predictor of outcome during non-invasive ventilation in decompensated COPD. Thorax 64: 857-862 [Abstract] [Full text]
GERSHMAN, A. J., REDDY, A. J., BUDEV, M. M., MAZZONE, P. J. (2008). Q: Does noninvasive positive pressure ventilation have a role in managing hypercapnic respiratory failure due to an acute exacerbation of COPD?. Cleveland Clinic Journal of Medicine 75: 458-461 [Full text]
Albert, P., Calverley, P. M. A. (2008). Drugs (including oxygen) in severe COPD. Eur Respir J 31: 1114-1124 [Abstract] [Full text]
MacIntyre, N., Huang, Y. C. (2008). Acute Exacerbations and Respiratory Failure in Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc 5: 530-535 [Abstract] [Full text]
Ambrosino, N., Vagheggini, G. (2008). Noninvasive positive pressure ventilation in the acute care setting: where are we?. Eur Respir J 31: 874-886 [Abstract] [Full text]
Quon, B. S., Gan, W. Q., Sin, D. D. (2008). Contemporary Management of Acute Exacerbations of COPD: A Systematic Review and Metaanalysis. Chest 133: 756-766 [Abstract] [Full text]
Storre, J. H., Steurer, B., Kabitz, H.-J., Dreher, M., Windisch, W. (2007). Transcutaneous PCO2 Monitoring During Initiation of Noninvasive Ventilation. Chest 132: 1810-1816 [Abstract] [Full text]
Rabe, K. F., Hurd, S., Anzueto, A., Barnes, P. J., Buist, S. A., Calverley, P., Fukuchi, Y., Jenkins, C., Rodriguez-Roisin, R., van Weel, C., Zielinski, J. (2007). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary. Am. J. Respir. Crit. Care Med. 176: 532-555 [Abstract] [Full text]
Kolodziej, M. A., Jensen, L., Rowe, B., Sin, D. (2007). Systematic review of noninvasive positive pressure ventilation in severe stable COPD. Eur Respir J 30: 293-306 [Abstract] [Full text]
Celli, B. R., Barnes, P. J. (2007). Exacerbations of chronic obstructive pulmonary disease. Eur Respir J 29: 1224-1238 [Abstract] [Full text]
Koenig, S. M., Truwit, J. D. (2006). Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention. Clin. Microbiol. Rev. 19: 637-657 [Abstract] [Full text]
Christie, G., Currie, G. P, Plant, P. (2006). Ventilatory support.. BMJ 333: 138-140 [Full text]
Chiumello, D. (2006). Is the Helmet Different Than the Face Mask in Delivering Noninvasive Ventilation?. Chest 129: 1402-1403 [Full text]
Rodriguez-Roisin, R (2006). COPD exacerbations {middle dot} 5: Management.. Thorax 61: 535-544 [Abstract] [Full text]
Vestbo, J. (2006). Clinical Assessment, Staging, and Epidemiology of Chronic Obstructive Pulmonary Disease Exacerbations. Proc Am Thorac Soc 3: 252-256 [Abstract] [Full text]
Scott, S, Walker, P, Calverley, P M A (2006). COPD exacerbations {middle dot} 4: Prevention. Thorax 61: 440-447 [Abstract] [Full text]
O'Donnell, D E, Parker, C M (2006). COPD exacerbations {middle dot} 3: Pathophysiology.. Thorax 61: 354-361 [Abstract] [Full text]
Honrubia, T., Garcia Lopez, F. J., Franco, N., Mas, M., Guevara, M., Daguerre, M., Alia, I., Algora, A., Galdos, P., on Behalf of the EMVIRA Investigators, (2005). Noninvasive vs Conventional Mechanical Ventilation in Acute Respiratory Failure: A Multicenter, Randomized Controlled Trial. Chest 128: 3916-3924 [Abstract] [Full text]
Antro, C, Merico, F, Urbino, R, Gai, V (2005). Non-invasive ventilation as a first-line treatment for acute respiratory failure: "real life" experience in the emergency department. Emerg. Med. J. 22: 772-777 [Abstract] [Full text]
Elliott, M. W. (2005). Noninvasive ventilation in acute exacerbations of COPD. ERR 14: 39-42 [Abstract] [Full text]
Duffy, N, Walker, P, Diamantea, F, Calverley, P M A, Davies, L (2005). Intravenous aminophylline in patients admitted to hospital with non-acidotic exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Thorax 60: 713-717 [Abstract] [Full text]
Cuvelier, A., Viacroze, C., Benichou, J., Molano, L. C., Hellot, M-F., Benhamou, D., Muir, J-F. (2005). Dependency on mask ventilation after acute respiratory failure in the intermediate care unit. Eur Respir J 26: 289-297 [Abstract] [Full text]
Windisch, W., Kostic, S., Dreher, M., Virchow, J. C. Jr, Sorichter, S. (2005). Outcome of Patients With Stable COPD Receiving Controlled Noninvasive Positive Pressure Ventilation Aimed at a Maximal Reduction of PaCO2. Chest 128: 657-662 [Abstract] [Full text]
Troosters, T., Casaburi, R., Gosselink, R., Decramer, M. (2005). Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease. Am. J. Respir. Crit. Care Med. 172: 19-38 [Full text]
Barnes, P. J., Stockley, R. A. (2005). COPD: current therapeutic interventions and future approaches. Eur Respir J 25: 1084-1106 [Abstract] [Full text]
Elliott, M. W. (2005). Non-invasive ventilation for acute respiratory disease. Br Med Bull 72: 83-97 [Abstract] [Full text]
Confalonieri, M., Garuti, G., Cattaruzza, M. S., Osborn, J. F., Antonelli, M., Conti, G., Kodric, M., Resta, O., Marchese, S., Gregoretti, C., Rossi, A., on behalf of the Italian noninvasive positive pres, (2005). A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Eur Respir J 25: 348-355 [Abstract] [Full text]
Elliott, M W (2004). Non-invasive ventilation in acute exacerbations of COPD: what happens after hospital discharge?. Thorax 59: 1006-1008 [Full text]
Peter, J. V., Moran, J. L. (2004). Noninvasive Ventilation in Exacerbations of Chronic Obstructive Pulmonary Disease: Implications of Different Meta-Analytic Strategies. ANN INTERN MED 141: W-78-W-79 [Full text]
Hurst, J R, Wedzicha, J A (2004). Chronic obstructive pulmonary disease: the clinical management of an acute exacerbation. Postgrad. Med. J. 80: 497-505 [Abstract] [Full text]
Celli, B.R., MacNee, W., Agusti, A., Anzueto, A., Berg, B., Buist, A.S., Calverley, P.M.A., Chavannes, N., Dillard, T., Fahy, B., Fein, A., Heffner, J., Lareau, S., Meek, P., Martinez, F., McNicholas, W., Muris, J., Austegard, E., Pauwels, R., Rennard, S., Rossi, A., Siafakas, N., Tiep, B., Vestbo, J., Wouters, E., ZuWallack, R. (2004). Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 23: 932-946 [Full text]
Aberegg, S. K., Ferrer, M., Torres, A. (2004). Noninvasive Ventilation and Weaning. Am. J. Respir. Crit. Care Med. 169: 882-882 [Full text]
Hill, N.S. (2004). Is there still a negative side to noninvasive ventilation?. Eur Respir J 23: 361-362 [Full text]
Girou, E., Brun-Buisson, C., Taille, S., Lemaire, F., Brochard, L. (2003). Secular Trends in Nosocomial Infections and Mortality Associated With Noninvasive Ventilation in Patients With Exacerbation of COPD and Pulmonary Edema. JAMA 290: 2985-2991 [Abstract] [Full text]
Brochard, L. (2003). Mechanical ventilation: invasive versus noninvasive. Eur Respir J 22: 31s-37s [Abstract] [Full text]
Rudolf, M (2003). Inpatient management of acute COPD: a cause for concern?. Thorax 58: 914-915 [Full text]
Tuggey, J M, Plant, P K, Elliott, M W (2003). Domiciliary non-invasive ventilation for recurrent acidotic exacerbations of COPD: an economic analysis. Thorax 58: 867-871 [Abstract] [Full text]
(2003). OTHER ARTICLES NOTED (24 Jan 03 to 18 Apr 03). Evid. Based Nurs. 6: e1-12 [Full text]
Partridge, M R (2003). Patients with COPD: do we fail them from beginning to end?. Thorax 58: 373-375 [Full text]
Elliott, M W (2003). Improving the care for patients with acute severe respiratory disease. Thorax 58: 285-288 [Full text]
(2003). Think NPPV Before Intubation!. JWatch Emergency Med. 2003: 6-6 [Full text]
(2003). Noninvasive Positive-Pressure Ventilation Helps with COPD Exacerbations. JWatch General 2003: 2-2 [Full text]
Babu, K S., Chauhan, A. J (2003). Non-invasive ventilation in chronic obstructive pulmonary disease. BMJ 326: 177-178 [Full text]

Rapid Responses:

Read all Rapid Responses

Twining between NIPPV and COPD: ABDULLAH MUHAMMAD SHEHAB
bmj.com, 25 Jan 2003 [Full text]
Heterogeneity and model to report results: Nicola Petrucci
bmj.com, 2 May 2003 [Full text]
Fixed or random effects in and heterogeneity in meta-analysis: Felix S F Ram
bmj.com, 7 May 2003 [Full text]
In hospital care of acute COPD: Andrew RL Medford, et al.
bmj.com, 11 Dec 2003 [Full text]