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

BMJ 2003; 326 doi: (Published 25 January 2003) Cite this as: BMJ 2003;326:185
  1. Josephine V Lightowler, specialist registrar in respiratory medicinea,
  2. Jadwiga A Wedzicha, professor of respiratory medicineb,
  3. Mark W Elliott, consultant respiratory and general physiciana,
  4. Felix S F Ram (fram{at}, research fellow in respiratory medicinec
  1. a Department of Respiratory Medicine, St James's University Hospital, Leeds LS9 7TF
  2. b Academic Respiratory Medicine, St Bartholomew's School and the Royal London School of Medicine and Dentistry, London EC1A 7BE
  3. c Department of Physiological Medicine, St George's Hospital Medical School, University of London, London SW17 0RE
  1. Correspondence to: Felix S F Ram
  • Accepted 16 October 2002


Objectives: To determine the effectiveness of non-invasive positive pressure ventilation (NPPV) in the management of respiratory failure secondary to acute exacerbation of chronic obstructive pulmonary disease.

Design: Systematic review of randomised controlled trials that compared NPPV and usual medical care with usual medical care alone in patients admitted to hospital with respiratory failure resulting from an exacerbation of chronic obstructive pulmonary disease and with PaCO2 >6 kPa.

Results: The eight studies included in the review showed that, compared with usual care alone, NPPV as an adjunct to usual care 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 treatment failure (relative risk 0.51 (0.38 to 0.67)), and greater improvements at 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)), and respiratory rate (weighted mean difference −3.08 breaths per minute (−4.26 to −1.89)). NPPV resulted in fewer complications associated with treatment (relative risk 0.32 (0.18 to 0.56)) and shorter duration of stay in hospital (weighted mean difference −3.24 days (−4.42 to −2.06)).

Conclusions: NPPV should be the first line intervention in addition to usual medical care to manage respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease in all suitable patients. NPPV should be tried early in the course of respiratory failure and before severe acidosis, to reduce mortality, avoid endotracheal intubation, and decrease treatment failure.

What is already known on this topic

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

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


  • Funding FSFR is funded by the Netherlands Asthma Foundation. JVL was funded by a British Lung Foundation project grant.

  • Competing interests JAW has received educational grant support from Respironics, one of the manufacturers of nasal ventilators. MWE has received an honorarium for lecturing from Respironics, has been lent ventilators for studies from ResMed and Breas, and has had a contribution from ResMed towards the salary of a research nurse.

  • Embedded Image A table showing details of the eight trials included in the systematic review is shown on

  • Accepted 16 October 2002
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