A controlled trial of noninvasive ventilation for chronic obstructive pulmonary disease exacerbations

Purpose

This prospective, multicenter, double-blind, placebo-controlled study tested the hypothesis that noninvasive positive pressure ventilation reduces the need for endotracheal intubation in patients hospitalized in a pulmonary ward because of acute exacerbation of chronic obstructive pulmonary disease.

Materials and Methods

Seventy-five consecutive patients with exacerbation (pH, 7.31 ± 0.02; Pao₂, 45 ± 9 mm Hg; Paco₂, 69 ± 13 mm Hg) were randomly assigned to receive noninvasive ventilation or sham noninvasive ventilation during the first 3 days of hospitalization on top of standard medical treatment.

Results

The need for intubation (according to predefined criteria) was lower in the noninvasive ventilation group (13.5% vs 34%, P < .01); in 31 patients with pH not exceeding 7.30, these percentages were 22% and 77%, respectively (P < .001). Arterial pH and Paco₂ improved in both groups, but changes were enhanced by noninvasive ventilation. Length of stay was lower in the noninvasive ventilation group (10 ± 5 vs 12 ± 6 days, P = .06). In-hospital mortality was similar in both groups.

Conclusions

These results demonstrate that noninvasive positive pressure ventilation, in a pulmonary ward, reduces the need for endotracheal intubation, particularly in the more severe patients, and leads to a faster recovery in patients with acute exacerbation of chronic obstructive pulmonary disease.     

无创通气治疗慢性阻塞性肺疾病急性加重期并肺性脑病临床研究

目的研究无创通气对慢性阻塞性肺疾病急性加重期(AECOPD)并肺性脑病患者的临床疗效。方法回顾性分析2008年6月至2012年6月在粤北人民医院呼吸内科行无创通气的AECOPD并肺性脑病的78例患者的临床资料,监测通气前及通气后2、12及24 h后的血气分析变化,观察患者的治疗转归及无创正压通气治疗的不良反应。结果与通气前比较,通气后患者临床症状逐渐改善,动脉血二氧化碳分压水平降低(P<0.01),动脉血氧分压水平升高(P<0.01),pH值升高(P<0.01)。结论无创通气对AECOPD并肺性脑病的患者有良好的治疗效果,值得临床推广。     

Noninvasive positive-pressure ventilation in patients with milder chronic obstructive pulmonary disease exacerbations: a randomized controlled trial

OBJECTIVES: To determine the effect of the addition of noninvasive positive-pressure ventilation (NPPV) to standard medical therapy on length of hospital stay among patients presenting with mild exacerbations of chronic obstructive pulmonary disease (COPD) requiring hospitalization. DESIGN: Randomized controlled unblinded study with concealed allocation. SETTING: Respiratory ward of a single-center, academic, tertiary-care hospital. PARTICIPANTS: Patients with a prior history of COPD who presented with a recent onset of shortness of breath and a pH of > 7.30 were eligible for inclusion in the study. INTERVENTIONS: NPPV daily for 3 days for intervals of 8, 6, and 4 hours, respectively, plus standard therapy, versus standard therapy alone. MEASUREMENTS: Borg dyspnea index at baseline, 1 hour, and daily. Length of hospital stay, endotracheal intubation, hospital survival. RESULTS: We found that NPPV was generally poorly tolerated, with only 12 of 25 patients wearing it for the prescribed 3 days. With the exception of a decrease in dyspnea at 1 hour and 2 days, significant between-group differences were not seen for any measured variable. CONCLUSIONS: The effectiveness and cost-effectiveness of the addition of NPPV to standard therapy in milder COPD exacerbations remains unclear. P(aCO(2)) related to this increased WOB that requires intervention with some form of assisted ventilation. All patients developing an exacerbation of COPD that requires hospitalization have an increased WOB and, we hypothesize, potentially develop some degree of associated respiratory muscle fatigue. We further hypothesize that adding intermittent NPPV during the initial days of hospital stay would afford respiratory muscle rest for patients with milder COPD exacerbations and that this rest would allow these patients to recover more quickly and to be discharged home earlier. The objective of this trial was to determine whether the addition of NPPV to standard therapy during the first 3 days of admission in milder COPD exacerbations could decrease length of hospital stay.     

Acute physiologic effects of nasal and full-face masks during noninvasive positive-pressure ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease

OBJECTIVE: To assess the efficacy of and patient tolerance for nasal and full-face masks during noninvasive positive-pressure ventilation (NPPV) with patients suffering acute exacerbations of chronic obstructive pulmonary disease. SETTING: A respiratory medicine ward of a referral hospital. METHODS: Fourteen patients were randomized to 2 groups. Seven used nasal masks and 7 used full-face masks. We used a portable ventilator and recorded arterial blood gases and indices of respiratory muscle effort before and after 15 min of NPPV. Patient tolerance was scored as follows: no tolerance (mask had to be withdrawn before the study period ended) = 0 points; poor tolerance (patient complained of discomfort from the ventilation devices but nevertheless remained compliant) = 1 point; fair tolerance (patient seemed uncomfortable but did not complain) = 2 points; excellent tolerance (patient felt better than before beginning NPPV) = 3 points. RESULTS: The groups were comparable in clinical and pulmonary function variables at baseline. NPPV improved both arterial blood gases and the indices of respiratory effort, with no significant differences between the groups. During NPPV the group that used full-face mask had a greater decrease in respiratory rate, but no other differences. NPPV was well tolerated in both groups. CONCLUSIONS: In patients suffering acute exacerbations of chronic obstructive pulmonary disease NPPV improves arterial blood gases and respiratory effort indices regardless of the type of mask used.     

Noninvasive ventilation for chronic obstructive pulmonary disease

Noninvasive positive-pressure ventilation (NPPV) should be considered a standard of care to treat COPD exacerbations in selected patients, because NPPV markedly reduces the need for intubation and improves outcomes, including lowering complication and mortality rates and shortening hospital stay. Weaker evidence indicates that NPPV is beneficial for COPD patients suffering respiratory failure precipitated by superimposed pneumonia or postoperative complications, to allow earlier extubation, to avoid re-intubation in patients who fail extubation, or to assist do-not-intubate patients. NPPV patient-selection guidelines help to identify patients who need ventilatory assistance and exclude patients who are too ill to safely use NPPV. Predictors of success with NPPV for COPD exacerbations have been identified and include patient cooperativeness, ability to protect the airway, acuteness of illness not too severe, and a good initial response (within first 1-2 h of NPPV). In applying NPPV, the clinician must pay attention to patient comfort, mask fit and air leak, patient-ventilator synchrony, sternocleidomastoid muscle activity, vital signs, hours of NPPV use, problems with patient adaptation to NPPV (eg, nasal congestion, dryness, gastric insufflation, conjunctival irritation, inability to sleep), symptoms (eg, dyspnea, fatigue, morning headache, hypersomnolence), and gas exchange while awake and asleep. For severe stable COPD, preliminary evidence suggests that NPPV might improve daytime and nocturnal gas exchange, increase sleep duration, improve quality of life, and possibly reduce the need for hospitalization, but further study is needed. There is consensus, but without strong supportive evidence, that COPD patients who have substantial daytime hypercapnia and superimposed nocturnal hypoventilation are the most likely to benefit from NPPV. Adherence to NPPV is problematic among patients with severe stable COPD.     

无创正压通气治疗COPD急性加重导致高碳酸血症的临床研究

目的对比无创正压通气（NPPV）对慢性阻塞性肺疾病（COPD）急性加重导致轻中度高碳酸血症与重度高碳酸血症的疗效。方法对比入选COPD急性加重导致轻中度高碳酸血症（PaCO2〈80mmHg,1mmHg=0.133kPa）组患者和重度高碳酸血症（PaCO2〉80mmHg）组患者NPPV2h后pH值和PaCO2的变化、24h后pH值恢复正常的人数、总的NPPV治疗时间和住院天数。结果轻中度高碳酸血症组44人,重度高碳酸血症组42人。轻中度高碳酸血症组和重度高碳酸血症组相对比,NPPV2h后pH值（分别为0.04±0.01和0.06±0.03,P=0.63）和PaCO2[分别为（14.3±7.4）mmHg和（18.1±11.2）mmHg,P=0.34]的改善程度相似。对比两组患者NPPV24h后pH值恢复正常比率（分别为65.9%和59.5%,P=0.65）、NPPV应用时间[分别为（103±8.1）h和（106±6.6）h,P=0.74]、住院天数[分别为（13±2.7）d和（15±4.1）d,P=0.53]及NPPV失败率（分别为13.6%和19.0%,P=0.56）也无差异。结论 NPPV治疗对COPD急性加重导致重度高碳酸血症的患者是有效的。     

Effects of inhalational bronchodilator treatment during noninvasive ventilation in severe chronic obstructive pulmonary disease exacerbations

Purpose

To study the effects of withdrawing noninvasive ventilation (NIV) used during acute exacerbation of chronic obstructive pulmonary disease for the delivery of aerosolized medications on physiologic parameters and dyspnea sensation.

Methods

We measured accessory muscle use, dyspnea sensation, heart rate (HR), respiratory rate (RR), blood pressure (BP), and arterial blood gases during NIV, 10 minutes after cessation of NIV (with oxygen), after nebulization with salbutamol (5 mg) and ipratropium (500 μg), and again, on restitution of NIV.

Results

We studied 19 patients (3 women; mean [±SD] age, 72 [± 9] years) with a mean postbronchodilator forced expiratory volume in 1 second 40% (±12) of predicted. Baseline RR (23/min), HR (98/min), BP (121/62 mm Hg), Spo₂ (95%), pH (7.31 [±0.06]), Paco₂ (65 [±12] mm Hg), and Borg score (1.8 [±0.43]) were recorded. There were no significant changes in physiologic parameters and oxygenation between NIV and nebulization periods. The only physiologic changes observed were increase in systolic BP (SBP, P = .012) and HR (P = .003) after nebulization. However, significant decrease in oxygen saturation (P = .009) and increase in SBP (P = nonsignificant) were observed between NIV and oxygenation phases.

Conclusion

Short-term cessation of NIV for nebulization treatment did not result in distress, discomfort, or physiologic instabilities. The only detectable changes were increase in SBP and HR, probably due to the systemic adrenergic effects of salbutamol.     

无创正压通气在慢性阻塞性肺疾病所致严重呼吸衰竭机械通气脱机过程中的应用

目的 探讨无创正压通气在慢性阻塞性肺疾病(COPD)并发呼吸衰竭患者有创机械通气撤机后的应用时机及治疗效果.方法 选择36例COPD患者,随机选取18例行气管插管机械通气并作为实验组,以同步间歇指令通气(SIMV) 压力支持通气(PSV) 呼气末正压(PEEP)方式行机械通气,待肺部感染控制窗出现,拔除气管插管,改为经面罩BIPAP无创通气,逐渐脱机.余18例做为对照组,行常规有创通气,最后以PSV方式至撤机.现察两组病例的呼吸机相关性肺炎(VAP)的发生例数、病死率、机械通气天数、总住院天数、动脉血气分析.结果 实验组住院时间少于对照组,(21.1±1.8)天vs(27.1±1.4)天(P<0.05);机械通气时间为(11.4±0.8)天vs(14.8±2.4)天(P<0.05);呼吸机相关性肺炎发生率为0 vs 5例(P<0.01);死亡例数为1例vs 4倒.实验组撤机前后血气分析比较差异无统计学意义(P>0.05);对照组撤机后pH降低、PaCO2升高(P<0.05).结论 对COPD并发呼吸衰竭患者采用早期有创机械通气,序贯应用无创正压通气可以显著降低VAP发生率,提高撤机成功率,缩短住院时间.     

无创通气治疗慢性阻塞性肺疾病急性加重期患者的护理

2004至2008年我科对100例慢性阻塞性肺疾病(COPD)急性加重期患者应用无创通气治疗及护理干预,效果满意,现报道如下. 临床资料 1.一般资料.2004至2008年我科住院的COPD患者100例,年龄51～82岁,平均年龄60.47岁.入选标准按照中华医学会呼吸病分会慢性阻塞性肺疾病学组提出的慢性阻塞性肺疾病诊治指南标准[1],短期内咳嗽、咳痰、气短和/或喘息加重、痰量增多.     

慢性阻塞性肺疾病患者急性发作期的细菌学分析

目的观察慢性阻塞性肺疾病患者急性发作期(acute exacerbation of chronic obstructive pulmonary disease,AECOPD)的病原菌种类及耐药情况。方法对119例AECOPD患者的痰培养及药敏结果进行统计分析。结果痰标本中分离出共64株致病菌,其中主要为革兰阴性菌(G-)(78.1%),铜绿假单胞菌占28.1%,肺炎克雷伯杆菌占18.8%、大肠埃希菌占14.1%;革兰阳性菌(G+)主要为肺炎链球菌,占6.3%,金黄色葡萄球菌占4.7%,表皮葡萄球菌占3.1%,真菌占7.8%。对革兰阴性杆菌有效的抗生素为亚胺培南、头孢三代、喹诺酮类和阿米卡星。肺炎链球菌对大多数β-内酰胺类抗生素敏感。而对金葡菌最有效的抗生素为万古霉素,其敏感性达100%。结论AECOPD患者呼吸道感然的病原菌以革兰阴性菌为主,因根据药敏结果合理地选用抗生素。     

Early and late failure of noninvasive ventilation in chronic obstructive pulmonary disease with acute exacerbation

BACKGROUND: Despite recent encouraging results, the use of noninvasive ventilation (NIV) in the management of acute exacerbations in chronic obstructive pulmonary disease (COPD), complicated by acute respiratory failure (ARF), is not always successful. Failure of NIV may require an immediate intubation after a few hours (usually 1-3) of ventilation ('early failure') or may result in clinical deterioration (one or more days later) after an initial improvement of blood gas tension and general conditions ('late failure'). MATERIALS AND METHODS: We enrolled 122 patients affected by COPD complicated by ARF, and treated with NIV. The schedule of NIV provided sessions of 2-6 h twice daily. RESULTS: Ninety-nine (81%) patients showed a progressive improvement of the clinical parameters and were discharged. Among the remaining 23 patients, 13 had an early failure and 10 had a late failure. In the 'success' group and 'late failure' groups we found after an increase of pH 2 h of NIV (from 7.31 +/- 0.05 to 7.38 +/- 0.04 P < 0.001 and from 7.29 +/- 0.03 to 7.36 +/- 0.02 P < 0.001, respectively) and a decrease of PaCO2 (from 80.93 +/- 9.79 to 66.48 +/- 5.95 P < 0.001 and from 85.96 +/- 10.77 to 76.41 +/- 11.02 P < 0.001, respectively). After 2 h of NIV in the 'late failure' group there were no significant changes in terms of pH (from 7.20 +/- 0.10 to 7.28 +/- 0.06) nor PaCO2 (from 92.86 +/- 35.49 to 93.68 +/- 23.68). The 'early failure' group had different characteristics and, owing to more severe conditions, the value of pH, of Glasgow Coma Score, and Apache II Score were the best predictors of the failure; while, among the complications on admission, metabolic alterations were the only independently significant predictor. CONCLUSIONS: Our study confirms that NIV may be useful to avoid intubation in approximately 80% of patients with COPD complicated by moderate-severe hypercapnic respiratory failure.     

Noninvasive ventilation in patients with acute hypercapnic exacerbation of chronic obstructive pulmonary disease who refused endotracheal intubation

OBJECTIVE: To determine the long-term outcome of noninvasive ventilation in chronic obstructive pulmonary disease patients who refused intubation for acute hypercapnic respiratory failure. DESIGN: Prospective, observational study. SETTING: Noninvasive ventilation unit in an acute regional hospital in Hong Kong. METHODS: The study recruited 37 chronic obstructive pulmonary disease patients who had the do-not-intubate code and developed acute hypercapnic respiratory failure. They were offered noninvasive ventilation, and their long-term outcomes were followed. Survival and event-free survival (an event is death or recurrent acute hypercapnic respiratory failure) were analyzed by survival analysis. Their disease profile and outcome were compared with another 43 chronic obstructive pulmonary disease patients without the do-not-intubate codes, who had acute hypercapnic respiratory failure and received noninvasive ventilation during the study period (usual care group). RESULTS: Patients in the do-not-intubate group were significantly older (p =.029), had worse dyspnea score (p <.001), worse Katz Activities of Daily Living score (p <.001), worse comorbidity score (p =.024), worse Acute Physiology and Chronic Health Evaluation II score (p =.032), lower hemoglobin (p =.001), and longer stay in the hospital during the past year (p =.001) than patients who received usual care. In the do-not-intubate group, the median survival was 179 days, and 1-yr actuarial survival was 29.7%; in the usual care group, the median survival was not reached during follow-up, and 1-yr actuarial survival was 65.1% (p <.0001). In the do-not-intubate group, the median event-free survival was 102 days, and 1-yr event-free survival was 16.2%; in the usual care group, median event-free survival was 292 days, and 1-yr event-free survival was 46.5% (p =.0004). CONCLUSIONS: A 1-yr survival of about 30% was recorded in chronic obstructive pulmonary disease patients with the do-not-intubate code who developed acute hypercapnic respiratory failure requiring noninvasive ventilation. The majority of survivors developed another life-threatening event in the following year. Information generated from this study is important to physicians and chronic obstructive pulmonary disease patients when they are considering using noninvasive ventilation as a last resort.     

Another step for noninvasive ventilation in chronic obstructive pulmonary disease patients!

The use of noninvasive positive pressure ventilation (NPPV) in chronic obstructive pulmonary disease (COPD) patients who are not eligible for the technique because of their incapability to spontaneously eliminate accumulated secretions associated with hypercapnic encephalopathy is not recommended and is often considered a contraindication. In a case-control study, an experienced team reported the feasibility and safety of the use of NPPV with early fibreoptic bronchoscopy in selected acutely decompensated COPD patients with hypercapnic encephalopathy, and reported the patients' inability to spontaneously clear copious secretions. The reported data suggest that this innovative therapeutic may be considered as a potential alternative to endotracheal intubation.     

Treatment of acute exacerbations in chronic obstructive pulmonary disease

Therapeutic interventions introduced and refined over the last 10 years, including chronic home oxygen and improved bronchodilators, have resulted in more patients with chronic obstructive pulmonary disease living longer despite more severe functional abnormalities. Episodes of acute respiratory failure in this population remain a major complication requiring rapid assessment and intervention. This article focuses on the diagnostic approach and therapeutic interventions in the patient with obstructive lung disease who presents in acute respiratory distress.     

Virus infection in exacerbations of chronic obstructive pulmonary disease requiring ventilation

Objectives We aimed to characterise and quantify the incidence of common infectious agents in acute exacerbations of chronic obstructive pulmonary disease (COPD) requiring ventilation, with a focus on respiratory viruses.Design An epidemiological study conducted over 3 years.Setting A 12-bed intensive care unit (ICU).Participants ICU patients over 45 years of age with a primary diagnosis of COPD exacerbation requiring non-invasive ventilation (NIV) or ventilation via endotracheal tube (ETT).Materials and methods Nasopharyngeal aspirates (NPA) and posterior pharyngeal swabs (PS) were tested for viruses with immunofluorescence assay (IFA), virus culture (VC) and polymerase chain reaction (PCR). Paired virus and atypical pneumonia serology assays were taken. Blood, sputum and endotracheal aspirates were cultured for bacteria.Results 107 episodes in 105 patients were recorded. Twenty-three (21%) died within 28 days. A probable infectious aetiology was found in 69 patient episodes (64%). A virus was identified in 46 cases (43%), being the sole organism in 35 cases (33%) and part of a mixed infection in 11 cases (10%). A probable bacterial aetiology was found in 25 cases (23%). There was no statistically significant difference in clinical characteristics or outcomes between the group with virus infections and that without.Conclusion Forty-six (43%) of the patients with COPD exacerbation requiring mechanical ventilation had a probable viral pathogen. Prodromal, clinical and outcome parameters did not distinguish virus from non-virus illness. PCR was the most sensitive whilst virus culture was the least of virus assays.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.The study was self-funded by internal grants from the Central Coast Health Services Research Fund and the Hunter Area Pathology Service. There was no funding from pharmaceutical or other commercial organisations or agencies.There was no conflict of interest.This article is discussed in the editorial available at:     

无创正压通气对不同基础肺疾病合并Ⅱ型呼吸衰竭患者的疗效分析

目的:通过对无创正压通气(NIPPV)治疗非慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭与慢性阻塞性肺疾病急性加重(AECOPD)合并Ⅱ型呼吸衰竭患者的对比分析,了解NIPPV对非慢性阻塞性肺疾病所致Ⅱ型呼吸衰竭的治疗作用,评价NIPPV在治疗非慢性阻塞性肺疾病所致Ⅱ型呼吸衰竭中的治疗价值。方法:对比分析NIPPV对非慢性阻塞性肺疾病与AECOPD所致Ⅱ型呼吸衰竭的治疗效应。非慢性阻塞性肺疾病组18例,男12例,女6例,年龄(63.8±12.5)岁,其中职业性肺疾病10例(尘肺8例,石棉肺2例),脊柱后凸畸形或严重胸膜肥厚粘连5例,支气管扩张3例;AECOPD组33例,男26例,女7例,年龄(69.0±8.5)岁。结果:与NIPPV治疗前比较,非慢性阻塞性肺疾病组应用NIPPV治疗后第5天和出院前动脉血二氧化碳分压(PaCO2)显著下降(P<0.05);pH值在出院前显著改善(P<0.05);动脉血氧分压(PaO2)在应用NIPPV治疗后及出院时各时间点均显著升高(P<0.05)。在AECOPD组同NIPPV治疗前比,应用NIPPV治疗后各时间点和出院前PaCO2均显著下降(P<0.05),pH值显著改善(P<0.05);同NIPPV治疗前比,应用NIPPV治疗第2天、第3天、第5天和出院前PaO2显著升高(P<0.05)。结论:NIPPV对非慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭和AECOPD合并Ⅱ型呼吸衰竭均有较好的治疗效果。NIPPV治疗AECOPD所致Ⅱ型呼吸衰竭与非慢性阻塞性肺疾病相比,pH值和二氧化碳潴留改善得更快,而氧合在非慢性阻塞性肺疾病组改善得更快。NIPPV可用于非慢性阻塞性肺疾病所致Ⅱ型呼吸衰竭的抢救治疗。