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Noninvasive Positive-Pressure Ventilation for COPD

NPPV reduced mortality and intubation rates among patients with COPD exacerbations.

Some patients with exacerbations of chronic obstructive pulmonary disease exhibit clear contraindications to noninvasive positive-pressure ventilation (NPPV); such contraindications include impending respiratory arrest, cardiovascular instability, and vomiting. But what about COPD patients without contraindications? North American researchers systematically searched the medical literature for randomized trials in which NPPV was compared with standard care for patients with COPD exacerbations. They summarized results from 11 papers, 1 unpublished manuscript, and 3 abstracts (total, more than 600 patients).

NPPV reduced in-hospital mortality by 10% and endotracheal intubation by 28% (both absolute risk reductions); hospital stay was reduced by 4.6 days. Significant heterogeneity across studies was noted for intubation and hospital stay. In a subgroup of studies that included patients with severe COPD exacerbations (defined as pH<7.3 or in-hospital mortality rate of >10% in the control group), NPPV reduced mortality (by 12%), intubation (by 34%), and length of stay (by 5.6 days) more than standard care did. In the other studies (72 patients), nonsignificant reductions of 2%, 0%, and 0.8 days, respectively, were found.

Comment: The evidence supports the use of NPPV for severe COPD exacerbations, as did results from another recent meta-analysis (Journal Watch Feb 25 2003). The authors of the current analysis point out that 1 study of severe COPD exacerbations among patients on a "general respiratory ward" showed no benefit for NPPV. This finding suggests that NPPV is most successful when personnel are skilled in its use and can adequately monitor patients who receive it.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine June 17, 2003

Citation(s):

Keenan SP et al. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med 2003 Jun 3; 138:861-70.

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