Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure Related to COPD

A review of a recent meta-analysis published in the Annals of Emergency Medicine indicates that noninvasive ventilation provides benefit in patients with acute hypercapnic respiratory failure during chronic obstructive pulmonary disease (COPD) exacerbations, reducing mortality and the need for mechanical ventilation.

Brit Long, MD, and Michael D. April, MD, DPhil, of the department of emergency medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas, added that noninvasive ventilation also may improve length of hospital stay, serum pH, and oxygen partial pressure. The meta-analysis included 17 randomized controlled trials with 1264 patients.

The review investigators noted that severe COPD is characterized by hyperinflation, airway obstruction, and decreased respiratory muscle function. In this setting, exacerbation can result in hypercarbic respiratory failure. Usual care includes controlled oxygenation, bronchodilators, corticosteroids, and antibiotics. If these interventions fail, intubation is initiated.

Limitations of the meta-analysis include the variability of usual care and noninvasive ventilation duration in the studies, the potential for publication bias regarding the need for intubation, and low heterogeneity for both mortality and the need for intubation. The implications for the use of noninvasive ventilation in the emergency department are not clear, as this was the setting for only 1 trial.

The meta-analysis provides strong evidence that noninvasive ventilation reduces mortality, the need for intubation, and hospital length of stay in patients with acute hypercapnic respiratory failure during an acute exacerbation of COPD. The findings support a trial of noninvasive ventilation in patients with a pH of less than 7.30 before proceeding with intubation. 

Reference

Long B, April MD. What is the utility of noninvasive ventilation in the management of acute hypercapnic respiratory failure associated with chronic obstructive pulmonary disease? [published online October 26, 2017]. Ann Emerg Med. 2017. doi:10.1016/j.annemergmed.2017.09.016