Current opinions on non-invasive ventilation as a treatment for chronic obstructive pulmonary disease

The long-term efficacy of domiciliary noninvasive positive pressure ventilation in COPD: A meta-analysis of randomized controlled trials

Background

We evaluated the long-term effects of domiciliary noninvasive positive-pressure ventilation (NIPPV) used to treat patients with chronic obstructive pulmonary disease (COPD).

Methods

Databases were searched to identify randomized controlled trials of COPD with NIPPV for longer than 1 year. Mortality rates were the primary outcome in this meta-analysis. The eight trials included in this study comprised data from 913 patients.

Results

The mortality rates for the NIPPV and control groups were 29% (118/414) and 36% (151/419), suggesting a statistically significant difference (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.65–0.95). Mortality rates were reduced with NIPPV in four trials that included stable COPD patients. There was no difference in admission, acute exacerbation and quality of life between the NIPPV and control groups. There was no significant difference in withdrawal rates between the two groups (RR, 0.99; 95% CI, 0.72–1.36; p=0.94).

Conclusion

Maintaining long-term nocturnal NIPPV for more than 1 year, especially in patients with stable COPD, decreased the mortality rate, without increasing the withdrawal rate compared with long-term oxygen treatment.

Treatment of exacerbations of chronic obstructive pulmonary disease

AIM

To assess the quality of medical care provided in large Russian hospitals to patients with COPD exacerbation.

MATERIALS AND METHODS

The study included patients with acute exacerbations of COPD hospitalized into three large clinical hospitals in Moscow. The diagnosis of "COPD exacerbation" was established in accordance with current clinical recommendations. We collected the data about patients' demography, clinical signs and symptoms, blood gas analysis, chest radiography, drug therapy, oxygen therapy and respiratory support. The follow-up period was 90 days. The obtained data were compared with the data of patients from the multicenter study "European COPD Audit".

RESULTS

The leading clinical symptoms in COPD exacerbation were dyspnea (95.4%) and sputum production (60.7%). The majority of patients with COPD received short-acting β2-agonists (77.4%), systemic steroids (85.1%), antibiotics (79.0%) and theophyllines (48.1%). Noninvasive ventilation was performed in 8.6% of patients, oxygen therapy - in 23,8% of patients, pulmonary rehabilitation - in only 6,2% of patients. Chest radiography was performed in 97.9% of patients, pulmonary function tests - in 79.8%, blood gases analysis - in 19.3% of patients. The mean duration of hospitalization was 18.2±3.9 days, repeated hospitalization within 90 days occurs in 36.2% of patients. In-hospital mortality was 3.3%.

CONCLUSION

Based on the results of the study practical recommendations for improving the quality of medical care in acute exacerbations of COPD are proposed.

Cost-utility of non-invasive mechanical ventilation: Analysis and implications in acute respiratory failure. A brief narrative review

The growing interest in the quality of patient care at the levels of the health care managers, insurance companies, and health professionals is evident. Further, the growing population requires good quality health services. In this review, we analyzed the cost-effectiveness of noninvasive ventilation (NIV) in an acute setting for the treatment of respiratory failure. The strength of this review is that it identified and summarized the most relevant studies regarding various aspects of the cost-utility of NIV in an acute setting. This is the first review that focuses on the importance of the skills and training of the team in the reduction of costs associated with NIV. However, the small number of studies, heterogeneity of quality, and different outcomes of the different studies are the greatest limitations of this review. In conclusion, although there is great variation in the data drawn from the literature, NIV seems to be a cost-effective tool, especially in specific patients (those with chronic obstructive pulmonary disease) for whom the addition of NIV improves outcomes and has a positive impact on this expenditure.

Noninvasive ventilation-neurally adjusted ventilator assist for management of acute exacerbation of chronic obstructive pulmonary disease

Patient-ventilator asynchrony is common with noninvasive ventilation (NIV) used for management of acute exacerbation of chronic obstructive pulmonary disease (COPD). Neurally adjusted ventilator assist (NAVA) is a mode of ventilatory support which can minimize the patient-ventilator asynchrony. Delivering NIV with NAVA (NIV-NAVA) during acute exacerbation of COPD seems a logical approach and may be useful in reducing patient-ventilator asynchrony. However, there are no published reports which describe the use of NIV-NAVA for management of acute exacerbation of COPD. We describe the successful management of a 56-year-old gentleman presenting to the emergency department of our hospital with acute exacerbation of COPD with hypercapnic respiratory failure with NIV-NAVA.

Noninvasive Mechanical Ventilation in Acute Ventilatory Failure: Rationale and Current Applications

Noninvasive ventilation plays a pivotal role in acute ventilator failure and has been shown, in certain disease processes such as acute exacerbation of chronic obstructive pulmonary disease, to prevent and shorten the duration of invasive mechanical ventilation, reducing the risks and complications associated with it. The application of noninvasive ventilation is relatively simple and well tolerated by patients and in the right setting can change the course of their illness.

Effectiveness assessment of a guideline based protocol for ventilatory support management of COPD exacerbations in an emergency department

OBJECTIVES

To investigate clinical outcomes according to ventilatory support indication in subjects with chronic obstructive pulmonary disease exacerbation in a "real-life" Emergency Department and to analyze potential predictors of successful noninvasive positive pressure ventilation.

METHODS

Retrospective cohort performed over an 18-month period, comparing the following patient groups with chronic obstructive pulmonary disease exacerbation: Group A composed of patients initially selected to receive noninvasive positive pressure ventilation without the subsequent need for invasive mechanical ventilation (successful-noninvasive positive pressure ventilation); Group B composed of patients transitioning from noninvasive positive pressure ventilation to invasive mechanical ventilation (failed-noninvasive positive pressure ventilation); and Group C composed of patients who presented with immediate need for invasive mechanical ventilation (without prior noninvasive positive pressure ventilation).

RESULTS

117 consecutive chronic obstructive pulmonary disease exacerbation admissions (Group A=96; Group B=13; Group C=8) of candidates for ventilatory support were reviewed. No differences in baseline disease severity and physiological parameters were found between the groups at Emergency Department admission. Nevertheless, Group B had higher intensive care unit admission, length of hospital stay, length of intensive care unit stay, and higher in-hospital mortality compared to Group A. Group C also had worse outcomes when compared to Group A. The only independent variable associated with the successful use of noninvasive positive pressure ventilation were improvement in arterial carbon dioxide pressure after 1h of noninvasive positive pressure ventilation use and its tolerance.

CONCLUSION

Our data confirmed in a "real life" Emergency Department cohort that successful management of chronic obstructive pulmonary disease exacerbation with noninvasive positive pressure ventilation showed lower in-hospital mortality and Intensive Care Unit stay when compared to patients transitioning from noninvasive positive pressure ventilation to invasive mechanical ventilation or patients who presented an immediate need for invasive mechanical ventilation. noninvasive positive pressure ventilation tolerance and higher arterial carbon dioxide pressure reduction after 1-h of noninvasive positive pressure ventilation were predictors of successful treatment. These results should be confirmed in a prospective randomized controlled trial.

Blunt thoracic trauma: recent advances and outstanding questions

PURPOSE OF REVIEW

The treatment of blunt thoracic injuries is complex and evolving. The aim of this review is to focus on what is new with ventilation for blunt chest trauma as well as an update on the current management strategies for blunt aortic injury and rib fractures.

RECENT FINDINGS

Early use of noninvasive ventilation appears to be well tolerated in select hemodynamically stable blunt trauma patients. For those patients requiring intubation, airway pressure release ventilation is an excellent mode to decrease the risk of posttraumatic acute lung injury. Endovascular repair of blunt thoracic aortic injuries provides benefit over open repair and, if possible, delayed repair confers a mortality advantage. Despite its increasing use, there continue to be conflicting results about the role of surgical rib fixation for the treatment of flail chest.

SUMMARY

Blunt thoracic injuries are commonly treated in the ICU and a solid knowledge of mechanical ventilation strategies (both noninvasive and invasive) is essential. Blunt thoracic aortic injuries require early diagnosis and aggressive blood pressure management. Not all such injuries need operative repair but those that do benefit from an endovascular approach. The management of flail chest includes early aggressive multimodal analgesia, adequate oxygen, and ventilatory support. Surgical rib fixation should be considered in select patients.