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Impact of noninvasive ventilation at a municipal emergency department on ICU admissions. Wien Klin Wochenschr 2023; 135:28-34. [PMID: 36441338 PMCID: PMC9703406 DOI: 10.1007/s00508-022-02111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 10/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 2015, the emergency department of a municipal hospital in Vienna began to perform noninvasive ventilation (NIV) on patients admitted for acute respiratory failure, given no intubation criteria were met. The intention of this study was to show to which type of hospital unit patients were transferred after undergoing NIV in the emergency department. Additionally, the impact of the underlying disease, a patient's sex and age and the year of intervention were analyzed. METHODS A single-center retrospective exploratory study was performed on 371 patients. All patients with acute respiratory failure who were noninvasively ventilated at the study center emergency department from 2015 to 2018 were eligible. Relevant data were extracted from the patient's medical records. RESULTS A total of 43.7% (95% confidence interval, CI 38.8-48.5%) of patients were successfully stabilized in the emergency department through NIV and subsequently transferred to a normal care unit or discharged. This nonintensive care admission rate was significantly associated with certain underlying medical conditions, age and year of intervention. A further 19.7% (95% CI 15.6-23.7%) of patients were transferred to an intermediate care unit instead of an intensive care unit. CONCLUSION These findings emphasize the importance of noninvasive ventilation at the emergency department in reducing load on intensive care units and ensuring an efficient hospital workflow. Nonintensive care admission rate appears to be the highest in patients with pulmonary edema, especially in the higher age range and is also associated with the level of staff training. Prospective trials are needed to accurately confirm these correlations.
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Wang J, Bian S, Tang X, Ye S, Meng S, Lei W. Influencing factors of noninvasive positive pressure ventilation in the treatment of respiratory failure: a 10-year study in one single center. Eur J Med Res 2021; 26:136. [PMID: 34861893 PMCID: PMC8641230 DOI: 10.1186/s40001-021-00615-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/20/2021] [Indexed: 12/12/2022] Open
Abstract
Background The utilization of noninvasive positive pressure ventilation (NPPV) is becoming more and more common, especially in patients with acute or chronic respiratory failure. The purpose of our study is to analyze the factors that influence the efficacy of NPPV in the treatment of respiratory failure caused by a variety of etiology. Methods From May 2011 to April 2020, patients treated with NPPV during hospitalization in the First Affiliated Hospital of Soochow University were enrolled. According to the clinical outcome of NPPV treatment and whether converted to invasive mechanical ventilation, patients were divided into the success group and the failure group. The clinical data and the characteristics of NPPV application were compared between the two groups. Results A total of 3312 patients were enrolled, including 2025 patients in the success group and 1287 patients in the failure group. Univariate analysis suggested that there were no statistical differences in patients' age, gender, use of analgesia and/or sedation, complicated with barotrauma, inspiratory positive airway pressure and expiratory positive airway pressure between the success and failure groups (P > 0.05). However, there were statistically significant differences in serum albumin levels, Ca2+ concentration, blood glucose levels, duration of NPPV treatment and length of hospital stay between the success and failure groups (P < 0.05). Multivariate logistic regression analysis indicated that serum albumin levels and duration of NPPV treatment had statistical significance on the therapeutic effect of NPPV (P < 0.05). Conclusion Serum albumin levels and duration of NPPV treatment were independent risk factors for the efficacy of NPPV treatment in respiratory failure.
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Affiliation(s)
- Juan Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Department of Internal Medicine, Weiting Community Health Service Center, Suzhou, Jiangsu, China
| | - Shuang Bian
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiaomiao Tang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Sheng Ye
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shen Meng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Wei Lei
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Wang SM, Zhang FY, Du CL, Wang XB, Li F, Hang JQ, Chen YJ, Cheng KW, Zhao L, Jin XY, Shi JD, Jie ZJ, Qu JM. Epidemiology and issues of NIV-treated AECOPD patients with hypercapnic respiratory failure in Shanghai: A multicentre retrospective survey. CLINICAL RESPIRATORY JOURNAL 2021; 15:550-557. [PMID: 33217227 DOI: 10.1111/crj.13311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 10/16/2020] [Accepted: 11/13/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the epidemiology, clinical features, treatment and outcome of Noninvasive ventilation (NIV)-treated acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients in secondary hospitals of Shanghai. METHOD Relying on Shanghai alliances for respiratory diseases, a retrospective observational study was performed in 34 secondary hospitals of Shanghai. The AECOPD patients treated with NIV and admitted to the respiratory department or respiratory intensive care unit were recruited between December 1, 2016, and November 30, 2017. RESULTS There were 555 patients finally recruited in this study. The age was 75.8 ± 9.6 years old and 380 patients (68.5%) were male. 70.5% of all patients had respiratory acidosis (pH <7.35). 55.3% of all patients received nebulised bronchodilator and 77.7% were treated with systemic or inhaled corticosteroids during hospitalisation. 525 patients (94.6%) recovered successfully and the mortality was 3.2%. The hospitalisation was 15.3 ± 6.7 days and hospital expenses were 22 911 ± 13 595 RMB. Inadequate and nonstandard drug treatments were the most important problems during management. CONCLUSION The NIV can be successfully used for AECOP patients in local hospitals of Shanghai, but accompanied by high costs and long hospital stays. However, the treatments for exacerbation and stable COPD patients are still insufficient.
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Affiliation(s)
- Sheng-Mei Wang
- Department of Pulmonary and Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Feng-Ying Zhang
- Department of Respiratory Medicine, Putuo District People's Hospital, Shanghai, China
| | - Chun-Ling Du
- Department of Respiratory Medicine, Zhongshan Hospital Subordinating Qingpu Hospital, Shanghai, China
| | - Xiong-Biao Wang
- Department of Respiratory Medicine, Putuo District Central Hospital, Shanghai, China
| | - Fan Li
- Department of Respiratory Medicine, Songjiang District Central Hospital, Shanghai, China
| | - Jing-Qing Hang
- Department of Respiratory Medicine, Putuo District People's Hospital, Shanghai, China
| | - Yuan-Jing Chen
- Department of Respiratory Medicine, Yangpu District Kongjiang Hospital, Shanghai, China
| | - Ke-Wen Cheng
- Department of Respiratory Medicine, Renhe Hospital, Shanghai, China
| | - Lei Zhao
- Department of Respiratory Medicine, Gongli Hospital, Shanghai, China
| | - Xiao-Yan Jin
- Department of Respiratory Medicine, Tong Ren Hospital, Shanghai, China
| | - Jin-Dong Shi
- Department of Pulmonary and Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Zhi-Jun Jie
- Department of Pulmonary and Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Jie-Ming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao-Tong University School of Medicine, China
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Stefan MS, Priya A, Pekow PS, Steingrub JS, Hill NS, Lagu T, Raghunathan K, Bhat AG, Lindenauer PK. A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure. BMC Pulm Med 2021; 21:52. [PMID: 33546651 PMCID: PMC7863252 DOI: 10.1186/s12890-021-01421-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients. DESIGN Retrospective cohort study of a multihospital electronic health record database. PATIENTS Non-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization. MEASUREMENT Primary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010-2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016. MAIN RESULTS Of all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%-2.8%] for low risk group; 9.3% [6.3%-13.5%] for intermediate risk category; and 35.7% [31.0%-45.8%] for high risk category. CONCLUSIONS In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.
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Affiliation(s)
- Mihaela S Stefan
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
| | - Aruna Priya
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Penelope S Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - Jay S Steingrub
- Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary and Critical Care, Tufts University School of Medicine, Boston, MA, USA
| | - Tara Lagu
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Karthik Raghunathan
- Division of Veterans Affairs, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Anusha G Bhat
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Head-To-Head Comparison of Treatment Failure and Costs among COPD Patients Who Used Noninvasive Ventilation in the Ward versus in the ICU: A Propensity-Matched Cohort Study. Can Respir J 2020; 2020:6682589. [PMID: 33488883 PMCID: PMC7790588 DOI: 10.1155/2020/6682589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/14/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background Head-to-head comparison of treatment failure and costs among chronic obstruct pulmonary disease (COPD) patients who used noninvasive ventilation (NIV) in the ward versus in the ICU is lacking. Methods This retrospective study was performed in a department of respiratory and critical care medicine in a teaching hospital. COPD patients who used NIV in the respiratory ward or respiratory ICU were screened. We enrolled patients with PaCO2 more than 45 mmHg and pH less than 7.35 before the use of NIV. Results We enrolled 83 patients who initiated NIV in the ward and 319 patients in the ICU. Only 5 (6%) patients in the ward were required to transfer to ICU for intensive care. The vital signs were worse but improved faster within 24 h of NIV among patients in the ICU than those in the ward. The NIV failure, hospital mortality, and the length of stay in hospital did not differ between the two groups. However, the duration of NIV was shorter (median 4.0 vs. 6.1 days, p < 0.01) and hospital costs were higher (median 4638 vs. 3093 $USD, p < 0.01) among patients in the ICU than those in the ward. After propensity matching, 42 patients were left in each group, and the baseline data were comparable between the two groups. The findings in the overall cohort were confirmed again in the propensity-matched cohort. Conclusions Among COPD patients, the use of NIV in the ward leads to longer duration of NIV, but lower hospital costs, and similar NIV failure and mortality compared with those in the ICU.
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Non-Invasive Ventilation in a Non-Standard Setting – Is it Safe to Ventilate Outside the ICU? ACTA MEDICA BULGARICA 2020. [DOI: 10.2478/amb-2020-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Non-invasive ventilation (NIV) is considered a fundamental method in treating patients with various disorders, requiring respiratory support. Often the lack of beds in the intensive care unit (ICU) and the concomitant medical conditions, which refer patients as unsuitable for aggressive treatment in the ICU, highlight the need of NIV application in general non-monitored wards and unusual settings – most commonly emergency departments, high-dependency units, pulmonary wards, and even ambulances. Recent studies suggest faster improvement of all physiological variables, reduced intubation rates, postoperative pulmonary complications and hospital mortality with better outcome and quality of life by early well-monitored ward-based NIV compared to standard medical therapy in patients with exacerbation of a chronic obstructive pulmonary disease, after a surgical procedure or acute hypoxemic respiratory failure in hematologic malignancies. NIV is a ceiling of treatment and a comfort measure in many patients with do-not-intubate orders due to terminal illnesses. NIV is beneficial only by proper administration with appropriate monitoring and screening for early NIV failure. Successful NIV application in a ward requires a well-equipped area and adequately trained multidisciplinary team. It could be initiated not only by attending physicians, respiratory technicians, and nurses but also by medical emergency teams. Ward-based NIV is supposed to be more cost-effective than NIV in the ICU, but further investigation is required to establish the safety and efficacy in hospital wards with a low nurse to patient ratio.
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Gao E, Zhang C, Wang J. Effects of Budesonide Combined with Noninvasive Ventilation on PCT, sTREM-1, Chest Lung Compliance, Humoral Immune Function and Quality of Life in Patients with AECOPD Complicated with Type II Respiratory Failure. Open Med (Wars) 2019; 14:271-278. [PMID: 30886898 PMCID: PMC6419390 DOI: 10.1515/med-2019-0023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 11/20/2018] [Indexed: 12/27/2022] Open
Abstract
Objective Our objective is to explore the effects of budesonide combined with noninvasive ventilation on procalcitonin (PCT), soluble myeloid cell triggering receptor-1 (sTREM-1), thoracic and lung compliance, humoral immune function, and quality of life in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with type II respiratory failure. Methods There were 82 patients with AECOPD complicated with type II respiratory failure admitted into our hospital between March, 2016-September, 2017. They were selected and randomly divided into observation group (n=41) and control group (n=41). The patients in the control group received noninvasive mechanical ventilation and the patients in the observation group received budesonide based on the control group. The treatment courses were both 10 days. Results The total effective rate in the observation group (90.25%) was higher than the control group (65.85%) (P<0.05). The scores of cough, expectoration, and dyspnea were decreased after treatment (Observation group: t=18.7498, 23.2195, 26.0043, control group: t=19.9456, 11.6261, 14.2881, P<0.05); the scores of cough, expectoration, and dyspnea in the observation group were lower than the control group after treatment (t=11.6205, 17.4139, 11.6484, P<0.05). PaO2 was increased and PaCO2 was decreased in both groups after treatment (Observation group: t=24.1385, 20.7360, control group: t=11.6606, 9.2268, P<0.05); PaO2 was higher and PaCO2 was lower in the observation group than the control group after treatment (t=10.3209, 12.0115, P<0.05). Serum PCT and sTREM-1 in both groups were decreased after treatment (Observation group: t=16.2174, 12.6698, control group: t=7.2283, 6.1634, P<0.05); serum PCT and sTREM-1 in the observation group were lower than the control group after treatment (t=10.1017, 7.8227, P<0.05). The thoracic and lung compliance in both groups were increased after treatment (Observation group: t=30.5359, 17.8471, control group: t=21.2426, 13.0007, P<0.05); the thoracic and lung compliance in the observation group were higher than the control group after treatment (t=10.8079, 5.9464, P<0.05). IgA and IgG in both groups were increased after treatment (Observation group: t=9.5794, 25.3274, control group: t=5.5000, 4.7943, P<0.05), however IgM was not statistically different after treatment (Observation group: t=0.7845, control group: t=0.1767, P>0.05); IgA and IgG in the observation group were higher than the control group (t=4.9190, 4.7943, P<0.05), however IgM was not statistically different between two groups after treatment (t=0.6168, P>0.05). COPD assessment test (CAT) scores were decreased in both groups after treatment (Observation group: t=20.6781, control group: t=9.0235, P<0.05); CAT score in the observation group was lower than the control group after treatment (t=12.9515, P<0.05). Forced expiratory volume in one second (FEV1%) and forced expiratory volume in one second/ forced expiratory volume in one second (FEV1/FVC) were increased in both groups after treatment (Observation group: t=15.3684, 15.9404, control group: t=10.6640, 12.8979, P<0.05); FEV1% and FEV1/FVC in the observation group were higher than the control group (t=6.9528, 7.3527,P<0.05). The rates of complication were not statistically different between two groups (P>0.05). Conclusion Budesonide combined with noninvasive mechanical ventilation has good curative effects in treating AECOPE patients complicated with type II respiratory failure. It can decrease serum PCT and sTREM-1, increase thoracic lung compliance, and improve the humoral immune function and life quality.
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Affiliation(s)
- Erxiang Gao
- Emergency Department, Xingyuan Hospital of Yulin, Shaanxi 719000, China
| | - Chi Zhang
- The Second Department of Internal Medicine, Xingyuan Hospital of Yulin, Shaanxi 719000, China
| | - Jianping Wang
- Department of Emergency, 1st Hospital of Yulin, Yulin City, Shaanxi Province 719000, China
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Comellini V, Pacilli AMG, Nava S. Benefits of non-invasive ventilation in acute hypercapnic respiratory failure. Respirology 2019; 24:308-317. [PMID: 30636373 DOI: 10.1111/resp.13469] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/09/2018] [Indexed: 02/02/2023]
Abstract
Non-invasive ventilation (NIV) with bilevel positive airway pressure is a non-invasive technique, which refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This technique is successful in correcting hypoventilation. It has become widely accepted as the standard treatment for patients with hypercapnic respiratory failure (HRF). Since the 1980s, NIV has been used in intensive care units and, after initial anecdotal reports and larger series, a number of randomized trials have been conducted. Data from these trials have shown that NIV is a valuable treatment for HRF. This review aims to explore the principal areas in which NIV can be useful, focusing particularly on patients with acute HRF (AHRF). We will update the evidence base with the goal of supporting clinical practice. We provide a practical description of the main indications for NIV in AHRF and identify the group of patients with hypercapnic failure who will benefit most from the application of NIV.
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Affiliation(s)
- Vittoria Comellini
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy
| | - Angela Maria Grazia Pacilli
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stefano Nava
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy.,Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
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Ward-Based Non-Invasive Ventilation in Acute Exacerbations of COPD: A Narrative Review of Current Practice and Outcomes in the UK. Healthcare (Basel) 2018; 6:healthcare6040145. [PMID: 30544857 PMCID: PMC6315392 DOI: 10.3390/healthcare6040145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 12/30/2022] Open
Abstract
Non-invasive ventilation (NIV) is frequently used as a treatment for acute hypercapnic respiratory failure (AHRF) in hospitalised patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In the UK, many patients with AHRF secondary to AECOPD are treated with ward-based NIV, rather than being treated in critical care. NIV has been increasingly used as an alternative to invasive ventilation and as a ceiling of treatment in patients with a ‘do not intubate’ order. This narrative review describes the evidence base for ward-based NIV in the context of AECOPD and summarises current practice and clinical outcomes in the UK.
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Petroianni A, Esquinas AM. Noninvasive mechanical ventilation on the ward for severe COPD: still unresolved question of balance among safety and drawbacks? Int J Chron Obstruct Pulmon Dis 2016; 11:2209-2210. [PMID: 27695307 PMCID: PMC5034906 DOI: 10.2147/copd.s117861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Angelo Petroianni
- Department of Cardiovascular and Respiratory diseases, Sapienza University of Rome, Rome, Italy
| | - Antonio M Esquinas
- Intensive Care and Noninvasive Ventilatory Unit, Hospital General Universitario Morales Meseguer, Murcia, Spain
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