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Does noninvasive positive pressure ventilation have a role in managing hypercapnic respiratory failure due to an acute exacerbation of COPD?

Cleveland Clinic Journal of Medicine. 2008 June;75(6):458-461
June 1, 2008|Cleveland Clinic Journal of Medicine
Ari J. Gershman, DO;Anita J. Reddy, MD;Marie M. Budev, DO, MPH;Peter J. Mazzone, MD, MPH, FCCP
Author and Disclosure Information

Ari J. Gershman, DO
Department of General Internal Medicine, Cleveland Clinic

Anita J. Reddy, MD
Respiratory Institute, Cleveland Clinic

Marie M. Budev, DO, MPH
Respiratory Institute, Cleveland Clinic

Peter J. Mazzone, MD, MPH
Respiratory Institute, Cleveland Clinic

Address: Peter J. Mazzone, MD, MPH, Department of Pulmonary, Allergy, and Critical Care Medicine, A90, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail mazzonp@ccf.org

WHICH PATIENTS SHOULD RECEIVE IT?

Consensus groups have offered guidelines for deciding who should receive NIPPV (Table 1).14–16 Patients who benefit the most include those who have moderate to severe dyspnea, tachypnea, and hypercarbia and whose pH is 7.25 to 7.35. Of importance, if this treatment is appropriate it should be started without delay, as studies have shown a higher success rate when it is applied early.17

NIPPV is not suitable for all patients with hypercapnic respiratory failure. It should not be substituted for endotracheal intubation and mechanical ventilation if they are indicated, eg, in patients who are medically unstable because of hypotension, sepsis, hypoxia, or other life-threatening systemic illness. In addition, those who cannot protect the airway, who have had a worsening in mental status, or who have excessive secretions should not undergo NIPPV because they have a high risk of aspiration. Factors that predict that this therapy will fail include an Acute Physiology and Chronic Health Evaluation (APACHE) score of 29 or higher, a respiratory rate of 30 or higher, and a pH lower than 7.25 after 2 hours of this therapy.15

GENERAL WARD OR INTENSIVE CARE UNIT?

Mild to moderate COPD exacerbations (in which the pH is 7.30 or higher) can be effectively treated with NIPPV in a general ward if the staff has appropriate expertise.5,18 Keeping the patient in a general ward reduces cost and provides a favorable outcome in selected patients.5,19 However, if the patient’s hemodynamic or mental status deteriorates or if gas exchange, pH, respiratory rate, or dyspnea fail to improve, he or she should be transferred to an intensive care unit and endotracheal intubation should be considered.18 The use of NIPPV in general wards should always be approached with caution and should never be attempted without adequate patient supervision and an experienced respiratory therapy team.

TAKE-HOME MESSAGE

NIPPV has been shown to be an effective adjunct in the treatment of acute hypercapnic respiratory failure secondary to a COPD exacerbation, reducing the need for endotracheal intubation, the length of hospital stay, and the mortality rate. On the basis of controlled trials, NIPPV is now considered the ventilatory therapy of choice in selected patients with this condition. However, it should not be used as a substitute for intubation and mechanical ventilation if these are needed or if the patient is at risk of aspiration.

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