Journal Mobile

M Telfer, A Lwin, P Jenkins
Journal Issue: 
Volume 37: Issue 1: 2007




In  the  UK, over  three  million  people  suffer  from  COPD, and  over 30,000  people  die  as  a  result  each  year.  Acute  exacerbations  of  COPD  are  a particularly heavy burden to patients, and to the Health Service.  Patients often present  with  AHRF,  and  this  presentation  accounts  for  20%  of  all  COPD admissions.  Non-invasive ventilation is of proven efficacy in the management of AHRF associated with an exacerbation of COPD.  Systematic reviews and meta-analysis have shown that the use of NIV in addition to standard medical therapy significantly  reduces  in-hospital  mortality, the  need  for  invasive  ventilation, and the  length  of  stay  in  hospital, when  compared  with  standard  medical  therapy alone.  Non-invasive ventilation is associated with greater improvements at one hour in pH, PaCO2, and respiratory rate.

Ideally, patients  who  require  NIV  should  be  able  to  protect  their  airway, be  co-operative with (and tolerant of) the technique, and be otherwise medically stable. It  must  be  remembered  that  COPD  with  AHRF  patients  who  survive  treatment with NIV have a high risk of subsequent death and life threatening events.  At the same time the reported outcome for patients admitted with AHRF secondary to COPD tends to be worse in the group not treated with NIV.  However, it is not sufficiently poor to render IMV inappropriate for COPD populations as a whole. A decision on the appropriateness of intubation and mechanical ventilation if NIV fails should be taken before NIV is initiated and this decision should be taken by senior medical staff with input from a critical care physician if necessary.  Non-invasive  ventilation  should  not  be  used  as  a  substitute  for  tracheal  intubation when  the  latter  intervention  is  clearly  more  appropriate.    In  addition,  it  is suggested that patients with a pH <7·25, or who are candidates for intubation, should be managed on ITU if at all possible, and should certainly have critical care input in their management.