Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure.

Non-invasive ventilation (NIV) in the management of acute type 2 respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. This document updates the 2002 British Thoracic Society guidance and provides a specific focus on the use of NIV in COPD patients with acute type 2 respiratory failure. While there are a variety of ventilator units available most centres now use bi-level positive airways pressure units and this guideline refers specifically to this form of ventilatory support although many of the principles encompassed are applicable to other forms of NIV. The guideline has been produced for the clinician caring for COPD patients in the emergency and ward areas of acute hospitals.

Randomized controlled trial of domiciliary noninvasive positive pressure ventilation and physical training in severe chronic obstructive pulmonary disease.

The addition of noninvasive positive pressure ventilation (NPPV) to an exercise training (ET) program in severe chronic obstructive pulmonary disease (COPD) may produce greater benefits in exercise tolerance and quality of life than after training alone. Forty-five patients with severe stable COPD-mean (SD) FEV(1) 0.96 (0.31) L, Pa(O(2)) 65.4 (9.07) mm Hg, Pa(CO(2)) 45.6 (7.89) mm Hg-were randomized to domiciliary NPPV + ET (n = 23) or ET alone (n = 22). Exercise capacity and health status were assessed at baseline and after an 8-wk training program. There was a significant improvement in mean shuttle walk test (SWT) in the NPPV + ET group: from 169 (112) to 269 (124) m (p = 0.001), compared with the ET group: 205 (100) to 233 (123) m (p = 0.19); mean difference (95% confidence interval [CI]): 72 (12.9 to 131) m. Repeated measures analysis of variance (ANOVA) showed that the differences between the two groups became evident only in the final 4 wk of the training program with a mean end study difference (95% 1CI) of 65.8 (17.1 to 114) m. There was a significant improvement in the Chronic Respiratory Disease Questionnaire (CRDQ) of mean (SD) 24.0 (17.4) (p = < 0.001) in the NPPV + ET group and 11.8 (15.8) (p = 0.003) points in the ET group; mean difference: 12.3 (1.19 to 23.4). Only the NPPV + ET group demonstrated a significant improvement in arterial oxygenation; mean difference: 3.70 mm Hg (0.37 to 7.27). This study suggests that domiciliary NPPV can be used successfully to augment the effects of rehabilitation in severe COPD.

Using nasal intermittent positive pressure ventilation on a general respiratory ward.

OBJECTIVES: To assess the use of nasal intermittent positive pressure ventilation (NIPPV) in treating acute-on-chronic respiratory failure in a general medical ward. DESIGN: Retrospective analysis of clinical outcome. SETTING: A general medical ward of a tertiary respiratory medicine referral centre. SUBJECTS: Altogether 75 patients admitted with acute exacerbations of chronic respiratory failure and treated NIPPV. MAIN OUTCOME MEASURES: Blood gas tensions determined at admission to hospital and during NIPPV, tolerance of NIPPV and mortality. RESULTS: During treatment with NIPPV, the mean (SD) PaO2 increased rapidly by 2.31 (3.58) kPa (p < 0.0001), while the mean PaCO2 fell by 1.07 (1.74) kPa (p < 0.0001) and the mean pH increased by 0.03 (0.07) (p = 0.001). Altogether 57 (76%) of patients tolerated NIPPV, and (9.3%) died in hospital. Improvement in PaO2 was more noticeable in patients with chronic obstructive pulmonary disease (+3.13 (3.49) kPa, p < 0.0001) than in those with restrictive chest wall disease (+1.20 (3.07) kPa, p = 0.25) or obstructive sleep apnoea (+0.18 (3.64), p = 0.88). The reduction in PaCO2 was similar in all three groups. CONCLUSIONS: In routine treatment of unselected patients with acute-on-chronic respiratory failure who are being cared for on a general ward, NIPPV rapidly improves hypoxaemia and hypercapnia, is well tolerated and is associated with low mortality.

Nasal ventilation in pregnancy: treatment of nocturnal hypoventilation in a patient with kyphoscoliosis.

The management of a young woman with congenital kyphoscoliosis, who developed symptomatic nocturnal hypoventilation during the third trimester of pregnancy, is described. Nasal intermittent positive pressure ventilation (NIPPV) was safely and effectively used to correct nocturnal hypoxaemia and hypercapnia from the 30th-36th week of gestation, when a healthy boy was delivered by Caesarean section. Following delivery, the mother no longer required NIPPV and returned to her prepregnancy level of activity.