Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial

BACKGROUND: Evidence is weak for the ability of long-term non-invasive positive pressure ventilation (NPPV) to improve survival in patients with stable hypercapnic chronic obstructive pulmonary disease (COPD). Previous prospective studies did not target a reduction in hypercapnia when adjusting ventilator settings. This study investigated the effect of long-term NPPV, targeted to markedly reduce hypercapnia, on survival in patients with advanced, stable hypercapnic COPD. METHODS: This investigator-initiated, prospective, multicentre, randomised, controlled clinical trial enrolled patients with stable GOLD stage IV COPD and a partial carbon dioxide pressure (PaCO2) of 7 kPa (51\ub79 mm Hg) or higher and pH higher than 7\ub735. NPPV was targeted to reduce baseline PaCO2 by at least 20% or to achieve PaCO2 values lower than 6\ub75 kPa (48\ub71 mm Hg). Patients were randomly assigned (in a 1:1 ratio) via a computer-generated randomisation sequence with a block size of four, to continue optimised standard treatment (control group) or to receive additional NPPV for at least 12 months (intervention group). The primary outcome was 1-year all-cause mortality. Analysis was by intention to treat. The intervention was unblinded, but outcome assessment was blinded to treatment assignment. This study is registered with ClinicalTrials.gov, number NCT00710541. FINDINGS: Patients were recruited from 36 respiratory units in Germany and Austria, starting on Oct 29, 2004, and terminated with a record of the vital status on July 31, 2011. 195 patients were randomly assigned to the NPPV group (n=102) or to the control group (n=93). All patients from the control group and the NPPV group were included in the primary analysis. 1-year mortality was 12% (12 of 102 patients) in the intervention group and 33% (31 of 93 patients) in the control group; hazard ratio 0\ub724 (95% CI 0\ub711-0\ub749; p=0\ub70004). 14 (14%) patients reported facial skin rash, which could be managed by changing the type of the mask. No other intervention-related adverse events were reported. INTERPRETATION: The addition of long-term NPPV to standard treatment improves survival of patients with hypercapnic, stable COPD when NPPV is targeted to greatly reduce hypercapnia

Wentylacja nieinwazyjna u pacjentów w zmienionym stanie świadomości. Przegląd kliniczny i uwagi praktyczne

Wentylacja nieinwazyjna odgrywa coraz większą rolę w leczeniu ostrej hipoksemicznej lub hiperkapnicznej niewydolności oddychania i ma wiele zalet w porównaniu z inwazyjną wentylacją mechaniczną. Do zalet tych zalicza się zachowanie mechanizmów obronnych dróg oddechowych, zmniejszoną potrzebę sedacji i zmniejszenie ryzyka powikłań związanych z intubacją dotchawiczą. Mimo niewątpliwych walorów wentylacji nieinwazyjnej istnieją również pewne przeciwwskazania do stosowania tej metody, jak na przykład ciężka encefalopatia. W niniejszym artykule przeglądowym przeanalizowano podstawy teoretyczne, dowody naukowe i wady stosowania wentylacji nieinwazyjnej u pacjentów z hiperkapnią lub bez hiperkapni, znajdujących się w stanie zaburzonej świadomości

Non-invasive ventilation in patients with an altered level of consciousness. A clinical review and practical insights

Non-invasive ventilation has gained an increasingly pivotal role in the treatment of acute hypoxemic and/or hypercapnic respiratory failure and offers multiple advantages over invasive mechanical ventilation. Some of these advantages include the preservation of airway defense mechanisms, a reduced need for sedation, and an avoidance of complications related to endotracheal intubation

Noninvasive ventilation: education and training. A narrative analysis and an international consensus document

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the timeand if properly applied, it can save patients’ lives and improve long-term prognosis. However, both knowledge and skills of itsproper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training.Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviewswith the results analyzed by a team of experts across the world through e-mail based communications.Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies withindirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implementedonly in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIVeducation and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated.Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care usingNIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developingcountries