“Ventilation is the profound secret of existence”
– Peter Sloterdijk
Article Citation: Brochard L, Mancebo J, Wysocki M, Lofaso F, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995 Sep 28;333(13):817-22. PMID: 7651472
What we already know about the topic: Noninvasive ventilation is an often used treatment in acute exacerbations of chronic obstructive pulmonary disease (COPD). However, intubation is often necessary and life saving. Intubation has known complications including infection and tracheal injury.
Why this study is important: This study addresses the importance of noninvasive ventilation in COPD exacerbations, specifically looking at whether noninvasive ventilation reduces the need for endotracheal intubation, length of hospital stay, and the in-hospital mortality.
Brief overview of the study: This multicenter, prospective, randomized trial compared efficacy of noninvasive ventilation through a facemask against standard care in the treatment of acute exacerbation of COPD. The study took place from 1990 to 1991 and involved patients from five different hospitals. Enrolled patients had known COPD or a high probability of the disease based on history, exam, and chest radiography. They needed to meet set criteria for acute exacerbation of COPD to be included in the study. The standard treatment group received oxygen supplementation through nasal cannula limited to 5 L/min. In the noninvasive ventilation group, patients additionally had periods of noninvasive ventilation for at least six hours each day. A standard set of criteria for endotracheal intubation was established in advance. 85 patients were enrolled in the study, with 42 in the standard group and 43 in the noninvasive group. 31 patients in the standard group required intubation, and 11 patients in the noninvasive group required intubation (p<0.001). Hospital stay was significantly longer in the standard treatment group at 35 ± 33 days, whereas hospital stay for the noninvasive group was 23 ± 17 days (p=0.02). In-hospital mortality was also higher in the standard group at 12 of the 42, as opposed to 4 of the 43 in the noninvasive group (p=0.02).
Limitations: (1) A significant percentage of intubations happened in the first twelve hours (23 of the 31 in the standard group and 9 of the 11 in the noninvasive group). These patients might have been excluded from the study, as they may have been considered too clinically unstable. However, even if excluded, it does not seem like the conclusions from this study would have been different. (2) The sample sizes in this study were small. Further and repeat studies would help assert the importance of noninvasive ventilatory treatment for COPD exacerbation.
Take home points: Use noninvasive ventilatory support for acute COPD exacerbation!