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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.

IntroductionNon-invasive ventilation (NIV) in the management of acute type II respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. The National Institute for Health and Clinical Excellence (NICE) recommend that NIV be available in all hospitals admitting patients with COPD. 1 This has led to a rapid expansion in the provision of NIV services with over 90% of UK admitting hospitals offering this intervention. The UK national audit of acute hospital COPD care in 2003, however, suggested that treatment was often applied to patients outside the existing British Thoracic Society (BTS) inclusion criteria. 2,3 This document updates the 2002 BTS 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 (BiPAP) 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. Guideline development was in accordance with the AGREE principles and is summarised in the online version of this guideline (www.rcplondon. ac.uk/pubs/brochure.aspx?e=258). An extended version of this guideline encompassing service provision is available on the BTS website. Clinical contextNon-invasive ventilation, within the intensive care unit and the ward environment, has been shown in randomised controlled trials and systematic reviews to reduce intubation rate and mortality in COPD patients with decompensated respiratory acidosis (pH <7.35 and PaCO 2 >6 kPa) following immediate medical therapy. 5-14 It should therefore be considered within the first 60 minutes of hospital arrival in all patients with an acute exacerbation of COPD in whom a respiratory acidosis persists despite maximum standard medical treatment, which includes:• controlled oxygen to maintain SaO 2 88-92% • nebulised salbutamol 2.5-5 mg • nebulised ipratroprium 500 µg • prednisolone 30 mg • antibiotic agent (when indicated).A clearly documented treatment plan for NIV, including how potential failure will be dealt with and whether escalation to intubation and mechanical ventilation is indicated, should be documented in the case notes at the outset of treatment. Whenever possible the patient and carers should be involved in these discussions. Once started, patient comfort, breathing synchrony and enhanced compliance are key factors in determining outcome. Low starting pressures increase patient compliance but should be quickly adjusted upwards to achieve therapeutic effect. If effective, treatment will usually be required until the acute cause has resolved, commonly about two to three days.s CONCISE GUIDELINES

Background: Hospitalisations are important events in COPD, and exacerbation prevention strategies are not completely effective. Experience with our research cohort suggested that availability of 24-hour telephone advice may reduce hospital admission.

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