A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation

Abstract

on behalf of the Italian noninvasive positive pressure ventilation (NPPV) study group ## ABSTRACT: Knowing the likelihood of failure of noninvasive positive pressure ventilation (NPPV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD) could indicate the best choice between NPPV and endotracheal intubation instituted earlier. For this purpose, two risk charts were designed (at admission and after 2 h of NPPV) that included all relevant measurable clinical prognostic indicators derived from a population representing the patients seen routinely in clinical practice.Risk stratification of NPPV failure was assessed in 1,033 consecutive patients admitted to experienced hospital units, including two intensive care units, six respiratory intermediate care units, and five general wards. NPPV was successful in 797 patients.Patients with a Glasgow Coma Score ,11, acute physiology and chronic health evaluation (APACHE) II o29, respiratory rate o30 breaths?min -1 and pH at admission ,7.25 have a predicted risk of failure .70%. A pH ,7.25 after 2 h greatly increases the risk (.90%). The risk charts were validated on an independent group of 145 consecutive COPD patients treated with NPPV due to an acute ventilatory failure episode. To identify patients with a probability of failure .50%, the sensitivity and specificity were 33% and 96.7% on admission and 52.9% and 94.1% after 2 h of NPPV, respectively. The prediction chart, based on data from the current study, can function as a simple tool to predict the risk of failure of noninvasive positive pressure ventilation and thus improve clinical management of patients tailoring medical intervention. KEYWORDS: Chronic obstructive pulmonary disease, endotracheal intubation, noninvasive ventilation, respiratory failure N oninvasive positive pressure ventilation (NPPV), in patients with exacerbations of chronic obstructive pulmonary disease (COPD) and respiratory acidosis, reduces the intubation rate and mortality [1][2][3][4][5][6][7][8][9]. Operated by well trained teams, NPPV is effective and safe in both intensive care settings [10] and general respiratory wards [8]. A randomised, clinical trial showed that NPPV also reduces mortality in COPD patients in the intensive care unit (ICU) within the inclusion criteria for intubation [6]. Nevertheless, two recent consensus guidelines on NPPV in acute respiratory failure (ARF) recommend that NPPV should not be used as a substitute for endotracheal intubation and invasive ventilation when the latter is clearly more appropriate [11,12].The likelihood of failure of NPPV is crucial in deciding if and when to apply this ventilatory technique. However, attempts to predict the success of NPPV have only been made in singlecentre studies that included a limited number of patients [13][14][15]. Furthermore, results from randomised, controlled studies could be affected significantly by the research setting, e.g. strict selection criteria of patients or a unique care location. This limits the possibility of generalising th...

Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit

“…During this period, each participating hospital completed a pre-defined dataset about the resources and the organisation of acute COPD care listed in online supplementary table s1. For the risk prediction models, respiratory acidosis was stratified as severe with a pH <7.25 and mild with a pH 7.25-7.35 [10,11]. The staff resources, i.e.…”

Increased Number and Expertise of Italian Respiratory High-Dependency Care Units: The Second National Survey

“…4,25 Moreover, noninvasive physiological data at baseline and after 2 hours of NIV can accurately predict the likelihood of NIV failure in COPD exacerbation. 26 Almost all the RHDCUs had NIV ventilators, which, in contrast to older-generation ICU ventilators, can adequately compensate for air leaks. 27 …”

Use of noninvasive ventilation for acute respiratory failure in intensive care unit.

“…Passarini et al (15) observing patients with COPD and APE, found that higher scores on the GCS were predictive of success of NIV. Similarly, Confalonieri et al (16) found that patients with GCS below 11, pH ≥ 7.25, respiratory rate ≥ 30 breaths per minute, and high level predictive of mortality on admission had risk > 70% of failure of NIV.…”