Severe exacerbations of chronic obstructive pulmonary disease: management with noninvasive ventilation on a general medicine ward

Abstract

Introduction: Recent evidence suggests that, with a well-trained staff, severe exacerbations of chronic obstructive pulmonary disease (COPD) with moderate respiratory acidosis (pH > 7.3) can be successfully treated with noninvasive mechanical ventilation (NIMV) on a general respiratory care ward. We conducted an open prospective study to evaluate the efficacy of this approach on a general medicine ward. Material and methods: This study population consisted in 27 patients admitted to a general medicine ward (median nurse:patient ratio 1:12) December 1, 2004 May 31, 2006 for acute COPD exacerbation with hypercapnic respiratory failure and acidosis (arterial pH < 7.34, PaC02 > 45 mmHg). All received assist-mode NIMV (average 12 h / day) via oronasal masks (inspiratory pressure 10-25 cm H2O, expiratory pressure 4-6 cm H2O) to maintain O2 saturation at 90-95%. Treatment was supervised by an experienced pulmonologist, who had also provided specific training in NIMV for medical and nursing staffs (90-day course followed by periodic refresher sessions). Arterial blood pressure, O2 saturation, and respiratory rate were continuously monitored during NIMV. Based on baseline arterial pH, the COPD was classified as moderate (7.25-7.34) or severe (< 7.25). Results: In patients with moderate and severe COPD, significant improvements were seen in arterial pH after 2 (p < 0.05) and 24 h (p< 0.05) of NIMV and in the PaC02 after 24 hours (p < 0.05). Four (15%) of the 27 patients died during the study hospitalization (in-hospital mortality 15%), in 2 cases due to NIMV failure. For the other 23, mean long-term survival was 14.5 months (95% CI 10.2 to 18.8), and no significant differences were found between the moderate and severe groups. Over half (61%) the patients were alive 1 year after admission. Conclusions: NIMV can be a cost-effective option for management of moderate or severe COPD on a general medicine ward. Its proper use requires: close monitoring of ventilated subjects, optimum staff:patient ratio, well-trained staff dedicated to NIMV, and supervision by a pulmonologist with experience in NIMV. The treatment was effective at improving arterial blood gases in both groups of COPD patients. The severity of the COPD did not significantly affect length of hospital stay, in-hospital mortality, or long-term survival.

Efficacy of non‐invasive mechanical ventilation in the general ward in patients with chronic obstructive pulmonary disease admitted for hypercapnic acute respiratory failure and pH < 7.35: a feasibility pilot study

“…However, the pH level has been reported to be a crucial factor in determining the NIV success rate. 4,5 Although the confidence of healthcare providers with NIV has progressively improved and although NIV has been applied with success also outside the critical care environment, 6,7 to date NIV is not recommended outside ICU in patients with severe hypercapnic ARF and a pH < 7.30. 8 In particular, it was shown that NIV treatment failed in approximately 50-60% of COPD-exacerbated subjects with a baseline pH < 7.25.…”

Il percorso diagnostico-assistenziale della broncopneumopatia cronica ostruttiva riacutizzata in Medicina Interna

“…Nello schema sopra riportato non viene considerata la possibile alternativa delle cosiddette ''Unità di Cure Intermedie'' (''High Dependency Units''), ovvero di aree ad alta intensità assistenziale (''high care''), implementabili anche nei reparti di Medicina Interna [34], particolarmente adatte per quei pazienti che hanno un basso rischio attuale ma sono suscettibili di complicanze maggiori e richiedono un monitoraggio di routine [35].…”