+1 Recommend
1 collections
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Predicting survival after acute exacerbation chronic obstructive pulmonary disease (ACOPD): is long-term application of noninvasive ventilation the last life guard?

      Read this article at

          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.


          Dear editor Patients with acute chronic obstructive pulmonary disease (ACOPD) admitted to an intensive care unit (ICU) still show substantial high hospital mortality (24%).1 After ICU discharge, long-term application noninvasive ventilation (NIV) may be a reasonable and effective indication.2 However, hospital mortality shows higher mortality rates for patients with COPD surviving their first episode after 2 and 5 years.2,3 Some patients with ventilatory failure at hospital discharge have increased arterial carbon dioxide tension (PaCO2), dyspnea, and reduced inspiratory muscle strength, compared with those of a normal patient. This is especially interesting for severe stable hypercapnic COPD, which can benefit substantially from using NIV, particularly showing improvements in gas change, dyspnea, and sleep quality. Currently, describing long-term survival in COPD patients receiving long-term NIV is a difficult issue. Titlestad et al analyzed the long-term survival rate in COPD patients receiving NIV for acute respiratory failure.3 We have read with interest this original and important epidemiological study that reports a 5-year mortality rate of 23.7%, and highlights the effects of NIV, with a trend toward more female mortality than male. However, we consider that it could be useful to add some aspects that are currently lacking, which could be analyzed and remarked on separately to understand this high mortality. First, there is a lack of relevant information on initial hospital admission that may influence higher mortality and could be interesting to take into account, such as: (a) rate of development of non-respiratory organ system dysfunction;1 (b) if there are some correlations with inspiratory pressure levels and adherence with NIV that have shown strength implications for long-term survival;4 (c) previous history of mechanical ventilation (MV); and (d) nutritional status and body mass index.5 Secondly, after hospital discharge, some aspects could be relevant to take into account. One study suggests that home NIV allows a lasting physiological stabilization in selected COPD patients, particularly those with an advanced disease, by reducing hypercapnia and improving inspiratory capacity.9 Further, in Titlestad et al’s article parameters of efficacy of home non invasive mechanical ventilation in non-survivors of COPD are unknown and may explain higher mortality;3 it could be interesting to know if there were some subgroups of COPD patients who remained at a hypercapnic high level after hospital discharge. In addition, for previous studies, prior domiciliary oxygen was a key predictor of 5-year mortality.5 Thirdly, it is very important to know the rate of readmission during this time, as after a severe ACOPD exacerbation, health conditions rapidly deteriorate.10 In this scenario of higher mortality, we need more solid scores after ACOPD to predict mortality and assess the protective role of long-term NIV application. Further large international surveys should be encouraged in order to consolidate new mortality prediction models, and discover whether the long-term application of NIV is the last life guard.

          Related collections

          Most cited references 7

          • Record: found
          • Abstract: found
          • Article: not found

          In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study.

           Tow Lim,  C Ai,  Hoe Lee (2005)
          The prognosis of patients with COPD requiring admission to the ICU is generally believed to be poor. There is a paucity of long-term survival data. We undertook a study to examine both the in-hospital and 5-year mortality rates and to identify the clinical predictors of these outcomes. We conducted a retrospective cohort study of 57 patients admitted to the ICU between January 1999 and December 2000 for acute respiratory failure attributable to COPD. The mean (+/-SD) age of the study population was 70 +/- 8 years. More than 90% of patients required intubation, and the mean duration of mechanical ventilation (MV) was 2.3 +/- 2.2 days. The in-hospital mortality rate for the entire cohort was 24.5%. The mortality rates at 6 months and 1, 3, and 5 years were 39.0%, 42.7%, 61.2%, and 75.9%, respectively, following admission to the ICU. The median survival time for all patients was 26 months. The mortality rate at 5 years was 69.6% for patients who were discharged alive from the hospital. Using multivariate analysis, hospital mortality correlated positively with age, previous history of MV, long-term use of oral corticosteroids, ICU admission albumin level, APACHE (acute physiology and chronic health evaluation) II score, and duration of hospitalization. No factors predictive of mortality at 5 years were identified. We support previous findings of good early survival and significant but acceptable long-term mortality rates in patients who have been admitted to the ICU for acute exacerbation of COPD. Increased age, previous history of MV, poor nutritional status, and higher APACHE II score on ICU admission could be identified as risk factors associated with increased mortality rates. Long-term survival of patients with COPD who required MV for an acute exacerbation of their disease cannot be predicted simply from data available at the time of intubation. Physicians should incorporate these factors in their decision-making process.
            • Record: found
            • Abstract: found
            • Article: not found

            Long-term non-invasive ventilation in COPD after acute-on-chronic respiratory failure.

            COPD patients who remain hypercapnic after acute respiratory failure requiring mechanical ventilation have a poor prognosis. Long-term nocturnal non-invasive ventilation (NIV) may be beneficial for these patients. We hypothesized that stable patients on long-term NIV would experience clinical worsening after withdrawal of NIV. We included 26 consecutive COPD patients (63 ± 6 years, 58% male, FEV(1) 31 ± 14% predicted) who remained hypercapnic after acute respiratory failure requiring mechanical ventilation. After a six month run-in period, during which all patients received NIV, they were randomised to either continue (ventilation group, n = 13) or to stop NIV (withdrawal group, n = 13). The primary endpoint was time to clinical worsening defined as an escalation of mechanical ventilation. All patients remained stable during the run-in period. After randomisation the withdrawal group had a higher probability of clinical worsening compared to the ventilation group (p = 0.0018). After 12 months, ten patients (77%) in the withdrawal group, but only two patients (15%) in the ventilation group, experienced clinical worsening (p = 0.0048). Six-minute walking distance increased in the ventilation group. COPD patients who remain hypercapnic after acute respiratory failure requiring mechanical ventilation may benefit from long-term NIV. Copyright © 2010. Published by Elsevier Ltd.
              • Record: found
              • Abstract: found
              • Article: not found

              Impact of noninvasive home ventilation on long-term survival in chronic hypercapnic COPD: a prospective observational study.

              The long-term benefit from noninvasive ventilation (NIV) in chronic hypercapnic chronic obstructive pulmonary disease (COPD) remains uncertain. Within a prospective observational design, we compared the long-term survival of 140 patients with severe persistent hypercapnic COPD (FEV(1) 28.7 +/- 8.7% predicted; PaCO(2) 60.1 +/- 9.2 mmHg) with (n = 99) or without (n = 41) NIV. End-point was all-cause mortality, determined up to 4 years by Kaplan-Meier analysis. Additionally, Cox's proportional hazards regression and stratification by risk factors was performed. Patients were characterised by anthropometric and functional parameters, comorbidities and medical therapy. Adherence in patients with NIV was high (88.9%), daily ventilator use being 6.4 +/- 2.6 h/day and inspiratory pressures 21.0 +/- 4.0 cmH(2)O. One- and 2-year survival rates were 87.7% and 71.8%, respectively, in patients with NIV vs. 56.7% and 42.0% in patients without NIV. Survival rates were significantly higher in patients with NIV compared to those without this therapy (p = 0.001; hazard ratio 0.380; 95% confidence interval 0.138-0.606). The difference between groups was still significant after adjustment for differences in baseline characteristics. Moreover, stratification by risk factors revealed beneficial effects, particularly in patients with high base excess (BE; > 8.9 mmol/l), low pH ( 189% predicted) upon inclusion (p < 0.05 each). In patients with severe chronic hypercapnic COPD receiving NIV at high inspiratory pressure levels and showing high adherence to this therapy, long-term survival was significantly higher than in non-ventilated patients. Patients displaying more severe disease according to known risk factors seemed to benefit most from long-term NIV.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                07 August 2013
                : 8
                : 379-381
                [1 ]Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain
                [2 ]Saga Medical School Hospital, Department of Anesthesiology and Intensive Care Medicine, Saga, Japan
                [3 ]Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Solingen, Germany
                [1 ]Department of respiratory Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
                [2 ]Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
                [3 ]Respiratory Research Group, Manchester Academic Health Sciences Centre, University Hospital South Manchester NHS Foundation Trust, University of Manchester, Manchester, UK
                Author notes
                Correspondence: Antonio M Esquinas, Intensive Care Unit, Hospital Morales Meseguer, Avenida Marques Velez s/n, Murcia, 30008 Spain, Tel +34 609 321 966, Fax +34 968 232 484, Email antmesquinas@
                Correspondence: Ingrid L Titlestad, Department of Respiratory Medicine, Odense University Hospital, University of Southern Denmark, Sdr Boulevard 29, 5000 Odense C, Denmark, Email ingrid.titlestad@
                © 2013 Esquinas et al. This work is published by Dove Medical Press Ltd, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.


                Respiratory medicine


                Comment on this article