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      Noninvasive mechanical ventilation with BiPAP therapy for comatose exacerbation of chronic obstructive pulmonary disease through an endotracheal tube: is it justified?

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          High-intensity versus low-intensity non-invasive ventilation in patients with stable hypercapnic COPD: a randomised crossover trial.

          The conventional approach of low-intensity non-invasive positive pressure ventilation (NPPV) produces only minimal physiological and clinical benefits in patients with stable hypercapnic chronic obstructive pulmonary disease (COPD). To determine whether the novel approach of high-intensity NPPV is superior to low-intensity NPPV in controlling nocturnal hypoventilation. A randomised controlled crossover trial comparing 6 weeks of high-intensity NPPV (using controlled ventilation with mean inspiratory pressures of 28.6+/-1.9 mbar) with low-intensity NPPV (using assisted ventilation with mean inspiratory pressures of 14.6+/-0.8 mbar) was performed in 17 patients with severe stable hypercapnic COPD. Two patients refused low-intensity NPPV and two patients dropped out while on low-intensity NPPV. Thirteen patients (mean forced expiratory volume in 1 s (FEV(1)) 0.76+/-0.29 l) completed the trial. High-intensity NPPV produced higher pneumotachographically-measured expiratory volumes, with a mean treatment effect of 96 ml (95% CI 23 to 169) (p=0.015). This resulted in a mean treatment effect on nocturnal arterial carbon dioxide tension (Paco(2)) of -9.2 mm Hg (95% CI -13.7 to -4.6) (p=0.001) in favour of high-intensity NPPV. Daily use of NPPV was increased in high-intensity NPPV compared with low-intensity NPPV, with a mean difference of 3.6 h/day (95% CI 0.6 to 6.7) (p=0.024). In addition, compared with baseline, only high-intensity NPPV resulted in significant improvements in exercise-related dyspnoea, daytime Paco(2), FEV(1), vital capacity and the Severe Respiratory Insufficiency Questionnaire Summary Score. High-intensity NPPV is better tolerated by patients with severe chronic hypercapnic COPD and has been shown to be superior to the conventional and widely-used form of low-intensity NPPV in controlling nocturnal hypoventilation. High-intensity NPPV therefore offers a new promising therapeutic option for these patients.
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            Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial.

            In patients with acute exacerbations of chronic obstructive pulmonary disease, mechanical ventilation is often needed. The rate of weaning failure is high in these patients, and prolonged mechanical ventilation increases intubation-associated complications. To determine whether noninvasive ventilation improves the outcome of weaning from invasive mechanical ventilation. Multicenter, randomized trial. Three respiratory intensive care units. Intubated patients with chronic obstructive pulmonary disease and acute hypercapnic respiratory failure. A T-piece weaning trial was attempted 48 hours after intubation. If this failed, two methods of weaning were compared: 1) extubation and application of noninvasive pressure support ventilation by face mask and 2) invasive pressure support ventilation by an endotracheal tube. Arterial blood gases, duration of mechanical ventilation, time in the intensive care unit, occurrence of nosocomial pneumonia, and survival at 60 days. At admission, all patients had severe hypercapnic respiratory failure (mean pH, 7.18+/-0.06; mean PaCO2, 94.2+/-24.2 mm Hg), sensory impairment, and similar clinical characteristics. At 60 days, 22 of 25 patients (88%) who were ventilated noninvasively were successfully weaned compared with 17 of 25 patients (68%) who were ventilated invasively. The mean duration of mechanical ventilation was 16.6+/-11.8 days for the invasive ventilation group and 10.2+/-6.8 days for the noninvasive ventilation group (P = 0.021). Among patients who received noninvasive ventilation, the probability of survival and weaning during ventilation was higher (P = 0.002) and time in the intensive care unit was shorter (15.1+/-5.4 days compared with 24.0+/-13.7 days for patients who received invasive ventilation; P = 0.005). Survival rates at 60 days differed (92% for patients who received noninvasive ventilation and 72% for patients who received invasive ventilation; P = 0.009). None of the patients weaned noninvasively developed nosocomial pneumonia, whereas 7 patients weaned invasively did. Noninvasive pressure support ventilation during weaning reduces weaning time, shortens the time in the intensive care unit, decreases the incidence of nosocomial pneumonia, and improves 60-day survival rates.
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              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.
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                Author and article information

                Journal
                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
                1176-9106
                1178-2005
                2012
                2012
                03 December 2012
                : 7
                : 807-808
                Affiliations
                [1 ]Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain
                [2 ]Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
                Department of Pulmonary Medicine, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Dehradun, Uttarakhand, India
                Author notes
                Correspondence: Antonio Esquinas, Intensive Care Unit, Hospital Morales Meseguer, Avenida Marques de los velez s/n Murcia, 30008, Spain, Tel +346 0932 1966, Fax +349 6823 2484, Email antmesquinas@ 123456gmail.com
                Correspondence: Jagdish Rawat, Department of Pulmonary Medicine, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Dehradun 248140, India, Tel +91 13 5247 1362, Fax +91 13 5247 1317, Email drjagdishrawat@ 123456yahoo.com
                Article
                copd-7-807
                10.2147/COPD.S38179
                3526869
                23271904
                © 2012 Esquinas and Agarwal, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                Categories
                Letter

                Respiratory medicine

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