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      Ward-Based Non-Invasive Ventilation in Acute Exacerbations of COPD: A Narrative Review of Current Practice and Outcomes in the UK

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          Abstract

          Non-invasive ventilation (NIV) is frequently used as a treatment for acute hypercapnic respiratory failure (AHRF) in hospitalised patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In the UK, many patients with AHRF secondary to AECOPD are treated with ward-based NIV, rather than being treated in critical care. NIV has been increasingly used as an alternative to invasive ventilation and as a ceiling of treatment in patients with a ‘do not intubate’ order. This narrative review describes the evidence base for ward-based NIV in the context of AECOPD and summarises current practice and clinical outcomes in the UK.

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          BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults

          A Craig Davidson, Stephen Banham, Mark C. Elliott … (2016)
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            Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit.

            Ady Castro-Acosta, Bernhard Kaiser, Sylvia Hartl … (2016)
            Studies report high in-hospital and post-discharge mortality of chronic obstructive pulmonary disease (COPD) exacerbations varying depending upon patient characteristics, hospital resources and treatment standards. This study aimed to investigate the patient, resource and organisational factors associated with in-hospital and 90-day post-discharge mortality and readmission of COPD exacerbations within the European COPD Audit. The audit collected data of COPD exacerbation admissions from 13 European countries.On admission, only 49.7% of COPD patients had spirometry results available and only 81.6% had blood gases taken. Using logistic regression analysis, the risk associated with in-hospital and post-discharge mortality was higher age, presence of acidotic respiratory failure, subsequent need for ventilatory support and presence of comorbidity. In addition, the 90-day risk of COPD readmission was associated with previous admissions. Only the number of respiratory specialists per 1000 beds, a variable related to hospital resources, decreased the risk of post-discharge mortality.The European COPD Audit identifies risk factors associated with in-hospital and post-discharge mortality and COPD readmission. Addressing the deficiencies in acute COPD care such as making spirometry available and measuring blood gases and providing noninvasive ventilation more regularly would provide opportunities to improve COPD outcomes.
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              Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations.

              C. Roberts, R. Buckingham, R. Stone … (2010)
              Reports of non-invasive ventilation (NIV) use in clinical practice reveal higher mortality rates than in corresponding randomised clinical trials. To explore factors related to chronic obstructive pulmonary disease (COPD) admissions and NIV use that may explain some of the previously reported high mortality rates. National UK audit of clinical care of consecutive COPD admissions from March to May 2008. Retrospective case note audit with prospective case ascertainment. Participating units completed a web-based audit proforma of process and outcomes of clinical care. 232 hospital units collected data on 9716 patients, mean age 73, 50% male. 1678 (20%) of those with gases recorded on admission were acidotic and another 6% became acidotic later. 1077 patients received NIV, 55% had a pH<7.26 and 49% (305/618) had or were still receiving high flow oxygen. 30% (136/453) patients with persisting respiratory acidosis did not receive NIV while 11% (15/131) of acidotic admissions had a pure metabolic acidosis and did. Hospital mortality was 25% (270/1077) for patients receiving NIV but 39% (86/219) for those with late onset acidosis and was higher in all acidotic groups receiving NIV than those treated without. Only 4% of patients receiving NIV who died had invasive mechanical ventilation. COPD admissions treated with NIV in usual clinical practice were severely ill, many with mixed metabolic acidosis. Some eligible patients failed to receive NIV, others received it inappropriately. NIV appears to be often used as a ceiling of treatment including patient groups in whom efficacy of NIV is uncertain. The audit raises concerns that challenge the respiratory community to lead appropriate clinical improvements across the acute sector.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Healthcare (Basel)
                Journal ID (iso-abbrev): Healthcare (Basel)
                Journal ID (publisher-id): healthcare
                Title: Healthcare
                Publisher: MDPI
                ISSN (Electronic): 2227-9032
                Publication date (Electronic): 09 December 2018
                Publication date Collection: December 2018
                Volume: 6
                Issue: 4
                Electronic Location Identifier: 145
                Affiliations
                [1 ]Respiratory Medicine & Physiology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B95SS, UK; s-trethewey@ 123456doctors.org.uk (S.P.T.); a.m.turner@ 123456bham.ac.uk (A.M.T.)
                [2 ]Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham B152TH, UK; r.edgar@ 123456bham.ac.uk
                [3 ]Institute of Applied Health Research, University of Birmingham, Birmingham B152TT, UK
                [4 ]Institute of Clinical Sciences, University of Birmingham, Birmingham B152TT, UK
                Author notes
                [* ]Correspondence: rmukherjee@ 123456doctors.org.uk ; Tel.: +44-0-121-424-3744
                Author information
                https://orcid.org/0000-0003-0150-2283
                https://orcid.org/0000-0002-5971-3035
                Article
                Publisher ID: healthcare-06-00145
                DOI: 10.3390/healthcare6040145
                PMC ID: 6315392
                PubMed ID: 30544857
                SO-VID: cd0a7881-873d-4f4a-9ac2-188eaa88d8bc
                Copyright © © 2018 by the authors.
                License:

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 02 November 2018
                Date accepted : 07 December 2018
                Categories
                Subject: Review

                Keywords: chronic obstructive pulmonary disease,copd,acute exacerbation,non-invasive ventilation,niv,ward-based,do not intubate,ceiling of treatment,mortality,uk
                Data availability:
                Keywords: chronic obstructive pulmonary disease, copd, acute exacerbation, non-invasive ventilation, niv, ward-based, do not intubate, ceiling of treatment, mortality, uk

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