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      Noninvasive mechanical ventilation on the ward for severe COPD: still unresolved question of balance among safety and drawbacks?

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          Abstract

          Dear editor, We read with interest the study by Yalcinsoy et al1 appreciating its relevance and clinical practice value. In the last decades, noninvasive ventilation (NIV) has revolutionized the management of acute respiratory failure (ARF) reducing the need for endotracheal intubation and its associated complications and also reducing the complications associated with a stay in the intensive care unit, the length of hospital stay, and mortality.2 Several studies investigated the factors associated with NIV failure in order to identify the high-risk subset of patients who are likely to fail a trial of NIV. Moreover, NIV has been proven as an effective modality in the management of ARF with a success rate significantly higher for ARF due to chronic obstructive pulmonary disease (COPD) than other causes of ARF.3 The work of Yalcinsoy et al1 reported the effectiveness of NIV in moderate and severe ARF from COPD treated on respiratory wards. As observed in other studies, the factors predicting success or failure with NIV in hypercapnic respiratory failure include pH at admission, pH after 1 hour of NIV trial, and severity of underlying illness.3–5 This study,1 as well as confirming the success of treatment with NIV for COPD patients with moderate and severe ARF, has interestingly pointed out the predictive value for NIV failure of delta pH value <0.30 and pH <7.31 after 2 hours of NIV application, rather than the initial values of pH. This result may support the need to try initially an NIV treatment in almost all patients with moderate and severe ARF and assess the effectiveness after 1 or 2 hours. We consider that some key points are needed to consider for a proper clinical extrapolation. First, a limitation of this retrospective study is the unavailability of the severity of the underlying illness as assessed by the APACHE II score or similar scoring systems, as predictors of NIV failure.5 Second, regarding the severity of acidosis and gas exchange: intriguing data not reported in the study involve the onset of hypercapnia – acute or chronic. Yalcinsoy et al report the efficacy of NIV on acidosis seems to be better in patients treated with NIV at home (~50%). However, in this study, nonresponders patients have values of pCO2 (76.8) higher than responders (69.6), compared with pH values that are similar (7.26 vs 7.27). Is it only a matter of adaptation to the NIV? In addition, initial values of bicarbonates and their change over time are not reported. It could be relevant to know the authors’ opinion about the potential role of bicarbonate and creatinine values and their variation over next time in identifying NIV success.6 Third, another discussed and interesting confirmation of the study is the relationship between reasons of ARF and NIV response. Comorbidities and reasons of ARF result are not significant in the NIV success or failure.1 We strongly agree with the authors about experienced staff being essential in achieving an NIV success in patients with ARF, evaluating failure criteria after a few hours, and applying the possible corrections in ventilation parameters for improved adaptation of the patient. In real-life setting, the use of the NIV in patients with ARF and severe acidosis is greatly increased in the respiratory ward.7 So, it is crucial to identify in a few hours patients at risk of NIV failure or intubation through the assessment of practical and fast clinical parameters. Further clinical trials need to define a solid tool for NIV applications for severe COPD in wards.

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          Most cited references 6

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          Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study.

          In patients with hypoxemic acute respiratory failure (ARF), randomized studies have shown noninvasive positive pressure ventilation (NPPV) to be associated with lower rates of endotracheal intubation. In these patients, predictors of NPPV failure are not well characterized. To investigate variables predictive of NPPV failure in patients with hypoxemic ARF. Prospective, multicenter cohort study. Eight Intensive Care Units (ICU) in Europe and USA. Of 5,847 patients admitted between October 1996 and December 1998, 2,770 met criteria for hypoxemic ARF. Of these, 2,416 were already intubated and 354 were eligible for the study. NPPV failed in 30% (108/354) of patients. The highest intubation rate was observed in patients with ARDS (51%) or community-acquired pneumonia (50%). The lowest intubation rate was observed in patients with cardiogenic pulmonary edema (10%) and pulmonary contusion (18%). Multivariate analysis identified age > 40 years (OR 1.72, 95% CI 0.92-3.23), a simplified acute physiologic score (SAPS II) > or = 35 (OR 1.81, 95% CI 1.07-3.06), the presence of ARDS or community-acquired pneumonia (OR 3.75, 95% CI 2.25-6.24), and a PaO2:FiO2 < or = 146 after 1 h of NPPV (OR 2.51, 95% CI 1.45-4.35) as factors independently associated with failure of NPPV. Patients requiring intubation had a longer duration of ICU stay ( P < 0.001), higher rates of ventilator-associated pneumonia and septic complications ( P < 0.001), and a higher ICU mortality ( P < 0.001). In hypoxemic ARF, NPPV can be successful in selected populations. When patients have a higher severity score, an older age, ARDS or pneumonia, or fail to improve after 1 h of treatment, the risk of failure is higher.
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            Noninvasive positive pressure ventilation in acute respiratory failure due to COPD vs other causes: Effectiveness and predictors of failure in a respiratory ICU in North India

            Objectives To determine the effectiveness of noninvasive positive pressure ventilation (NIPPV), and the factors predicting failure of NIPPV in acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) versus other causes of ARF. Patients and methods This was a prospective observational study and all patients with ARF requiring NIPPV over a one-and-a-half year period were enrolled in the study. We recorded the etiology of ARF and prospectively collected the data for heart rate, respiratory rate, arterial blood gases (pH, partial pressure of oxygen in the arterial blood [PaO2], partial pressure of carbon dioxide in arterial blood [PaCO2]) at baseline, one and four hours. The patients were further classified into two groups based on the etiology of ARF as COPD–ARF and ARF due to other causes. The primary outcome was the need for endotracheal intubation during the intensive care unit (ICU) stay. Results During the study period, 248 patients were admitted in the ICU and of these 63 (25.4%; 24, COPD–ARF, 39, ARF due to other causes; 40 male and 23 female patients; mean [standard deviation] age of 45.7 [16.6] years) patients were initiated on NIPPV. Patients with ARF secondary to COPD were older, had higher APACHE II scores, lower respiratory rates, levels compared to other causes of ARF. After one hour there was lower pH and higher PaCO2 levels with increase a significant decrease in respiratory rate and heart rate and decline in PaCO2 levels in patients successfully managed with NIPPV. However, there was no in pH and PaO2 difference in improvement of clinical and blood gas parameters between the two groups except at one hour which was significantly the rate of decline of pH at one and four hours and PaCO2 faster in the COPD group. NIPPV failures were significantly higher in ARF due to other causes (15/39) than in ARF–COPD (3/24) (p = 0.03). The mean ICU and hospital stay and the hospital mortality were similar in the two groups. In the multivariate logistic regression model (after and adjusting for gender, APACHE II scores and improvement in respiratory rate, pH, PaO2 at one hour) only the etiology of ARF, ie, ARF–COPD, was associated with a decreased PaCO2 risk of NIPPV failure (odds ratio 0.23; 95% confidence interval, 0.58–0.9). Conclusions NIPPV is more effective in preventing endotracheal intubation in ARF due to COPD than other causes, and the etiology of ARF is an important predictor of NIPPV failure.
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              Utility of respiratory ward-based NIV in acidotic hypercapnic respiratory failure.

              We sought to elicit predictors of in-hospital mortality for first and subsequent admissions with acidotic hypercapnic respiratory failure (AHRF) in a cohort of chronic obstructive pulmonary disease patients who have undergone ward-based non-invasive ventilation (NIV), and identify features associated with long-term survival.
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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
                2016
                19 September 2016
                : 11
                : 2209-2210
                Affiliations
                [1 ]Department of Cardiovascular and Respiratory diseases, Sapienza University of Rome, Rome, Italy
                [2 ]Intensive Care and Noninvasive Ventilatory Unit, Hospital General Universitario Morales Meseguer, Murcia, Spain
                Author notes
                Correspondence: Angelo Petroianni, Department of Cardiovascular and Respiratory Diseases, Policlinico Umberto I, Sapienza University of Rome Viale del Policlinico 155, 00162 Rome, Italy, Tel +39 06 49979062, Email angelo.petroianni@ 123456uniroma1.it
                Article
                copd-11-2209
                10.2147/COPD.S117861
                5034906
                © 2016 Petroianni and Esquinas. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Letter

                Respiratory medicine

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