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a Division of
Pneumology, Azienda Ospedaliera Policlinico, Modena, Italy, b Department of Microbiological and Statistical
Sciences, University of Modena, Italy, c Respiratory Intensive Care Unit, Fondazione S
Maugeri, Clinica del Lavoro e della Riabilitazione IRCCS, Istituto
Scientifico di Montescano, Italy, d Fondazione
S Maugeri, Clinica del Lavoro e della Riabilitazione IRCSS, Istituto
Scientifico di Pavia, 27100 Pavia, Italy
Correspondence to: Dr S Nava email: snava{at}fsm.it
Received 5 January 2000; Returned to authors 20 March 2000; Revised version received 17 May 2000; Accepted for publication 20 June 2000
BACKGROUND
The rate of
failure of non-invasive mechanical ventilation (NIMV) in patients with
chronic obstructive pulmonary disease (COPD) with acute respiratory
insufficiency ranges from 5% to 40%. Most of the studies report an
incidence of "late failure" (after >48 hours of NIMV) of about
10-20%. The recognition of this subset of patients is critical
because prolonged application of NIMV may unduly delay the time of intubation.
METHODSIn this
multicentre study the primary aims were to assess the rate of "late
NIMV failure" and possible associated predictive factors; secondary
aims of the study were evaluation of the best ventilatory strategy in
this subset of patients and their outcomes in and out of hospital. The
study was performed in two respiratory intensive care units (ICUs) on
patients with COPD admitted with an episode of hypercapnic respiratory
failure (mean (SD) pH 7.23 (0.07), PaCO2 85.3 (15.8) mm Hg).
RESULTSOne hundred
and thirty seven patients initially responded to NIMV in terms of
objective (arterial blood gas tensions) and subjective improvement.
After 8.4 (2.8) days of NIMV 31 patients (23%; 95% confidence
interval (CI) 18 to 33) experienced a new episode of acute respiratory
failure while still ventilated. The occurrence of "late NIMV
failure" was significantly associated with functional limitations
(ADL scale) before admission to the respiratory ICU, the presence of
medical complications (particularly hyperglycaemia),
and a lower pH on admission. Depending on their willingness or not to
be intubated, the patients received invasive ventilation (n=19) or
"more aggressive" (more hours/day) NIMV (n=12). Eleven (92%) of
those in this latter subgroup died while in the respiratory ICU
compared with 10 (53%) of the patients receiving invasive ventilation.
The overall 90 day mortality was 21% and, after discharge from
hospital, was similar in the "late NIMV failure" group and in
patients who did not experience a second episode of acute respiratory failure.
CONCLUSIONSThe chance
of COPD patients with acute respiratory failure having a second episode
of acute respiratory failure after an initial (first 48 hours)
successful response to NIMV is about 20%. This event is more likely to
occur in patients with more severe functional and clinical disease who
have more complications at the time of admission to the ICU. These
patients have a very poor in-hospital prognosis, especially if NIMV is
continued rather than prompt initiation of invasive ventilation.
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