Which Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Benefit from Noninvasive Positive-Pressure Ventilation?

A Systematic Review of the Literature

3 June 2003 | Volume 138 Issue 11 | Pages 861-870

Background: Over the past decade, noninvasive positive-pressure ventilation (NPPV) in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased in popularity. Although several trials have been published on the relative effectiveness of this treatment, apparent inconsistencies in study results remain.

Purpose: To assess the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality rate in patients with an acute exacerbation of COPD and to determine the effect of exacerbation severity on these outcomes.

Data Sources: MEDLINE (1966 to 2002) and EMBASE (1990 to 2002). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. There were no language restrictions.

Study Selection: The researchers selected randomized, controlled trials that 1) examined patients with acute exacerbation of COPD; 2) compared noninvasive ventilation and standard therapy with standard therapy alone; and 3) included need for endotracheal intubation, length of hospital stay, or hospital survival as an outcome.

Data Extraction: Methodologic quality and results were abstracted independently and in duplicate.

Data Synthesis: The addition of NPPV to standard care in patients with an acute exacerbation of COPD decreased the rate of endotracheal intubation (risk reduction, 28% [95% CI, 15% to 40%]), length of hospital stay (absolute reduction, 4.57 days [CI, 2.30 to 6.83 days]), and in-hospital mortality rate (risk reduction, 10% [CI, 5% to 15%]). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations.

Conclusions: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.

Editors' Notes Context Several randomized, controlled trials have evaluated potential benefits of noninvasive positive-pressure ventilation (NPPV) in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). Contribution This meta-analysis of 15 trials found that adding NPPV to standard care reduced rates of endotracheal intubation, length of hospital stay, and in-hospital mortality rates in patients with severe exacerbations but not in those with milder exacerbations. Implications Noninvasive positive-pressure ventilation should be added to standard medical therapy for patients with severe exacerbations of COPD. –The Editors

 

Author and Article Information

From Royal Columbian Hospital, New Westminster, and St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada; McMaster Faculty of Sciences, Hamilton, Ontario, Canada; and Tufts–New England Medical Center, Boston, Massachusetts.

Grant Support: Dr. Cook is a Critical Care Chair of the Canadian Institute of Health Research. Dr. Sinuff is supported by a Canadian Institute of Health Research Fellowship Award.

Potential Financial Conflicts of Interest:Consultancies: N.S. Hill (ResMed); Honoraria: N.S. Hill (Respironics, Inc., and ResMed); Expert testimony: N.S. Hill (ResMed); Grants received: S.P. Keenan (Respironics, Inc.), N.S. Hill (Respironics, Inc., and ResMed); Grants pending: N.S. Hill (Respironics, Inc., and ResMed).

Requests for Single Reprints: Sean P. Keenan, MD, FRCPC, MSc (Epid), Suite 103, 250 Keary Street, New Westminster, British Columbia V3L 5E7, Canada; e-mail, Sean_Keenan{at}telus.net.

Current Author Addresses: Dr. Keenan: Suite 103, 250 Keary Street, New Westminster, British Columbia V3L 5E7, Canada.

Drs. Sinuff and Cook: Department of Clinical Epidemiology and Biostatistics, McMaster University Medical Centre, Room 2C10, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.

Dr. Hill: Tufts–New England Medical Center, 750 Washington Street, Boston, MA 02111.

Author Contributions: Conception and design: S.P. Keenan, T. Sinuff.

Analysis and interpretation of the data: S.P. Keenan, D.J. Cook.

Drafting of the article: S.P. Keenan, T. Sinuff.

Critical revision of the article for important intellectual content: T. Sinuff, D.J. Cook, N.S. Hill.

Final approval of the article: S.P. Keenan, T. Sinuff, D.J. Cook, N.S. Hill.

Statistical expertise: S.P. Keenan, D.J. Cook.

Collection and assembly of data: S.P. Keenan, T. Sinuff.