Chest
Volume 114, Issue 6, December 1998, Pages 1636-1642
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Clinical Investigations in Critical Care
Comparison of Noninvasive Positive Pressure Ventilation With Standard Medical Therapy in Hypercapnic Acute Respiratory Failure

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Study objective

To compare the efficacy of standard medical therapy (ST) and noninvasive mechanical ventilation additional to standard medical therapy in hypercapnic acute respiratory failure (HARF).

Design

Single center, prospective, randomized, controlled study.

Setting

Pulmonary medicine directed critical care unit in a university hospital.

Patients

Between March 1993 and November 1996, 30 HARF patients were randomized to receive ST or noninvasive positive pressure ventilation (NPPV) in addition to ST.

Interventions

NPPV was given with an air-cushioned face via a mechanical ventilator (Puritan Bennett 7200) with initial setting of 5 cm H2O continuous positive airway pressure and 15 cm H2O pressure support.

Results

At the time of randomization, patients in the ST group had (mean ± SD) Pao2 of 54 ± 13 mm Hg, Paco2 of 67 ± 11 mm Hg, pH of 7.28 ± 0.02, and respiratory rate of 35.0 ± 5.8 breaths/min. Patients in the NPPV group had Pao2 of 55 ± 14, Paco2 of 69 ± 15, pH of 7.27 ± 0.07, and respiratory rate of 34.0 ±8.1 breaths/min. With ST, there was significant improvement of only respiratory rate (p < 0.05). However, with NPPV, Pao2 (p < 0.001), Paco2 (p < 0.001), pH (p < 0.001), and respiratory rate (p < 0.001) improved significantly compared with baseline. Six hours after randomization, pH (p < 0.01) and respiratory rate (p < 0.01) in NPPV patients were significantly better than with ST. Hospital stay for NPPV vs ST patients was, respectively, 11.7 ± 3.5 and 14.6 ± 4.7 days (p < 0.05). One patient in the NPPV group required invasive mechanical ventilation. The conditions of six patients in the ST group deteriorated and they were switched to NPPV; this was successful in four patients, two failures were invasively ventilated.

Conclusion

This study suggests that early application of NPPV in HARF patients facilitates improvement, decreases need for invasive mechanical ventilation, and decreases the duration of hospitalization.

Section snippets

Materials and Methods

Between March 1993 and August 1996, all patients with acute exacerbation of COPD evaluated in the emergency department were considered for the study. The ethics committee of Marmara University Medical Faculty approved the study. Informed consent was obtained from the patients or, if the patient was unable, informed consent was obtained from a first-degree relative.

Patients included into the study were known to have COPD diagnosed on the basis of previous pulmonary function testing (FEV1/FVC <

Results

Thirty patients were enrolled in the study. Fifteen patients were randomized to the ST group and 15 patients to the NPPV plus ST group. Pulmonary function data were available at study initiation in eight of the patients in the ST group and seven of those in the NPPV group. In, respectively, the ST and NPPV groups, pulmonary function data were as follows: FEV1 (1 ± 0.33 L [40% ± 14% of the predicted value], 1.03 ± 0.19 [38% ± 11%]); FVC (1.72 ± 0.82 L [56% ± 18% of predicted], and 2.12 ± 0.46 L

Discussion

With ST, approximately 25% of COPD patients in ARF require mechanical ventilation.18 The application of noninvasive mechanical ventilation for these patients is widely accepted. However, there are, to date and to our knowledge, only four published, prospective and randomized studies comparing noninvasive mechanical ventilation with ST in this situation.15, 16, 17,19 Survival, or avoidance of endotracheal intubation, was significantly better with noninvasive mechanical ventilation in all except

Acknowledgment

The authors thank our medical housestaff, medical ICU nurses for their support of the study, Nural Bekiroglu for statistical analysis, and Joseph Layon, MD, FCCP, for revision of the article.

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