Noninvasive positive-pressure ventilation for acute exacerbation of chronic obstructive pulmonary disease
Sübutlu məlumatların xülasələri
18.09.2017 • Sonuncu dəyişiklik 18.09.2017
Editors
Non-invasive positive pressure ventilation (NIV) is effective in decreasing death, need for intubation and treatment failure in patients with acute exacerbations of chronic obstructive pulmonary disease.
A Cochrane review included 17 studies with a total of 1264 patients.
Use of NIV decreased the risk of mortality by 46% (RR 0.54, 95% CI 0.38 to 0.76; N = 12 studies; number needed to treat for an additional beneficial outcome (NNTB 12, 95% CI 9 to 23) and decreased the risk of needing endotracheal intubation by 65% (RR 0.36, 95% CI 0.28 to 0.46; N = 17 studies; NNTB 5, 95% CI 5 to 6).
NIV use was also associated with reduced length of hospital stay (MD -3.39 days, 95% CI -5.93 to -0.85; N = 10 studies), reduced incidence of complications (unrelated to NIV) (RR 0.26, 95% CI 0.13 to 0.53; N = 2 studies), and improvement in pH (MD 0.05, 95% CI 0.02 to 0.07; N = 8 studies) and in partial pressure of oxygen (PaO2) (MD 7.47 mmHg, 95% CI 0.78 to 14.16 mmHg; N = 8 studies) at one hour. A trend towards improvement in PaCO2 was observed, but this finding was not statistically significant (MD -4.62 mmHg, 95% CI -11.05 to 1.80 mmHg; N = 8 studies). Treatment intolerance was significantly greater in the NIV group than in the usual care group (risk difference (RD) 0.11, 95% CI 0.04 to 0.17; N = 6 studies). Results of analysis showed a non-significant trend towards reduction in dyspnoea with NIV compared with usual care (standardised mean difference (SMD) -0.16, 95% CI -0.34 to 0.02; N = 4 studies).
Non-invasive positive pressure ventilation (NPPV) resulted in decreased mortality (RR 0.52; 95% CI 0.35 to 0.76), decreased need for intubation (RR 0.41; 95% CI 0.33 to 0.53), reduction in treatment failure (RR 0.48; 95% CI 0.37 to 0.63), rapid improvement within the first hour in pH (WMD 0.03; 95% CI 0.02 to 0.04), PaCO2 (WMD –0.40 kPa; 95% CI –0.78 to –0.03) and respiratory rate (WMD –3.08 bpm; 95% CI –4.26 to –1.89). In addition, complications associated with treatment (RR 0.38; 95% CI 0.24 to 0.60) and length of hospital stay (WMD –3.24 days; 95% CI –4.42 to – 2.06) were also reduced in the NPPV group.
A systematic review
including 15 studies with a total of 636 subjects was abstracted in DARE. In comparison with standard therapy alone, NPPV significantly reduced in-hospital mortality (risk difference RD 10%, 95% CI 5 to 15; 11 RCTs, 629 patients), the rate of endotracheal intubation (RD 28%, 95% CI 15 to 40; 13 RCTs, 654 patients), and the length of hospital stay (WMD 4.57 days, 95% CI 2.30 to 6.83; 9 RCTs, 340 patients). In the two latter comparisons, statistically significant heterogeneity was detected (P<0.001). In planned subgroup analyses of patients with severe COPD exacerbations, NPPV significantly reduced in-hospital mortality (RD 12%, 95% CI 6 to 18), rate of endotracheal intubation (RD 34, 95% CI 22 to 46) and length of hospital stay (WMD 5.59 days, 95% CI 3.66 to 7.52), compared with standard therapy alone, based on 9 RCTs. In patients with nonsevere exacerbations, there was no significant difference between treatments, based on 2 RCTs with 72 patients.
Another systematic review
including 8 RCTs and 3 case series was abstracted in DARE. For patients presenting with acute exacerbation of COPD, pooled data from 6 RCTs showed a decrease in hospital mortality (OR 0.22, 95% CI 0.09 to 0.54) and endotracheal intubation (OR 0.12, 95% CI 0.05 to 0.29). In one RCT including mild exacerbations (n=24) no patient required intubation. Only 1 RCT and 3 case series (n=28) reported use of noninvasive ventilation in acute asthmatic attack, with no clear results.
A third systematic review
including 7 RCTs with a total of 286 subjects with acute respiratory failure, with or without chronic obstructive pulmonary disease (COPD), was abstracted in DARE. Using data from 5 RCTs (4 full reports, 1 abstract) the summary odds ratio for total mortality was 0.29 (95% CI 0.15 to 0.59). Using data from 5 RCTs (3 full reports, 2 abstracts) the odds ratio for need for endotracheal intubation was 0.20 (95% CI 0.11 to 0.36). If COPD patients were analysed separately, the odds ratio was 0.12 (95% CI 0.05 to
0.29), while it was 0.77 (95% CI 0.23 to 2.55) for non-COPD patients.
Ədəbiyyat
- Osadnik CR, Tee VS, Carson-Chahhoud KV et al. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017;(7):CD004104. .
Keenan SP, Sinuff T, Cook DJ, Hill NS. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med 2003 Jun 3;138(11):861-70.
Keenan SP, Brake D. An evidence-based approach to noninvasive ventilation in acute respiratory failure. Crit Care Clin 1998 Jul;14(3):359-72.
Keenan SP, Kernerman PD, Cook DJ, Martin CM, McCormack D, Sibbald WJ. Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis. Crit Care Med 1997 Oct;25(10):1685-92.