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COPD Exacerbations:Significance, Assessment, and Current Management
 

COPD Exacerbations: Significance, Assessment, and Current Management

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  • Dear Professor,

    Dear,Professor,
    I think that your topic is very complete et useful. Could you please allowed me to get this your presentation, I would like to share your precious et wonderful knowledges for my students about management of COPD and acute exacerbations.
    Thank you very much,
    Thanh-Phuong Nguyen-Hoang, M.D., M,S,C,
    Respiratory Department, Nguyen Tri Phuong Hospital, HoChiMinh city, VietNam
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  • Dear, Sir
    Could you please allowed me to get this ppt , I have to present case about COPD exacerbation and your ppt is wonderful, complete and full of knowledge.
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    COPD Exacerbations:Significance, Assessment, and Current Management COPD Exacerbations: Significance, Assessment, and Current Management Presentation Transcript

    • David J Pierson MD Professor of Medicine University of Washington Seattle, WA, USA December, 2008 COPD Exacerbations: Significance, Assessment, and Current Management
    • COPD Exacerbations
      • What is an exacerbation, and why are they important?
      • Diagnosis and assessment of severity
      • When and how to use bronchodilators, corticosteroids, and antibiotics
      • Oxygen therapy in the acute setting
      • When to use noninvasive ventilation
    • What Is an Exacerbation, and Why Are They Important?
      • Definition: a sustained worsening of the patient’s symptoms from his or her usual stable state that is beyond normal day-to-day variation and acute in onset
        • Onset usually over 1 to 3 days
        • Term should not be used for other acute processes occurring in a COPD patient
      • 750,000 hospitalizations annually in US
      • Mannino DM, Respir Care 2003;48(12):1185-91
      • Account for ~ 70% of direct medical costs for COPD Sullivan SD et al, Chest 2000;117(suppl):S5-S9
      • Acute mortality 10-15% www.goldcopd.com
      • Subsequent mortality as high as 40% in first year and 70% at 5 years
      • http://thorax.bmjjournals.com/content/vol59/suppl_1/
      What Is an Exacerbation, and Why Are They Important?
    • Importance of Exacerbations: Lessons from the East London COPD Study*
      • More common than previously thought (2.5-3.0 per year); half not brought to MD’s attention
      • Recovery takes longer than previously thought (PEF not back to baseline at 1 mo in 25%)
      • Faster FEV 1 decline with frequent exacerbations
      • Worse QOL with more frequent exacerbations
      • Early Rx hastens recovery and improves QOL
      * Wedzicha JA. Chest 2002;121(5 Suppl):136S-141S Wedzicha JA et al. Respir Care. 2003;48(12):1204-13
    • Survival after ICU Admission for COPD Exacerbation* *Rivera-Fernandez R et al, Crit Care Med 2006;34(Sep):(e-pub)
      • 742 pts with COPD admitted to 86 ICUs in Spain in 1992-1995
      • 508 admitted because of COPD exacerbations
      • 75% required mechanical ventilation
      • Mortality: In ICU: 23%
        • In hospital: 32%
        • After 6 years: 82%
    • According to Pre-Admission Quality of Life According to Patient Age Survival after ICU Admission for COPD Exacerbation* *Rivera-Fernandez R et al, Crit Care Med 2006;34(Sep):(e-pub)
    • Managing COPD Exacerbations: Performance of 360 US Hospitals vs ACP-ACCP Guidelines* *Lindenaur PK et al, Ann Intern Med 2006;144(12):894-903 ( ~ 70,000 Patients; 2001)
    • Diagnosis and Assessment of Severity
      • Does this patient have COPD?
      • Is it a COPD exacerbation or something else?
      • When to get arterial blood gases, chest X-rays, and other studies
      • When to admit the patient to the hospital
      • Indications for admission to the ICU
    • Does This Patient Have COPD?
      • Only 15% of all smokers have COPD (35-45% in high-risk groups)
      • To be certain of the diagnosis requires spirometry
        • GOLD definition: chronic respiratory symptoms, plus incompletely reversible airflow obstruction (FEV 1 /FVC < 70%) www.goldcopd.com
      • There are other common causes of dyspnea and cough in middle-aged and elderly smokers
    • *Damarla M et al, Respir Care 2006 (Oct);51(10):1120-4. Use of Appropriate Diagnostic Confirmation in COPD vs CHF*
      • 6-month review of patients admitted to Caritas St Elizabeth’s Medical Center (Boston) with primary or secondary diagnosis of either COPD or CHF
      • How many patients had had spirometry or cardiac echo, respectively, to confirm the clinical diagnosis?
      • COPD: 553 patients; CHF: 789 patients
    • *Damarla M et al, Respir Care 2006 (Oct);51(10):1120-4. Use of Appropriate Diagnostic Confirmation in COPD vs CHF (in previous 8 years)*
    • *Damarla M et al, Respir Care 2006 (Oct);51(10):1120-4. Use of Appropriate Diagnostic Confirmation in COPD vs CHF*
      • A large proportion of patients hospitalized with COPD (presumably patients with severe disease) have never had the diagnosis confirmed with spirometry
      • Patients diagnosed with COPD are much less likely to have had the appropriate confirmatory test than patients diagnosed with CHF
      • This is true even for patients with both conditions
    • Is It a COPD Exacerbation or Something Else?
      • Pneumonia
      • Pneumothorax
      • Pulmonary embolism
      • Congestive heart failure/ pulmonary edema
      • Recurrent aspiration
      • Lung Cancer
      • Pleural effusion
    • Indications for Laboratory Evaluation (ABGs, CXR, CBC) in Patients with COPD Exacerbation
      • Recent hospitalization, treatment for exacerbation, or other acute respiratory problem
      • Known very severe COPD (GOLD Stage IV * )
      • Patient on continuous oxygen at home
      • Respiratory symptoms that are new for this patient
      *www.goldcopd.com
    • Indications for Laboratory Evaluation (ABGs, CXR, CBC) in Patients with COPD Exacerbation
      • Marked, sustained increase in patient’s usual degree of dyspnea
      • Inability to speak in complete sentences
      • Pleuritic chest pain
      • Onset of respiratory distress sudden rather than over several hours or days
      • Hemoptysis
    • Indications for Laboratory Evaluation (ABGs, CXR, CBC) in Patients with COPD Exacerbation
      • Altered mental status (new confusion; somnolence or obtundation)
      • Sustained tachypnea (RR > 30 breaths/min)
      • Sustained tachycardia (HR >100 beats/min)
      • Oximetry saturation < 90% on room air or patient’s usual supplemental oxygen
      • Fever (T > 38.3 C)
    • Indications for Laboratory Evaluation (ABGs, CXR, CBC) in Patients with COPD Exacerbation
      • Hypotension (systolic BP < 100 mm Hg or 20% lower than patient’s usual)
      • Arrhythmias (new for this patient, or worse, or different pattern)
      • New or markedly worsened edema
      • Sustained use of accessory muscles of respiration at rest
      • Paradoxical chest/abdominal wall motion
      • Persistence of symptoms and signs listed previously despite initial treatment
      • Respiratory acidosis (eg, pH < 7.35) uncorrected with initial treatment
      • Presence of a complicating acute respiratory process (eg, pneumonia, pneumothorax)
      • Diagnostic uncertainty
      • Presence of significant comorbidities
      Indications for Hospital Admission in Patients with COPD Exacerbation
      • Severe impairment of activities of daily living
      • Significant recent decline in overall condition
      • Inability to eat or sleep because of ongoing respiratory symptoms
      • Older age
      • Need for therapy that cannot be provided in the home
      • Insufficient home support
      Indications for Hospital Admission in Patients with COPD Exacerbation
      • Need for NPPV, especially in initial hours of management
      • Need for invasive ventilatory support
      • Persistence of severe dyspnea, tachypnea, or tachycardia despite initial therapy
      Which Patients Should Be Admitted to the ICU?
      • Persistence of confusion, somnolence, or obtundation
        • Inability to deliver necessary therapy
        • Higher likelihood of deterioration
      • Persistence of severe hypoxemia (eg, need for > 40% O 2 )
      • Persistence (or worsening) of respiratory acidosis (eg, elevated PCO 2 with pH < 7.30)
      Which Patients Should Be Admitted to the ICU?
    • Respiratory Arrest
      • An All-Too-Common Scenario:
      • COPD Pt with exacerbation
      • Admitted to floor & worked up
      • Standard therapy begun
      • OK when last checked, but then…
    • Sudden Development vs Sudden Discovery Tachypnea Characteristic EMG Changes Paradoxical Respiration Respiratory Alternans CO 2 Retention Bradypnea Respiratory Arrest
    • COPD Exacerbations
      • What is an exacerbation, and why are they important?
      • Diagnosis and assessment of severity
      • When and how to use bronchodilators, corticosteroids, and antibiotics
      • Oxygen therapy in the acute setting
      • When to use noninvasive ventilation
    • Bronchodilator Therapy in COPD Exacerbations
      • Most studies have been done in:
        • Acute asthma, not COPD
        • ED, with short-term outcomes
      • Inhaled (vs parenteral) beta-agonists give equivalent benefit with fewer adverse effects
      • MDI + spacer is equivalent to nebulizer:
        • In stable COPD
        • In stable & acute asthma, in children and adults
        • In intubated patients
    • *McCrory DC et al, Cochrane Reviews 2003(1):CD003900 Ipratropium vs Beta-Agonist in COPD Exacerbations : Meta-Analysis of RCTs*
    • *McCrory DC et al, Cochrane Reviews 2003(1):CD003900 Beta-Agonist +/- Ipratropium in COPD Exacerbations : Meta-Analysis of RCTs*
    • *McCrory DC et al, Cochrane Reviews 2003(1):CD003900 Beta-Agonist +/- Ipratropium in COPD Exacerbations : Meta-Analysis of RCTs*
    • Beta-Agonist Administration with MDI+Spacer vs Nebulizer in Adults with Acute Asthma: Improvement in FEV 1 * *Cates CJ et al, Cochrane Reviews 2006(2):CD000052
    • Beta-Agonist Administration with MDI+Spacer vs Nebulizer in Adults with Acute Asthma: Hospital Admission* *Cates CJ et al, Cochrane Reviews 2006(2):CD000052
    • *McCrory DC et al, Cochrane Reviews 2003(1):CD003900 Ipratropium vs Beta-Agonist and Their Combination in COPD Exacerbations*
      • Meta-analysis of RCTs examining FEV 1 short-term and at 24h, PaO 2 , and side-effects of:
        • β -agonist vs ipratropium
        • β -agonist with and without ipratropium
      • No differences in any measure examined
    • Bronchodilators in COPD Exacerbations: Current GOLD Recommendation*
      • Short-acting inhaled β 2 -agonists are the primary therapy.
      • Short-acting inhaled anticholinergics are recommended if poor response.
      • Methylxanthines (theophylline) are optional.
      • There is no current role for long-acting β 2 -agonists, with or without inhaled corticosteroids.
      *www.goldcopd.com
    • Corticosteroids In COPD Exacerbations
    • *Albert RK, Martin TR, Lewis SW. Ann Intern Med 1980;92:753-758 Systemic Corticosteroids in COPD Exacerbations: The Albert Study*
      • 44 pts admitted to Seattle VA with exacerbations
      • FEV 1 < 60% pred or FEV 1 /FVC < 60%
      • PaO 2 < 65 on RA or PaCO 2 > 50 & pH < 7.35
      • Exclusions: asthma, infiltrate, recent steroids
      • Methylprednisolone 0.5 mg/kg IVq6h vs placebo
      • All pts got aminophylline, isoproterenol, ABX
      • Duration: 72 hrs
      • Outcomes: pre/post BD FEV 1 , ABGs, glucose
    • *Albert RK, Martin TR, Lewis SW. Ann Intern Med 1980;92:753-758 Systemic Corticosteroids in COPD Exacerbations: The Albert Study*
      • Greater improvement in both pre- and post-BD FEV 1 in steroid group (p < 0.001)
      • More patients with increases in FEV 1 of 40% or more in steroid group (p < 0.01)
      • 2 pts died, 1 psychosis, 1 UGI bleed (all in steroid group); 1 UGI bleed in placebo group
      • Conclusion: IV methylprednisolone improves airflow more than placebo in COPD exacerbations.
    • Systemic Corticosteroids in COPD Exacerbations: The Thompson Study* *Thompson WH et al, AJRCCM 1996 Aug;154(2 Pt 1):407-12
      • 27 Boise VA outpatients with exacerbations
      • FEV 1 < 60% pred or post-BD FEV 1 /FVC < 65%
      • Acute resp Sx for > 24h prompting hospital visit
      • Exclusions: asthma, other lung disease, CHF, recent steroid Rx, T > 38.5, pH < 7.35
      • Prednisone 60 mg qd x 3d, then 40 mg qd x 3d, then 20 mg qd x 3d (vs vitamin B6 x 9d)
      • Usual meds, ABX only if infection on gram stain
      • Outcomes: spirometry; dyspnea (VAS), ABGs, Rx failure (hospitalization or prednisone)
    • Systemic Corticosteroids in COPD Exacerbations: The Thompson Study* *Thompson WH et al, AJRCCM 1996 Aug;154(2 Pt 1):407-12
      • More rapid improvement in oxygenation
        • PaO 2 : 1.12 mm Hg/d vs -0.03 mm Hg/day; p = 0.002
        • P(A-a)O 2 : 1.16 mm Hg/d vs -0.03 mm Hg/d; p = 0.04
      • More rapid improvement in airflow
        • FEV 1 : 50 mL/d vs 0 mL/d, p = 0.006
        • PEF: 0.15 L/s/d vs 0.04 L/s/d, p = 0.009
      • Fewer treatment failures (p = 0.002)
      • Trend toward more rapid improvement in dyspnea scores
    • *Wood-Baker RR et al, Cochrane Reviews 2005(1):CD001288 Systemic Corticosteroids in COPD Exacerbations: Meta-Analysis of RCTs*
      • 10 good-quality studies (951 pts) as of 2005
      • Effects of Steroids (vs placebo, other Rx same):
        • Fewer treatment failures within 30 days (Odds ratio = 0.48; Number needed to treat = 9)
        • More rapid FEV 1 improvement (WMD 140 mL @ 72 h)
        • Significant improvement in dyspnea and ABGs
        • No difference in mortality
        • Increased likelihood of adverse drug effect (OR 2.29; NNH = 6); hyperglycemia most likely (OR 5.48)
    • *Wood-Baker RR et al, Cochrane Reviews 2005(1):CD001288 Management of COPD Exacerbation: Effect of Steroids on Early FEV 1 *
    • *Wood-Baker RR et al, Cochrane Reviews 2005(1):CD001288 Management of COPD Exacerbation: Effect of Steroids on Treatment Failure*
    • Wood-Baker RR et al, Cochrane Reviews 2005(1):CD001288
    • Wood-Baker RR et al, Cochrane Reviews 2005(1):CD001288
    • Corticosteroids in COPD Exacerbations: Current GOLD Recommendation*
      • Recommended for hospitalized patients, and for home management if baseline FEV 1 < 50% predicted
      • Prednisone 30-40 mg/d for 7-10 days is effective; no benefit but  side effects with longer courses
      • Possible advantages of higher doses and/or parenteral administration unknown
      *www.goldcopd.com
    • Antibiotics In COPD Exacerbations
    • *Anthonisen NR et al, Ann Intern Med 1987;106:196-204 Antibiotics in COPD Exacerbations: The Anthonisen Study*
      • 362 exacerbations in 173 patients over 3.5-yrs
      • Randomized, double-blind, crossover trial
      • Rx with antibiotics (182 episodes) or placebo (180 episodes), plus usual therapy
      • Exacerbation severity:
        • Type 1: Increased dyspnea, increased sputum
        • volume, and increased sputum purulence
        • Type 2: Any 2 of the above
        • Type 3: Any 1 of the above
    • *Anthonisen NR et al, Ann Intern Med 1987;106:196-204 Antibiotics in COPD Exacerbations: The Anthonisen Study*
      • 362 exacerbations in 173 COPD patients over 3.5-yr period
      • Randomized, double-blind, crossover trial
      • Rx with antibiotics (182 episodes) or placebo (180 episodes), plus usual therapy
      • Successful Rx (as defined): 68% vs 55%
      • Rx failure with deterioration: 10% vs 19%
      • No difference in adverse effects
    • Efficacy of Antibiotics According to Exacerbation Severity* *Anthonisen NR et al, Ann Intern Med 1987;106:196-204
    • *Anthonisen NR et al, Ann Intern Med 1987;106:196-204 Treatment Failure with Deterioration According to Exacerbation Severity*
    • *Ram FSF et al, Cochrane Reviews 2006(2):CD004403 Antibiotics in COPD Exacerbations: Meta-Analysis of RCTs*
    • Antibiotics vs Placebo in Managing COPD Exacerbations: Mortality in Best-Designed RCTs* *Ram FSF et al, Cochrane Reviews 2006(2):CD004403
    • RCTs of Antibiotics in COPD Exacerbations: Hospitalized Patients vs Outpatients* *Ram FSF et al, Cochrane Reviews 2006(2):CD004403
    • *Ram FSF et al, Cochrane Reviews 2006(2):CD004403 Antibiotics vs Placebo in COPD Exacerbations: Short-Term Mortality*
    • *Ram FSF et al, Cochrane Reviews 2006(2):CD004403 Antibiotics vs Placebo in COPD Exacerbations: Treatment Failure*
    • Antibiotics in COPD Exacerbations: Current GOLD Recommendation*
      • Anthonisen Type 1 exacerbation (  dyspnea,  sputum volume,  sputum purulence)—and also Type 2 (?)
      • Severe exacerbation requiring NPPV
      • Should cover most likely organisms
        • S. pneumoniae
        • H. influenzae
        • M. catarrhalis
      *www.goldcopd.com
    • COPD Exacerbations
      • What is an exacerbation, and why are they important?
      • Diagnosis and assessment of severity
      • When and how to use bronchodilators, corticosteroids, and antibiotics
      • Oxygen therapy in the acute setting
      • When to use noninvasive ventilation
      • What is the physiologic mechanism?
      • Which patients are most at risk?
      • How big a problem is it?
      • What should we do about it?
      CO 2 Retention and Oxygen Therapy In COPD
    • RCT of High vs Low PaO 2 Targets in Managing COPD Exacerbations*
      • 34 pts with COPD exacerbations (RA PO 2 <50, PCO 2 >50) admitted to ICU
      • Randomized for O 2 titration to PO 2 50-70 or >70 mm Hg
      • 2 pts in low-O 2 group required MV; 1 died
      • No pts in high-O 2 group had bad outcome
      • No statistically significant differences
      • Conclude that traditional teaching to avoid over-oxygenation may be wrong
      *Gomersall CD et al, Crit Care Med 2002;30(1):113-6
    • RCT of High vs Low PaO 2 Targets in Managing COPD Exacerbations*
      • Several study design problems
      • Under-powered
      • Other differences in pt management (use of doxapram, etc)
      • Only RCT on this published to date
      *Gomersall CD et al, Crit Care Med 2002;30(1):113-6
    • Does Injudicious Oxygen Administration Cause Respiratory Acidosis?*
      • 1-yr prevalence study of COPD exacerbations
      • 983 admissions to 3 hospitals in Leeds
      • 918 (95%) had ABG on admission
      • 47% were hypercapnic and 20% were acidemic (pH < 7.35)
      • Pts with highest initial PO 2 tended to be more acidemic
      *Plant PK et al, Thorax 2000;55:550-4
    • Patients with Higher Initial PaO 2 Tended to Have More Severe Acidemia* (Assumption is that they received too much O 2 initially) *Plant PK et al, Thorax 2000;55:550-4 < 55 55-75 75-100 > 100 Initial PaO 2 (mm Hg)
      • 22 COPD pts hospitalized with exacerbations
      • Mean FEV 1 0.75 L (30% pred)
      • Studied within 72 h of admission
      • ABGs, Cardiac output, and V/Q distributions (MIGET) determined on RA and after 20 min breathing 100% O 2
      * CO 2 Retention with O 2 Therapy in COPD Exacerbations: What Causes It?* *Robinson TD et al, AJRCCM 2000;161:1524-9
      • 10 pts had < 3 mm Hg rise (non-retainers)
      • 12 pts had > 3 mm Hg PCO 2 rise (retainers)
      • Minute ventilation fell in retainers (from 9.0 to 7.2 L/min) but not in nonretainers
      • V distribution in relation to Q became more deranged while breathing 100% O 2 in the retainers than in the non-retainers
      • Retainers had higher Bohr deadspace on O 2
      CO 2 Retention with O 2 Therapy in COPD Exacerbations: What Causes It?* *Robinson TD et al, AJRCCM 2000;161:1524-9
      • 22 COPD pts hospitalized with exacerbations
      • Mean FEV 1 0.75 L (30% pred)
      • Studied within 72 h of admission
      • ABGs on RA and after 20 min on 100% O 2
      • 10 pts had < 3 mm Hg rise (non-retainers)
      • 12 pts had > 3 mm Hg PCO 2 rise (retainers)
        • PO 2 : 54 on RA, 371 on 100% O 2
        • PCO 2 : 56 on RA, 65 on 100%O 2
      *Robinson TD et al, AJRCCM 2000;161:1524-9 CO 2 Retention with O 2 Therapy in COPD Exacerbations: How Big a Problem?*
      • 24 consecutive pts in ED with exacerbation
      • Median age 71; FEV 1 37% pred (26-49%)
      • Mean presenting PO 2 46, PCO 2 56
      • Given O 2 by 24-40% Venturi mask to keep SpO 2 90-91%
      • ABGs repeated in 2 hr & regularly thereafter
      *Moloney ED et al, Lancet 2001;357:526-8 Clinically Important CO 2 Retention with Controlled Oxygen Therapy: How Often Does It Happen?*
      • Arterial PCO 2 rose more than 7.5 mm Hg in only 3 of 24 pts
      • Arterial pH fell below 7.25 in only 1 pt
      • No pt developed CO 2 narcosis or required assisted ventilation
      • Further PCO 2 rise did not occur after initial 2 hr
      • Pts with higher initial PCO 2 tended to have greater PCO 2 rises in with O 2 therapy
      *Moloney ED et al, Lancet 2001;357:526-8 Clinically Important CO 2 Retention with Controlled Oxygen Therapy: How Often Does It Happen?*
    • *Moloney ED et al, Lancet 2001;357:526-8 45 55 65 75 mm Hg 30 15 0 15 30 Changes in PCO 2 with Oxygen Therapy When SpO 2 is kept at 90-91%* PCO 2 Change vs Initial PCO 2 PCO 2 Change vs Initial pH
      • Depression of hypoxic ventilatory drive
      • Increased mismatching of ventilation and perfusion
      • Haldane effect
        • Saturation of hemoglobin with oxygen reduces CO 2 -carrying capacity of blood
      CO 2 Retention and Oxygen Therapy In COPD: Physiologic Mechanisms
      • There are probably several mechanisms.
      • It is only a threat when patients are acutely ill.
      • It happens in only a minority of patients.
      • It can be avoided by keeping SpO 2 90-92%.
      • Hypoxemia should not be allowed to persist because of fear of CO 2 narcosis and acidosis.
      • The goal is to get SpO 2 to 90% (PO 2 60 mm Hg) in all patients.
      CO 2 Retention and Oxygen Therapy In COPD: The Bottom Line
      • Pulse oximetry alone is not enough, in any potentially severe exacerbation
      • Presence and severity of acute-on-chronic respiratory acidosis is important, both prognostically and therapeutically
      • Must use ABGs in initial assessment, and also in initial monitoring of O 2 therapy (eg, at 30 ’ )
      • Oximetry is valuable for subsequent monitoring once initial response to O 2 is determined
      COPD Exacerbations: Assessment of Oxygenation and Acid-Base Status
    • How Should Oxygen Be Delivered in Managing COPD Exacerbations? Nasal Venturi Cannula Mask Known, constant No (but this Yes (but delivered O 2 may not be not really) concentration? important) Likely to stay Yes No on patient? No need to remove Less well tolerated; for talking, eating, Must come off for aerosol Rx, etc talking, eating, meds Overall effectiveness ++ +
    • COPD Exacerbations
      • What is an exacerbation, and why are they important?
      • Diagnosis and assessment of severity
      • When and how to use bronchodilators, corticosteroids, and antibiotics
      • Oxygen therapy in the acute setting
      • When to use noninvasive ventilation
    • *Brochard L et al, NEJM 1995;333(13):817-822 NPPV vs Usual Medical Care in Managing COPD Exacerbations *
      • 85 patients (out of 275 screened) admitted to 5 ICUs with COPD exacerbation
      • RR > 30, PO 2 < 45, pH < 7.35 (needed 2)
      • Exclusions: specific respiratory process, comorbidity, need for immediate intubation, unsuitability for NPPV, DNI
      • Randomized to NPPV vs usual Rx
      • PSV 20 (no PEEP) via special face mask
      • Standardized (strict) criteria for intubation
    • *Brochard L et al, NEJM 1995;333(13):817-822 NPPV in COPD Exacerbations : Patient Characteristics & Changes in the 1 st Hour*
    • *Brochard L et al, NEJM 1995;333(13):817-822 NPPV in COPD Exacerbations : Need for Intubation and Other Outcomes*
    • *Brochard L et al, NEJM 1995;333(13):817-822 NPPV in COPD Exacerbations : Timing of Need for Intubation*
    • *Brochard L et al, NEJM 1995;333(13):817-822 NPPV in COPD Exacerbations : Initial Effect on PCO 2 and PO 2 *
    • *Brochard L et al, NEJM 1995;333(13):817-822 NPPV in COPD Exacerbations : Effect on Length of Hospital Stay*
    • *Ram FSF et al, Cochrane Reviews 2004(3):CD004104 NPPV in COPD Exacerbations : Meta-Analysis of Randomized Trials*
      • 14 good-quality studies (758 pts) as of 2003
      • Effects of NPPV (vs usual medical care):
        • Decreases mortality (Relative risk = 0.52; Number needed to treat = 10)
        • Decreases need for intubation (RR 0.41; NNT = 4)
        • Reduces treatment failure (RR 0.48; NNT = 5)
        • Improves pH, PCO 2 , and respiratory rate
        • Decreases Rx-associated complications (RR 0.38)
        • Shortens hospital stay (WMD -3.24 days)
    • *Ram FSF et al, Cochrane Reviews 2004(3):CD004104 NPPV in COPD Exacerbations : Effect on Treatment Failure*
    • *Ram FSF et al, Cochrane Reviews 2004(3):CD004104 NPPV in COPD Exacerbations : Effect on Mortality*
    • *Ram FSF et al, Cochrane Reviews 2004(3):CD004104 Effect of NPPV on Need for Intubation*
    • *Ram FSF et al, Cochrane Reviews 2004(3):CD004104 NPPV in COPD Exacerbations : Effect on Length of Hospital Stay*
    • Adverse Effects of NPPV
      • Inability to ventilate (mask leaks)
      • Inability to tolerate mask (claustrophobia)
      • Eye irritation
      • Dryness of upper airway; rhinitis
      • Facial reddening, pain, or ulceration
      • Gastric distension (aerophagia)
    • *Ram FSF et al, Cochrane Reviews 2004(3):CD004104 NPPV in COPD Exacerbations : Meta-Analysis of Randomized Trials*
      • 14 good-quality studies (758 pts) as of 2003
      • Effects of NPPV (vs usual medical care):
        • Decreases mortality (Relative risk = 0.52; Number needed to treat = 10)
        • Decreases need for intubation (RR 0.41; NNT = 4 )
        • Reduces treatment failure (RR 0.48; NNT = 5 )
        • Improves pH, PCO 2 , and respiratory rate
        • Decreases Rx-associated complications ( RR 0.38 )
        • Shortens hospital stay ( WMD -3.24 days )
    • Trends in NPPV Use, Nosocomial Infections, and ICU Mortality, 1994-2001*
      • text
      *All patients admitted with COPD exacerbation and cardiac pulmonary edema. Girou E et al, JAMA 2003;290:2985-91
    • NPPV in Acute Respiratory Failure: Patient Selection
      • Acute ventilatory failure (  PCO 2 ,  pH)
      • Hypoxemia easily correctable (eg, with 50% oxygen or less)
      • Respiratory distress (eg, tachypnea, accessory muscle use)
    • NPPV in Acute Respiratory Failure: Patient Selection
      • Expected need for ventilatory support not more than 2-3 days
      • Secretions moderate in quantity; patient able to clear them spontaneously
      • Patient hemodynamically stable (no hypotension or serious arrhythmias)
    • NPPV in Acute Respiratory Failure: Patient Selection
      • Intact bulbar function; ability to protect lower airway
      • Patient alert and cooperative
      • Availability of experienced staff and appropriate ICU setting
    • *Confalonieri M et al, Eur Respir J 2005;25:348-55 Predicting NPPV Failure in COPD Exacerbations*
      • Risk stratification assessed in 1,033 consecutive patients (797 successes) in 2 ICUs, 6 special RICUs, and 5 general wards in Italy
      • > 70% likelihood of failure at time of admission:
        • Glasgow Coma Scale score < 11
        • APACHE II > 28
        • Respiratory rate > 30
        • Initial pH < 7.25
      • > 90% likelihood of failure after 2 hours of NPPV:
        • Arterial pH < 7.25
    • *Confalonieri M et al, Eur Respir J 2005;25:348-55 Prospective Validation Cohort Original 1033 Patients Solid = On admission Dashed = After 2 hrs Predicting NPPV Failure in COPD Exacerbations*
      • Results used to construct a risk failure chart
      • Chart validated prospectively on another series of 145 consecutive patients
    • *Confalonieri M et al, Eur Respir J 2005;25:348-55 Predicting NPPV Failure in COPD Exacerbations: Risk of Failure at Time of Presentation*
    • *Confalonieri M et al, Eur Respir J 2005;25:348-55 Predicting NPPV Failure in COPD Exacerbations: Risk of Failure after 2 Hours*
    • *Confalonieri M et al, Eur Respir J 2005;25:348-55 Predicting NPPV Failure in COPD Exacerbations*
    • COPD Exacerbation: Exclusion Criteria for NPPV
      • Respiratory arrest
      • Cardiovascular instability
      • Impaired mental status
      • Uncooperative patient
      • High aspiration risk
      NHLBI/WHO Workshop Report, www.goldcopd.com
      • Viscous or copious secretions
      • Recent facial or gastroesophageal surgery
      • Craniofacial trauma; fixed nasopharyngeal abnormalities
      • Extreme obesity
      COPD Exacerbation: Exclusion Criteria for NPPV NHLBI/WHO Workshop Report, www.goldcopd.com
    • COPD Exacerbations
      • What is an exacerbation, and why are they important?
      • Diagnosis and assessment of severity
      • When and how to use bronchodilators, corticosteroids, and antibiotics
      • Oxygen therapy in the acute setting
      • When to use noninvasive ventilation
      • Respiratory arrest
      • Somnolence; impaired mental status
      • Failure of noninvasive ventilation
      • Severe dyspnea with use of accessory muscles and paradoxical abdominal motion
      • Sustained respiratory rate > 35 breaths/min
      COPD Exacerbation: Indications for Intubation NHLBI/WHO Workshop Report, www.goldcopd.com
      • Life-threatening hypoxemia (PaO 2 < 40 or PaO 2 /FIO 2 < 200)
      • Severe acidosis (pH < 7.25) and hypercapnia (PaCO 2 > 60)
      • Cardiovascular complications (hypotension, shock, heart failure)
      • Other complications (metabolic abnormalities, sepsis, pneumonia, pulmonary embolism, barotrauma, massive pleural effusion)
      COPD Exacerbation: Indications for Intubation NHLBI/WHO Workshop Report, www.goldcopd.com