Francis Whalen, MD
In elderly patients with acute hypercapnic respiratory failure (AHRF), does noninvasive mechanical ventilation (NIV) reduce the need for endotracheal intubation (ETI)?
Randomized controlled trial.
1 hour (primary outcome) and 12 months (mortality).
3 respiratory intensive care units (ICUs) in Italy and Switzerland.
82 patients > 75 years of age (mean age 81 y, 66% men) who were admitted to the ICU with an acute exacerbation of chronic pulmonary disease and developed AHRF (pH < 7.35, PaCO2 > 5.99 KPa, PaO2 < 7.33 KPa, respiratory rate > 20 breaths/min, and severe dyspnea [Borg score ≥ 5] measured while breathing room air). Exclusion criteria were decompensated cardiac disease and other serious comorbid conditions.
NIV (n = 41) vs standard medical therapy (n = 41). For patients meeting ETI criteria at 1 hour, rescue therapy was either ETI or NIV for patients with do-not-intubate (DNI) orders.
Primary outcome was need for ETI at 1 hour (≥ 1 of < 0.01 improvement in pH at 1 and 3 h if pH ≤ 7.30, worsening pH after 1 h if pH ≤ 7.32, PaO2 < 5.99 KPa with oxygen supplementation, ≥ 1-point reduction in Kelly's neurological score, respiratory arrest, loss of consciousness, hemodynamic instability, or loss of alertness; or ≥ 2 of dyspnea [Borg score > 5], respiratory rate > 35 breaths/min, or weak cough reflex with secretions). Secondary outcomes included dyspnea score at 1 hour and mortality at 12 months.
100% at 1 hour; 95% at 12 months (intention-to-treat analysis).
NIV reduced need for ETI and 12-month mortality more than standard therapy (Table). NIV improved dyspnea scores more than standard therapy (score change at 1 h −1 vs −0.4, P = 0.05).
In elderly patients with acute hypercapnic respiratory failure, noninvasive mechanical ventilation reduced the need for endotracheal intubation and mortality more than standard medical therapy.
†ETI = endotracheal intubation; other abbreviations defined in Glossary. RRR, NNT, and CI calculated from control event rates and odds ratios in article.
Francis Whalen. Noninvasive ventilation reduced need for intubation in elderly patients with acute hypercapnic respiratory failure. Ann Intern Med. 2012;156:JC2–2. doi: 10.7326/0003-4819-156-4-201202210-02002
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Published: Ann Intern Med. 2012;156(4):JC2-2.
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