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NONINVASIVE VENTILATION FOR ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Citation/s:
Noninvasive Ventilation for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 1995; 333(13):817-22
 

Lead author's name and fax: Brochard L

Three-part Clinical Question:

1) Patients - exacerbations of COAD

2) Treatment - Non invasive ventilation

3) Outcome - avoiding intubation, reducing hospital stay and mortality

Search Terms: NIV, noninvasive ventliation, COAD, COPD, exacerbation

The Study:
Non-blinded concealed randomised controlled trial with intention-to-treat.

The Study Patients: Patients admitted to ITU with COAD and a respiratory acidosis

Control group (N = 42; 42 analysed): Patients received standard care with oxygen limites to 5 litres by nasal prongs, and medications including heparin , antibiotic agents, bronchodilators and correction of electrolytes.

Experimental group (N = 43; 43 analysed): Patients received the same medication as above with the addition of non-invasive ventilation

The Evidence:

Comments:
A well conducted randomised control trial. However it was not blinded due to the nature of the intervention and was thus open to bias. In addition I have reservations about the equal treatment of the control and experimental group in that the control group was limited to 5 litres of oxygen whereas the experimental group was not. Hypoxia was a minor criteria for intubation

EBM questions:

1) Do the methods allow adequate testing of the hypothesis? - yes; a well designed and conducted study

2) Do the statistical tests correctly test the results to allow differentiation of statistically significant result? - the tests stated seem correct but are not repeatable by me to confirm a significant result

3) Are conclusions valid in light of results? - Yes in light of p value for intubation, hospital mortality and complications

4) Did results get omitted and why? - no; all results were present on an intention to treat basis

5) Did they suggest areas of further research? -no

6) Did they make recommendations based on results and were they appropriate? - no

7) Is this study relevant to my clinical practice? - yes as it suggests the avoidance of intubation by NIV is possible in a group of patients with COAD and this will have an effect on survival. However the amonut of difference may not be as large in my patients as the local standard treatment would include more oxygen

8) What level of evidence does this study represent? – 1^-

9) What grade of recommendation can I make on this result alone? - B

10) Should I change my practice because of theses results? - Yes, I should consider the use of NIV in patients presenting with acute exacerbations of COAD with respiratory acidosis

11) Should I audit my current practice because of these results? - Yes, I need to consider the range of conditions with physiological variables we are currently using NIV for and their outcomes. I should also audit COAD patients who are intubated to ensure the opportunity to have received NIV has not been missed

Conclusions:

NIV should be used in patients in Scotland who present with exacerbations of COAD with respiratory acidosis if there are no contraindications

Appraised by: Michael MacMillan Mhmacmillan@aol.com ; 05 August 2004
Email: Mhmacmillan@aol.com

Kill or Update By: Aug 2007

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 ©2004 Scottish Intensive Care Society Evidence-Based Medicine Group