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1 Medical Intensive Care Unit, Henri Mondor Hospital, Assistance Publique-Hôspitaux de Paris, Paris XII Université and Institut National de la Santé et de la Recherche Médicale Unit 492, Créteil, France. 2 Intensive Care Unit, Sant Pau Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain. 3 Consultant Physician, St James's University Hospital, Beckett Street, Leeds, UK
CORRESPONDENCE: L. Brochard, Service de Réanimation Médicale, Hôpital Henri Mondor, 94010, Créteil Cedex, France. Fax: 33 142079943. E-mail: laurent.brochard@hmn.ap-hop-paris.fr
Keywords: intensive care, invasive ventilation, noninvasive ventilation, respiratory failure
Received: June 13, 2001
Accepted November 14, 2001
Abstract
Noninvasive ventilation (NIV) has emerged as a significant advance in the management of respiratory failure. There is now a wide body of prospective randomized-controlled trial data to support its use, particularly in the management of patients with acute or respiratory failure due to exacerbations of chronic obstructive pulmonary disease (COPD). Its successful application results in a more rapid resolution of the physiological derangements, reduces the need for intubation and, in larger studies, improves survival. A reduction in the number of infectious complications is a particular advantage.
In patients with acute exacerbations of COPD there is evidence of benefit when NIV is introduced earlier in the course of the illness than would be the case for invasive ventilation and it should now be considered even with mild acidosis (pH<7.35) and tachypnoea (respiratory rate >23 breaths·min–1) after initial medical therapy.
There is less clinical-trial data in patients with hypoxaemic respiratory failure, but again as with COPD those with less severe physiological disturbance are more likely to benefit. By contrast noninvasive continuous positive airways pressure, while being widely used has not been shown to reduce the need for intubation or to improve survival in patients with hypoxaemic respiratory failure, with the exception of acute cardiogenic pulmonary oedema.
Noninvasive ventilation has been a real advance in the treatment of the critically ill. Most of the studies published to date, have excluded patients needing immediate intubation and it should be viewed as a complimentary technique rather than an alternative to invasive ventilation. It is best viewed as a means of preventing the need for endotracheal intubation and as a result should be introduced earlier than would be the case for invasive ventilation.
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