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Eur Respir J 2005; 25:348-355
Copyright ©ERS Journals Ltd 2005

A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation

M. Confalonieri1, G. Garuti2, M. S. Cattaruzza3, J. F. Osborn3, M. Antonelli4, G. Conti4, M. Kodric1, O. Resta5, S. Marchese6, C. Gregoretti7 and A. Rossi on behalf of the Italian noninvasive positive pressure ventilation (NPPV) study group8

1 S.C. Pneumologia, Ospedali Riuniti di Trieste, Trieste, 2 Unità di Pneumologia, Ospedale di Mirandola, Modena, 3 Dipartimento di Sanità Pubblica, Università "La Sapienza", and 4 Istituto di Anestesia e Rianimazione, Università del S.Cuore, Roma, 5 Istituto di Malattie dell'Apparato Respiratorio, Università di Bari, Bari, 6 Divisione di Pneumologia, Ospedale Civico, Palermo, 7 Servizio di Anestesia e Rianimazione, CTO, Torino, and 8 Divisione di Pneumologia, Ospedali Riuniti, Bergamo, Italy

CORRESPONDENCE: M. Confalonieri, Ospedale di Cattinara, Strada di Fiume, 447, I-34100 Trieste, Italy. Fax: 39 0403994668. E-mail: mconfalonieri@qubisoft.it

Keywords: Chronic obstructive pulmonary disease, endotracheal intubation, noninvasive ventilation, respiratory failure

Received: July 19, 2004
Accepted November 8, 2004

Knowing the likelihood of failure of noninvasive positive pressure ventilation (NPPV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD) could indicate the best choice between NPPV and endotracheal intubation instituted earlier. For this purpose, two risk charts were designed (at admission and after 2 h of NPPV) that included all relevant measurable clinical prognostic indicators derived from a population representing the patients seen routinely in clinical practice.

Risk stratification of NPPV failure was assessed in 1,033 consecutive patients admitted to experienced hospital units, including two intensive care units, six respiratory intermediate care units, and five general wards. NPPV was successful in 797 patients.

Patients with a Glasgow Coma Score <11, acute physiology and chronic health evaluation (APACHE) II ≥29, respiratory rate ≥30 breaths·min–1 and pH at admission <7.25 have a predicted risk of failure >70%. A pH <7.25 after 2 h greatly increases the risk (>90%). The risk charts were validated on an independent group of 145 consecutive COPD patients treated with NPPV due to an acute ventilatory failure episode. To identify patients with a probability of failure >50%, the sensitivity and specificity were 33% and 96.7% on admission and 52.9% and 94.1% after 2 h of NPPV, respectively.

The prediction chart, based on data from the current study, can function as a simple tool to predict the risk of failure of noninvasive positive pressure ventilation and thus improve clinical management of patients tailoring medical intervention.




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