⇓Severe chronic obstructive pulmonary disease (COPD) patients, especially those with chronic respiratory failure, may frequently require periods of intensive treatment, monitoring, nursing and, occasionally, ventilatory assistance in order to overcome acute exacerbations. Ventilatory assistance is only rarely provided in the conventional ward 1, therefore admission to an intensive care unit (ICU) is often needed 2. ICU, however, are very precious and expensive resources where nursing costs represent a major expense 3. Patients with acute on chronic respiratory failure may experience a prolonged stay in the ICU not only because of the severity of their illness which precipitates the underlying acute respiratory failure (ARF) 2, but also because of ICU-related complications 4. For these reasons the treatment of acute on chronically ill patients in these areas creates ethical 5 and economic concerns 6, 7.
It has been reported that ∼40% of the patients admitted to ICUs never received active intensive care, including mechanical ventilation 8–10. Only ∼40% of patients with ARF due to pulmonary disease needed to be invasively ventilated 11, 12. However, in some countries, such as the UK, with a severe ICU bed shortage, the vast majority of ICU admissions require mechanical ventilation.
A recent Italian survey carried out on 99 ICUs showed that COPD was the dominant underlying chronic disease in patients admitted to the Italian ICU, and the need for cardiorespiratory monitoring was the most frequent indication for admission (31.2%) 13.
These studies clearly indicate that in some centres there is an “overutilisation” of ICU resources for monitoring purposes, and that acute on chronic respiratory failure could be managed in many patients without invasive ventilation.
Patients with chronic respiratory failure, especially those with underlying COPD, very often suffer from a high frequency of …