A Cochrane Review has confirmed that non-invasive bi-level positive pressure ventilation (NIV) should form part of the initial management of patients admitted to hospital with acute hypercapnic respiratory failure due to acute COPD exacerbations.

The systematic review, including 17 trials comprising 1264 participants, found the addition of NIV to usual care reduced the risk of death by 46% compared to usual care alone.

Lead co-author Dr Christian Osadnik, from the Department of Physiotherapy at Monash University, said lingering concerns about the possible risks of NIV remained despite it being a first line treatment in many countries including Australia.

He told the limbic one of the perceived concerns was that NIV might delay necessary intubation and mechanical ventilation in some patients, resulting in potentially poorer outcomes.

“No treatment is risk free and a small proportion of patients who received NIV in this review still needed intubation. However, the evidence confirms what many clinicians know and do – that this treatment is lifesaving for many people.”

The review found NIV reduced the need for intubation by 65% and reduced the length of hospital stay by about 3.5 days.

“The resultant number needed to treat to derive a clinical benefit was only five to reduce the need for intubation and 12 to reduce mortality,” Dr Osadnik said.

Subgroup analysis showed the benefits were consistent across different patient locations (ward v ICU) and level of acidosis (pH<7.30 v 7.30-7.35).

Dr Osadnik said complications of NIV treatment were infrequent and mild such as abdominal bloating or facial pressure areas compared to the risks associated with invasive mechanical ventilation and the potential difficulties associated with ventilator weaning.

“The combination of mortality benefit and the protective effect against the risks associated with invasive intubation and mechanical ventilation will make it difficult to ethically deny patients access to NIV in the future.”

He said an important caveat to the findings was the need for hospitals delivering NIV to have access to appropriate forms of medical care, such as intensive care and invasive ventilation, should escalation of treatment be required.

Dr Osadnik said future research was warranted to clarify the precise role for different NIV masks, modes and settings, as well as the role of NIV in pre-hospital settings or post-extubation.