Noninvasive Mechanical Ventilation in the Weaning of Patients with Respiratory Failure Due to Chronic Obstructive Pulmonary Disease

A Randomized, Controlled Trial

  1. Stefano Nava, MD;
  2. Nicolino Ambrosino, MD;
  3. Enrico Clini, MD;
  4. Maurizio Prato, MD;
  5. Giacomo Orlando, MD;
  6. Michele Vitacca, MD;
  7. Paolo Brigada, MD;
  8. Claudio Fracchia, MD; and
  9. Fiorenzo Rubini, MD
  1. Acknowledgments: The authors thank Dr. R.C. Stenner for review of the English of the manuscript and Marco Pagani for assistance with statistical analysis. Requests for Reprints: Stefano Nava, MD, Division of Pneumology, Centro Medico di Riabilitazione di Montescano, 27040 Montescano (PV), Italy. Current Author Addresses: Drs. Nava, Brigada, Fracchia, and Rubini: Pneumology Division, Centro Medico di Riabilitazione di Montescano, via per Montescano, 27040 Montescano (PV), Italy.

    Abstract

    Background: In patients with acute exacerbations of chronic obstructive pulmonary disease, mechanical ventilation is often needed. The rate of weaning failure is high in these patients, and prolonged mechanical ventilation increases intubation-associated complications.

    Objective: To determine whether noninvasive ventilation improves the outcome of weaning from invasive mechanical ventilation.

    Design: Multicenter, randomized trial.

    Setting: Three respiratory intensive care units.

    Patients: Intubated patients with chronic obstructive pulmonary disease and acute hypercapnic respiratory failure.

    Intervention: A T-piece weaning trial was attempted 48 hours after intubation. If this failed, two methods of weaning were compared: 1) extubation and application of noninvasive pressure support ventilation by face mask and 2) invasive pressure support ventilation by an endotracheal tube.

    Measurements: Arterial blood gases, duration of mechanical ventilation, time in the intensive care unit, occurrence of nosocomial pneumonia, and survival at 60 days.

    Results: At admission, all patients had severe hypercapnic respiratory failure (mean pH, 7.18 ± 0.06; mean PaCO 2, 94.2 ± 24.2 mm Hg), sensory impairment, and similar clinical characteristics. At 60 days, 22 of 25 patients (88%) who were ventilated noninvasively were successfully weaned compared with 17 of 25 patients (68%) who were ventilated invasively. The mean duration of mechanical ventilation was 16.6 ± 11.8 days for the invasive ventilation group and 10.2 ± 6.8 days for the noninvasive ventilation group (P = 0.021). Among patients who received noninvasive ventilation, the probability of survival and weaning during ventilation was higher (P = 0.002) and time in the intensive care unit was shorter (15.1 ± 5.4 days compared with 24.0 ± 13.7 days for patients who received invasive ventilation; P = 0.005). Survival rates at 60 days differed (92% for patients who received noninvasive ventilation and 72% for patients who received invasive ventilation; P = 0.009). None of the patients weaned noninvasively developed nosocomial pneumonia, whereas 7 patients weaned invasively did.

    Conclusions: Noninvasive pressure support ventilation during weaning reduces weaning time, shortens the time in the intensive care unit, decreases the incidence of nosocomial pneumonia, and improves 60-day survival rates.

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    This Article

    1. Ann Intern Med May 1, 1998 vol. 128 no. 9 721-728
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