High flow nasal therapy versus noninvasive ventilation for AECOPD with acute hypercapnic respiratory failure: a meta-analysis of randomized controlled trials

Annals of Intensive Care volume 15, Article number: 64 Published: 14 May 2025

Background

Guidelines recommend the use of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) in patients with chronic obstructive pulmonary disease (COPD) and hypercapnic acute respiratory failure (ARF). It is unclear whether HFNC is noninferior to NIV in terms of the rate of tracheal intubation or mortality. This meta-analysis aimed to compare the efficacy of HFNC and NIV in patients with AECOPD and hypercapnic ARF.

Methods

A systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of hypercapnic AECOPD with HFNC, compared with NIV, were reviewed. Estimated effects of included studies were pooled as risk ratios (RRs), with 95% confidence intervals (CIs).

Results

Four RCTs (enrolling 486 patients) met the inclusion criteria. There was no statistically significant difference in all-cause mortality (RR 0.97, 95% CI 0.56 to 1.68), and intubation rate (RR 1.67, 95% CI 0.99 to 2.83) between the two groups. The treatment switch rate (RR 2.60, 95% CI 1.54 to 4.38) and treatment failure rate (RR 1.64, 95% CI 1.04 to 2.60) were significantly lower in NIV groups.

Conclusions

Compared with NIV, HFNC was not associated with increased mortality and intubation rate. More patients receiving HFNC oxygen therapy experienced treatment failure and switched to NIV, which may mask the fact that HFNC is inferior to NIV in patients with AECOPD and hypercapnic ARF.

 

Incidence and risk factors of weaning-induced pulmonary oedema: results from a multicentre, observational study

Critical Care volume 29, Article number: 140 (2025) Published: 31 March 2025

Background

During the weaning process, the transition from positive to negative pressure ventilation may induce cardiac dysfunction, which may lead to pulmonary oedema. The incidence of weaning-induced pulmonary oedema (WIPO) is poorly documented and shows huge variations. Our study aims to investigate the incidence and risk factors for WIPO during weaning from mechanical ventilation in general critically ill patients.

Methods

This multicentre study was conducted in France, Italy, and India. Adult critically ill patients receiving invasive ventilation were included once a spontaneous breathing trial (SBT) was performed. The SBT technique could be either T-piece or pressure support mode with (PSV-PEEP) or without positive end expiratory pressure (PEEP) (PSV-ZEEP). A consensual diagnosis of WIPO was made a posteriori by five experts who analysed changes observed during the SBT that were retrospectively recorded.

Results

From July 2019 to February 2021, 634 SBTs were performed in 500 patients from 13 ICUs. Weaning success occurred in 417 patients (66%) and weaning failure in 217 (34%). Weaning was short in 414 (83%) of SBTs, difficult in 47 (9%) SBTs, and prolonged in 39 (8%) SBTs. WIPO was diagnosed in 79 (12%) cases, which accounted for 36% of the 217 weaning failures. WIPO occurred in 54/358 (15%) of T-piece SBT, in 7/84 (8%) of PSV-PEEP SBT (p = 0.072 vs. T-piece), and in 18/192 (9%) of PSV-ZEEP SBT (p = 0.002 vs. T-piece). In multilevel logistic regression analysis including 202 weaning failures from 149 different patients, COPD, and previous cardiomyopathy were identified as independent risk factors associated with WIPO.

Conclusion

In general ICU patients, WIPO accounts for 36% of weaning failure cases. Previous heart disease and COPD are two independent risk factors for developing WIPO during the weaning process.

Critical Care Bulletin: October 2024

 

Predicting outcomes in patients with exacerbation of COPD requiring mechanical ventilation

Annals of Intensive Care volume 14, Article number: 159, Published: 20 October 2024

Background

Acute exacerbations of COPD (AECOPD) are common and significantly contribute to mortality in patients with COPD. Prognostic scores can assist clinicians in making tailored decisions to manage AECOPD. In the current study, we therefore aimed to evaluate the performance of the Noninvasive Ventilation Outcomes (NIVO) score, originally designed to assess in-ICU mortality, in predicting 1 year mortality and NIV failure in AECOPD.

Methods

This retrospective study analyzed data from patients hospitalized for AECOPD requiring mechanical ventilation between January 1st, 2018, and December 31st, 2022. Mortality was assessed at the end of ICU stay and 1 year after admission, while NIV failure was defined as intubation or death without intubation.

Results

Among 302 ICU admissions of COPD patients, 190 patients with AECOPD requiring mechanical ventilation were included. Of these, 44 (23%) died in the ICU, 62 out of 184 (34%) failed NIV, and 78 (41%) died within 1 year of admission. Patients who died in ICU or experienced NIV failure had more severe COPD and more impaired blood gas parameters at admission. The NIVO score demonstrated an AUC of 0.68 in predicting 1-year mortality and an AUC of 0.85 in predicting NIV failure. A NIVO score over 7 was associated with higher 1-year mortality and NIV failure (HR of 4.4 [1.8–10.9] and 41.6 [5.6–307.9], respectively).

Conclusion

Beyond predicting in-ICU mortality, the NIVO-score is a reliable tool in predicting 1-year mortality and NIV failure in AECOPD.

 

Early and late effects of volatile sedation with sevoflurane on respiratory mechanics of critically ill COPD patients

 

by Boris Jung, Maxime Fosset, Matthieu Amalric, Elias Baedorf-Kassis, Brian O’Gara, Todd Sarge, Valerie Moulaire, Vincent Brunot, Arnaud Bourdin, Nicolas Molinari and Stefan Matecki 

 

Annals of Intensive Care volume 14, Article number: 91, Published: 18 June 2024

 

Background

The objective was to compare sevoflurane, a volatile sedation agent with potential bronchodilatory properties, with propofol on respiratory mechanics in critically ill patients with COPD exacerbation.

Methods

Prospective study in an ICU enrolling critically ill intubated patients with severe COPD exacerbation and comparing propofol and sevoflurane after 1:1 randomisation. Respiratory system mechanics (airway resistance, PEEPi, trapped volume, ventilatory ratio and respiratory system compliance), gas exchange, vitals, safety and outcome were measured at inclusion and then until H48. Total airway resistance change from baseline to H48 in both sevoflurane and propofol groups was the main endpoint.

Results

Sixteen patients were enrolled and were sedated for 126 h(61–228) in the propofol group and 207 h(171–216) in the sevoflurane group. At baseline, airway resistance was 21.6cmH2O/l/s(19.8–21.6) in the propofol group and 20.4cmH2O/l/s(18.6–26.4) in the sevoflurane group, (p = 0.73); trapped volume was 260 ml(176–290) in the propofol group and 73 ml(35–126) in the sevoflurane group, p = 0.02. Intrinsic PEEP was 1.5cmH2O(1–3) in both groups after external PEEP optimization. There was neither early (H4) or late (H48) significant difference in airway resistance and respiratory mechanics parameters between the two groups.

Conclusions

In critically ill patients intubated with COPD exacerbation, there was no significant difference in respiratory mechanics between sevoflurane and propofol from inclusion to H4 and H48.

The use of extracorporeal CO2 removal in acute respiratory failure

 

The use of extracorporeal CO2 removal in acute respiratory failure

 

by Raphaël Giraud, Carlo Banfi, Benjamin Assouline, Amandine De Charrière, Maurizio Cecconi and Karim Bendjelid 

 

Annals of Intensive Care volume 11, Article number: 43 (2021)

 

Background

Chronic obstructive pulmonary disease (COPD) exacerbation and protective mechanical ventilation of acute respiratory distress syndrome (ARDS) patients induce hypercapnic respiratory acidosis.

Main text

Extracorporeal carbon dioxide removal (ECCO2R) aims to eliminate blood CO2 to fight against the adverse effects of hypercapnia and related acidosis. Hypercapnia has deleterious extrapulmonary consequences, particularly for the brain. In addition, in the lung, hypercapnia leads to: lower pH, pulmonary vasoconstriction, increases in right ventricular afterload, acute cor pulmonale. Moreover, hypercapnic acidosis may further damage the lungs by increasing both nitric oxide production and inflammation and altering alveolar epithelial cells. During an exacerbation of COPD, relieving the native lungs of at least a portion of the CO2 could potentially reduce the patient's respiratory work, Instead of mechanically increasing alveolar ventilation with MV in an already hyperinflated lung to increase CO2 removal, the use of ECCO2R may allow a decrease in respiratory volume and respiratory rate, resulting in improvement of lung mechanic. Thus, the use of ECCO2R may prevent noninvasive ventilation failure and allow intubated patients to be weaned off mechanical ventilation. In ARDS patients, ECCO2R may be used to promote an ultraprotective ventilation in allowing to lower tidal volume, plateau (Pplat) and driving pressures, parameters that have identified as a major risk factors for mortality. However, although ECCO2R appears to be effective in improving gas exchange and possibly in reducing the rate of endotracheal intubation and allowing more protective ventilation, its use may have pulmonary and hemodynamic consequences and may be associated with complications.

Conclusion

In selected patients, ECCO2R may be a promising adjunctive therapeutic strategy for the management of patients with severe COPD exacerbation and for the establishment of protective or ultraprotective ventilation in patients with ARDS without prognosis-threatening hypoxemia.

 

 

 

Beta-blockers doubled risk of hospitalization from COPD exacerbations (BLOCK-COPD)

Beta-blockers doubled risk of hospitalization from COPD exacerbations (BLOCK-COPD)

PulmCCM - November 17, 2019

Beta-blockers have generally been considered safe and beneficial for patients with COPD, but a new randomized trial calls that assumption into doubt. The use of oral beta blockers without a cardiac indication appeared to double the risk of hospitalization for people experiencing a COPD exacerbation.

Authors randomized 532 patients with moderate or severe COPD with an exacerbation within the past year to receive either extended release metoprolol or placebo. Patients were not already taking beta blockers and had not had myocardial infarctions or other cardiac indications for beta blocker use. The trial was called BLOCK-COPD and was published in the New England Journal of Medicine.

Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score

Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score

by Jun Duan, Shengyu Wang, Ping Liu, Xiaoli Han, Yao Tian, Fan Gao, Jing Zhou, Junhuan Mou, Qian Qin, Jingrong Yu, Linfu Bai, Lintong Zhou and Rui Zhang

Annals of Intensive Care volume 9, Article number: 108 (2019)

Background

Early identification of noninvasive ventilation (NIV) failure is a promising strategy for reducing mortality in chronic obstructive pulmonary disease (COPD) patients. However, a risk-scoring system is lacking.

Methods

To develop a scale to predict NIV failure, 500 COPD patients were enrolled in a derivation cohort. Heart rate, acidosis (assessed by pH), consciousness (assessed by Glasgow coma score), oxygenation, and respiratory rate (HACOR) were entered into the scoring system. Another two groups of 323 and 395 patients were enrolled to internally and externally validate the scale, respectively. NIV failure was defined as intubation or death during NIV.

Results

Using HACOR score collected at 1–2 h of NIV to predict NIV failure, the area under the receiver operating characteristic curves (AUC) was 0.90, 0.89, and 0.71 for the derivation, internal-validation, and external-validation cohorts, respectively. For the prediction of early NIV failure in these three cohorts, the AUC was 0.91, 0.96, and 0.83, respectively. In all patients with HACOR score > 5, the NIV failure rate was 50.2%. In these patients, early intubation (< 48 h) was associated with decreased hospital mortality (unadjusted odds ratio = 0.15, 95% confidence interval 0.05–0.39, p < 0.01).

Conclusions

HACOR scores exhibited good predictive power for NIV failure in COPD patients, particularly for the prediction of early NIV failure (< 48 h). In high-risk patients, early intubation was associated with decreased hospital mortality.

Hospital Volume and Outcomes of Noninvasive Ventilation in Patients Hospitalized With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Hospital Volume and Outcomes of Noninvasive Ventilation in Patients Hospitalized With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease
Critical Care Medicine: January 2017 - Volume 45 - Issue 1 - p 20–27
Stefan, M S et al

Objective: To determine the relationship between hospital noninvasive ventilation caseload and outcomes among patients with an acute chronic obstructive pulmonary disease exacerbation. Design: Cross-sectional study of 13,893 patients with chronic obstructive pulmonary disease treated with noninvasive ventilation. Setting: A total of 243 U.S. hospitals participating in the Premier Inpatient Database. Patients: A total of 13,893 patients admitted between July 2009 and June 2011. Interventions: None. Measurements and Main Results: Annual hospital volume of noninvasive ventilation was analyzed as a continuous variable, as well as after grouping it in four categories. The median hospital annual volume of noninvasive ventilation use was 627 and varied from 234 admissions in quartile 1 to 1,529 admissions in quartile 4. Noninvasive ventilation failure occurred in 15.2%, and in-hospital mortality was 6.5%. After adjusting for patient characteristics, relative to low-volume hospitals, high-volume hospitals did not have lower noninvasive ventilation failure (odds ratio quartile 4 vs quartile 1, 1.05; 95% CI, 0.65–1.68) or in-hospital mortality (odds ratio quartile 4 vs quartile 1, 0.88; 95% CI, 0.69–1.12). In a hierarchical multivariable analysis with adjustment for patient characteristics where volume was assessed as a continuous variable, hospital volume was not related to outcomes, including noninvasive ventilation failure (p = 0.87), in-hospital mortality (p = 0.88), 30-day readmission for chronic obstructive pulmonary disease (p = 0.83), or hospital length of stay (p = 0.12). Conclusions: The results of this large retrospective cohort study suggest that hospitals with higher noninvasive ventilation volume do not achieve better outcomes of patients with chronic obstructive pulmonary disease exacerbation treated with noninvasive ventilation; even hospitals with low noninvasive ventilation volume are able to successfully implement this intervention.

Comparative Effectiveness of Noninvasive and Invasive Ventilation in Critically Ill Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Comparative Effectiveness of Noninvasive and Invasive Ventilation in Critically Ill Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Critical Care Medicine: July 2015 - Volume 43 - Issue 7 - p 1386–1394 doi: 10.1097/CCM.0000000000000945

Stefan, MS. Et al

http://journals.lww.com/ccmjournal/Fulltext/2015/07000/Comparative_Effectiveness_of_Noninvasive_and.6.aspx

Objectives: To compare the characteristics and hospital outcomes of patients with an acute exacerbation of chronic obstructive pulmonary disease treated in the ICU with initial noninvasive ventilation or invasive mechanical ventilation.
Design: Retrospective, multicenter cohort study of prospectively collected data. We used propensity matching to compare the outcomes of patients treated with noninvasive ventilation to those treated with invasive mechanical ventilation. We also assessed predictors for noninvasive ventilation failure. 

Neural versus pneumatic control of pressure support in patients with chronic obstructive pulmonary diseases at different levels of positive end expiratory pressure: a physiological study

Critical Care 2015, 19:244  doi:10.1186/s13054-015-0971-0

 

Ling Liu et al

http://www.ccforum.com/content/19/1/244/abstract

Intrinsic positive end-expiratory pressure (PEEPi) is a “threshold” load that must be overcome to trigger conventional pneumatically-controlled pressure support (PSP) in chronic obstructive pulmonary disease (COPD). Application of extrinsic PEEP (PEEPe) reduces trigger delays and mechanical inspiratory efforts. Using the diaphragm electrical activity (EAdi), neurally controlled pressure support (PSN) could hypothetically eliminate asynchrony and reduce mechanical inspiratory effort, hence substituting the need for PEEPe. The primary objective of this study was to show that PSN can reduce the need for PEEPe to improve patient-ventilator interaction and to reduce both the “pre-trigger” and “total inspiratory” neural and mechanical efforts in COPD patients with PEEPi. A secondary objective was to evaluate the impact of applying PSN on breathing pattern.

Intensive care unit admission in chronic obstructive pulmonary disease

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process. Critical Care 2014, 18: R115

Schmidt, M., et al.

http://ccforum.com/content/pdf/cc13906.pdf

ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD 
patients to the ICU and to propose invasive mechanical ventilation. 

A prospective longitudinal multicentre study of health related qualify of life in ICU survivors with COPD

A prospective longitudinal multicentre study of health related quality of life of ICU survivors with COPD. Critical care, Sept 2013, 17:R211

Berkius, J., et al.

http://ccforum.com/content/pdf/cc13019.pdf

Mortality amongst COPD patients treated on the ICU is high. Health-related quality of life (HRQL) after intensive care is a relevant concern for COPD patients, their families and providers of health care. Still, there are few HRQL studies after intensive care of this patient group. Our hypothesis was that HRQL of COPD patients treated on the ICU declines rapidly with time.

Duration of salmeterol-induced bronchodilation in mechanically ventilated chronic obstructive pulmonary disease patients: a prospective clinical study

Research Malliotakis P, Linardakis M, Gavriilidis G, Georgopoulos DCritical Care, 2008 12:R140 ( 14 November 2008 )[Abstract][Full text] [PDF] [PubMed]

Procalcitonin levels in acute exacerbation of COPD admitted in ICU: a prospective cohort study

Research article Procalcitonin levels in acute exacerbation of COPD admitted in ICU: a prospective cohort study

Daubin C, Parienti JJ, Vabret A, Ramakers M, Fradin S, Terzi N, Freymuth F, Charbonneau P, du Cheyron DBMC Infectious Diseases 2008, 8:145 (23 October 2008)[Abstract] [Full text] [PDF] [PubMed] [Related articles]

National Knowledge Week for Chronic Obstructive Pulmonary Disease 2008

3 March 2008 - National Knowledge Week for Chronic Obstructive Pulmonary Disease 2008

Published by the Respiratory Specialist Library and prepared by members of the COPD National Service Framework External Reference Group. Includes results of comprehensive literature search of the evidence base.Published by the Respiratory Specialist Library and prepared by members of the COPD National Service Framework External Reference Group. Includes results of comprehensive literature search of the evidence base.