Research Activities, February 2014
Increased use of noninvasive ventilation could save more lives for patients with chronic obstructive pulmonary disease
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) account for 1.5 million emergency department (ED) visits and 726,000 hospitalizations each year in the United States. Over the last 20 years, noninvasive ventilation (NIV) has emerged as a potentially useful treatment in AECOPD patients with acute respiratory failure. NIV commonly refers to positive-pressure breathing support delivered through a nasal or full-face mask.
Since earlier, small studies have shown that NIV use resulted in fewer complications and shorter hospital stays than invasive mechanical ventilation (IMV), researchers decided to look at the use of NIV treatment in a much larger patient population. Their study of 67,651 ED visits for AECOPD found that NIV use, compared with IMV, was associated with a reduction of inpatient mortality of 46 percent, shortened hospital length of stay by 3 days, reduced hospital charges by approximately $35,000 per visit, and modestly reduced risk of iatrogenic pneumothorax.
The frequency of NIV use (including combined use of NIV and IMV) varied widely among hospitals, ranging from 0 percent to 100 percent with a median of 11 percent. Hospitals in the Northeast and in nonmetropolitan areas were early adopters. Although NIV use increased between 2006 and 2008, the utilization of NIV remained low (16 percent in 2008).
The researchers asked why, given its demonstrated efficacy (both in their study and earlier studies), NIV has not been more widely adopted. Previous surveys have identified several reasons, including lack of physician knowledge, insufficient respiratory therapist training, inadequate equipment, and the time required to set up NIV. One incentive to promote NIV use in clinical practice is the cost-effectiveness of NIV compared with usual treatment, mainly resulting from less use of the ICU.
The researchers believe that increasing the use of NIV as recommended in the guidelines may help reduce COPD mortality. This study was supported by AHRQ (HS20722).
See "Comparative effectiveness of noninvasive ventilation vs invasive mechanical ventilation in chronic obstructive pulmonary disease patients with acute respiratory failure," by Chu-Lin Tsai, M.D., Wen-Ya Lee, M.S., George L. Delclos, M.D., and others in the April 2013 Journal of Hospital Medicine 8(4), pp. 165-172.