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עברית
November 6, 2024
Written by Jason Lesnick
This RCT found high-intensity non-invasive positive pressure ventilation (NPPV) in COPD patients with persistent hypercapnia decreased the need for endotracheal intubation according to prespecified criteria.
Stop trying to make COPD HAPPEN, Gretchen
This multicenter RCT was performed across 30 hospitals in China from January 2019 to January 2022 and randomized 300 patients. It examined whether high-intensity NPPV would decrease the need for intubation in hospitalized COPD patients compared to low-intensity NPPV. High-intensity NPPV was defined as increasing IPAP to obtain a tidal volume of 10-15 mL/kg of predicted body weight (PBW), usually 20-30 cm H2O. Low-intensity NPPV was defined as increasing IPAP to a maximum of 20 cm H2O with a goal tidal volume of 6-10 mL/kg of PBW. Authors defined criteria for requiring intubation as a combination of multiple lab and clinical features (page E3-E4). They found 7/147 (4.8%) patients in the high-intensity NPPV group met criteria for intubation compared to 21/153 (13.7%) in the low-intensity group. 13 of the patients in the low-intensity group crossed over to the high-intensity arm after meeting criteria for intubation, but only 2 were intubated. Thus, after crossover, the between group rate of intubation was not significantly different. The authors suggest that this means there may be no difference between intubation rates of patients starting with a strategy of low-intensity NPPV if allowed to cross over to high-intensity NPPV, versus starting with high-intensity NPPV.
How will this change my practice?
This study will make me more aggressive with increasing IPAP and has given me a new framework for increasing NPPV settings on my severe COPD patients (10-15 mL/kg predicted body weight) prior to moving to intubation.
Source
Effect of High-Intensity vs Low-Intensity Noninvasive Positive Pressure Ventilation on the Need for Endotracheal Intubation in Patients With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: The HAPPEN Randomized Clinical Trial. JAMA. 2024 Sep 16:e2415815. doi: 10.1001/jama.2024.15815. Epub ahead of print. PMID: 39283649; PMCID: PMC11406453.
