Clinical presentation and predictors of outcome in patients with severe acute exacerbation of chronic obstructive pulmonary disease requiring admission to intensive care unit Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial. Non-invasive ventilation for acute exacerbation of COPD with very high PaCO2: A randomized controlled trial High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. Non-invasive ventilation in pediatric status asthmaticus: a prospective observational study. Noninvasive ventilation in a tertiary pediatric intensive care unit in a middle-income country A prospective randomized controlled trial on the efficacy of noninvasive ventilation in severe acute asthma. Role of noninvasive ventilation in weaning from mechanical ventilation in patients of chronic obstructive pulmonary disease: An Indian experience Predictive factors for the success of noninvasive mask ventilation in infants and children with acute respiratory failure Cost effectiveness of ward based non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease: economic analysis of randomised controlled trial Noninvasive positive pressure ventilation in acute respiratory failure due to COPD vs other causes: Effectiveness and predictors of failure in a respiratory ICU in North India Non-invasive ventilation with bubble CPAP is feasible and improves respiratory physiology in hospitalised Malawian children with acute respiratory failure Non-invasive ventilation in acute respiratory failure in children Noninvasive ventilation: Are we overdoing it? Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. A study on the role of noninvasive ventilation in mild-to-moderate acute respiratory distress syndrome Randomized comparison of oxygen mask treatment vs. nasal continuous positive airway pressure in dengue shock syndrome with acute respiratory failure. A prospective, randomized, controlled trial of noninvasive ventilation in pediatric acute respiratory failure* Mortality Predictors of ARDS in Medical Intensive Care Unit of a Tertiary Care Centre in a Tropical Country. An evaluation of the role of noninvasive positive pressure ventilation in the management of acute respiratory failure in a developing country. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial Outcomes of noninvasive ventilation in acute hypoxemic respiratory failure in a respiratory intensive care unit in north India. Predictive factors of non invasive ventilation failure in critically ill children: a prospective epidemiological study Non-Invasive Ventilation after Extubation in Patients with Chronic Obstructive Airways Disease: A Randomised Controlled Trial Outcomes of Patients with Respiratory Distress Treated with Bubble CPAP on a Pediatric Ward in Malawi. Critically ill patients with 2009 H1N1 infection in an Indian ICU A randomized clinical trial evaluating nasal continuous positive airway pressure for acute respiratory distress in a developing country. Use of Nasal Bubble CPAP in Children with Hypoxemic Clinical Pneumonia-Report from a Resource Limited Set-Up. Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. Weaning of mechanically ventilated chronic obstructive pulmonary disease patients by using non-invasive positive pressure ventilation: A prospective study
Background Severe acute exacerbation of chronic obstructive pulmonary disease ( AE- COPD ) is a common reason for emergency room ( ER ) visit about which little has been documented from India . Methods Prospect i ve study of the clinical presentation and predictors of outcome in 116 patients presenting with severe AE- COPD requiring admission to the medical intensive care unit between January 2000 and December 2004 . Results Their mean age was 62.1 ± 9.8 years . There were 102 males . Mean duration of COPD was 7.2 ± 5.8 years . All males were smokers ( 22.3 ± 11.2 pack years ) ; 35.2 % smoked cigarettes and 64.8 % smoked bidis . All women were exposed to domestic fuel . Associated co-morbid illnesses were present in 81 patients ( 69.8 % ) ; 53(45.7 % ) had one co-morbid illness and the remaining 28 ( 54.3 % ) had two or more co-morbid illnesses . Evidence of past pulmonary tuberculosis ( PTB ) was present in 28.4 % patients ; 5 patients who also had type II diabetes mellitus had active PTB . Arterial blood gas analysis revealed respiratory failure in 40 ( 33.8 % ) patients ( type I 17.5 % and type II 82.5 % ) .  Invasive mechanical ventilation  was required in 18 patients . Sixteen ( 13.7 % ) patients died . Stepwise multivariate logistic regression analysis revealed need for invasive ventilation ( OR 45.809 , 95%CI 607.46 to 3.009;p < 0.001 ) ; presence of co-morbid illness ( OR 0.126 , 95%CI 0.428 to 0.037;p < 0.01 ) and hypercapnia ( OR 0.114 , 95%CI 1.324 to 0.010;p < 0.05 ) were predictors of death . Conclusion Co-morbid conditions and metabolic abnormalities render the diagnosis of AE- COPD difficult and also contribute to mortality . High prevalence of past PTB and active PTB in patients with AE- COPD suggests an intriguing relationship between smoking , PTB and COPD which merits further study BACKGROUND In developing countries , mortality in children with very severe pneumonia is high , even with the provision of appropriate antibiotics , st and ard oxygen therapy , and other supportive care . We assessed whether oxygen therapy delivered by bubble continuous positive airway pressure ( CPAP ) improved outcomes compared with st and ard low-flow and high-flow oxygen therapies . METHODS This open , r and omised , controlled trial took place in Dhaka Hospital of the International Centre for Diarrhoeal Disease Research , Bangladesh . We r and omly assigned children younger than 5 years with severe pneumonia and hypoxaemia to receive oxygen therapy by either bubble CPAP ( 5 L/min starting at a CPAP level of 5 cm H2O ) , st and ard low-flow nasal cannula ( 2 L/min ) , or high-flow nasal cannula ( 2 L/kg per min up to the maximum of 12 L/min ) . R and omisation was done with use of the permuted block methods ( block size of 15 patients ) and Fisher and Yates tables of r and om permutations . The primary outcome was treatment failure ( ie , clinical failure , intubation and mechanical ventilation , death , or termination of hospital stay against medical advice ) after more than 1 h of treatment . Primary and safety analyses were by intention to treat . We did two interim analyses and stopped the trial after the second interim analysis on Aug 3 , 2013 , as directed by the data safety and monitoring board . This trial is registered at Clinical Trials.gov , number NCT01396759 . FINDINGS Between Aug 4 , 2011 , and July 17 , 2013 , 225 eligible children were recruited . We r and omly allocated 79 ( 35 % ) children to receive oxygen therapy by bubble CPAP , 67 ( 30 % ) to low-flow oxygen therapy , and 79 ( 35 % ) to high-flow oxygen therapy .  Treatment failed for 31 ( 14 % ) children , of whom five ( 6 % ) had received bubble CPAP , 16 ( 24 % ) had received low-flow oxygen therapy , and ten ( 13 % ) had received high-flow oxygen therapy . Significantly fewer children in the bubble CPAP group had treatment failure than in the low-flow oxygen therapy group ( relative risk [ RR ] 0·27 , 99·7 % CI 0·07 - 0·99 ; p=0·0026 ) . No difference in treatment failure was noted between patients in the bubble CPAP and those in the high-flow oxygen therapy group ( RR 0·50 , 99·7 % 0·11 - 2·29 ; p=0·175 ) . 23 ( 10 % ) children died . Three ( 4 % ) children died in the bubble CPAP group , ten ( 15 % ) children died in the low-flow oxygen therapy group , and ten ( 13 % ) children died in the high-flow oxygen therapy group . Children who received oxygen by bubble CPAP had significantly lower rates of death than the children who received oxygen by low-flow oxygen therapy ( RR 0·25 , 95 % CI 0·07 - 0·89 ; p=0·022 ) . INTERPRETATION Oxygen therapy delivered by bubble CPAP improved outcomes in Bangladeshi children with very severe pneumonia and hypoxaemia compared with st and ard low-flow oxygen therapy . Use of bubble CPAP oxygen therapy could have a large effect in hospitals in developing countries where the only respiratory support for severe childhood pneumonia and hypoxaemia is low-flow oxygen therapy . The trial was stopped early because of higher mortality in the low-flow oxygen group than in the bubble CPAP group , and we acknowledge that the early cessation of the trial reduces the certainty of the findings . Further research is needed to test the feasibility of scaling up bubble CPAP in district hospitals and to improve bubble CPAP delivery technology . FUNDING International Centre for Diarrhoeal Disease Research , Bangladesh , and Centre for International Child Health , University of Melbourne CONTEXT Continuous positive airway pressure ( CPAP ) is widely used in the belief that it may reduce the need for intubation and mechanical ventilation in patients with acute hypoxemic respiratory insufficiency . OBJECTIVE To compare the physiologic effects and the clinical efficacy of CPAP vs st and ard oxygen therapy in patients with acute hypoxemic , nonhypercapnic respiratory insufficiency . DESIGN , SETTING , AND PATIENTS R and omized , concealed , and unblinded trial of 123 consecutive adult patients who were admitted to 6 intensive care units between September 1997 and January 1999 with a PaO(2)/FIO(2 ) ratio of 300 mm Hg or less due to bilateral pulmonary edema ( n = 102 with acute lung injury and n = 21 with cardiac disease ) . INTERVENTIONS Patients were r and omly assigned to receive oxygen therapy alone ( n = 61 ) or oxygen therapy plus CPAP ( n = 62 ) . MAIN OUTCOME MEASURES Improvement in PaO(2)/FIO(2 ) ratio , rate of endotracheal intubation at any time during the study , adverse events , length of hospital stay , mortality , and duration of ventilatory assistance , compared between the CPAP and st and ard treatment groups . RESULTS Among the CPAP vs st and ard therapy groups , respectively , causes of respiratory failure ( pneumonia , 54 % and 55 % ) , presence of cardiac disease ( 33 % and 35 % ) , severity at admission , and hypoxemia ( median [ 5th-95th percentile ] PaO(2)/FIO(2 ) ratio , 140 [ 59 - 288 ] mm Hg vs 148 [ 62 - 283 ] mm Hg ; P = .43 ) were similarly distributed . After 1 hour of treatment , subjective responses to treatment ( P<.001 ) and median ( 5th-95th percentile ) PaO(2)/FIO(2 ) ratios were greater with CPAP ( 203 [ 45 - 431 ] mm Hg vs 151 [ 73 - 482 ] mm Hg ; P = .02 ) . No further difference in respiratory indices was observed between the groups . Treatment with CPAP failed to reduce the endotracheal intubation rate ( 21 [ 34 % ] vs 24 [ 39 % ] in the st and ard therapy group ; P = .53 ) , hospital mortality ( 19 [ 31 % ] vs 18 [ 30 % ] ; P = .89 ) , or median ( 5th-95th percentile ) intensive care unit length of stay ( 6.5 [ 1 - 57 ] days vs 6.0 [ 1 - 36 ] days ; P = .43 ) . A higher number of adverse events occurred with CPAP treatment ( 18 vs 6 ; P = .01 ) . CONCLUSION In this study , despite early physiologic improvement , CPAP neither reduced the need for intubation nor improved outcomes in patients with acute hypoxemic , nonhypercapnic respiratory insufficiency primarily due to acute lung injury . JAMA . 2000;284:2352 - 2360 Objective : To assess the role of non-invasive positive pressure ventilation ( NIPPV ) for management of Indian patients with acute exacerbation of chronic obstructive pulmonary disease ( AE COPD ) . Material s and Methods : Forty patients ( mean age 57.6 ± 10.8 years ; M : F 31:9 ) with AE COPD with pH < 7.35 , admitted to the intensive care unit were included . Patients were r and omized to receive  NIPPV  ( N , n = 20 ) with conventional therapy or conventional therapy  ( C , n = 20 ) alone at admission .  NIPPV was given through the nasal mask . Incidence of need of endotracheal intubation ( ETI ) was the primary efficacy variable . Hospital mortality , duration of hospital stay and change in clinical and blood gas parameters were the secondary outcome variables . Results : Mean pH at baseline for N and C groups were similar ( 7.23 ± 0.07 ) whereas PaCO2 was 85.4 ± 14.8 and 81.1 ± 11.6 mm of Hg , respectively . At one hour , patients in N group had greater improvement in pH ( P = 0.017 ) as well as PaCO2 ( P = 0.04 ) which corroborated with clinical improvement . Whereas need of ETI was reduced in patients who received NIPPV ( 3/20 vs 12/20 , P = 0.003 ) , in-hospital mortality was similar ( 3/20 and 2/20 , P = NS ) . The mean duration of hospital stay was significantly shorter in N group ( 9.4 ± 4.3 days ) as compared to C group ( 17.8 ± 2.6 days ) ; P = 0.001 . Conclusions : In patients with AE COPD  , NIPPV leads to rapid improvement in blood gas parameters and reduces the need for BACKGROUND Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated . Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia . METHODS We performed a multicenter , open-label trial in which we r and omly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy , st and ard oxygen therapy delivered through a face mask , or noninvasive positive-pressure ventilation . The primary outcome was the proportion of patients intubated at day 28 ; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28 . RESULTS A total of 310 patients were included in the analyses .  The intubation rate ( primary outcome ) was 38 % ( 40 of 106 patients ) in the high-flow-oxygen group , 47 % ( 44 of 94 ) in the st and ard group , and 50 % ( 55 of 110 ) in the noninvasive-ventilation group ( P=0.18 for all comparisons ) . The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group ( 24±8 days , vs. 22±10 in the st and ard-oxygen group and 19±12 in the noninvasive-ventilation group ; P=0.02 for all comparisons ) . The hazard ratio for death at 90 days was 2.01 ( 95 % confidence interval [ CI ] , 1.01 to 3.99 ) with st and ard oxygen versus high-flow oxygen ( P=0.046 ) and 2.50 ( 95 % CI , 1.31 to 4.78 ) with noninvasive ventilation versus high-flow oxygen ( P=0.006 ) . CONCLUSIONS In patients with nonhypercapnic acute hypoxemic respiratory failure , treatment with high-flow oxygen , st and ard oxygen , or noninvasive ventilation did not result in significantly different intubation rates . There was a significant difference in favor of high-flow oxygen in 90-day mortality . ( Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health ; FLORALI Clinical Trials.gov number , NCT01320384 . ) OBJECTIVE Non-invasive ventilation ( NIV ) has been shown to be effective in different causes of respiratory failure in both adult and pediatric patients . However , its role in status asthmaticus ( SA ) remains unclear . We design ed a prospect i ve study to assess the feasibility of NIV in children with SA . STUDY DESIGN Prospect i ve observational study , over a 4.5-year period . PATIENT SELECTION Children with SA unresponsive to conventional therapy with a modified Wood 's clinical asthma score ( m-WCAS ) ≥4 and marked increased work of breathing , were included . METHODOLOGY Patients were placed on  pressure support NIV . During NIV therapy , salbutamol was nebulized continuously and ipratropium bromide every 2 hr ; methyl-prednisolone was given at a dose of 1 - 2 mg/kg/6 hr . Clinical variables were measured at baseline and at 1 , 6 , 12 , 24 , and 48 hr . RESULTS During the study period , there were 122 PICU admissions due to SA ; 72 episodes fulfilled inclusion criteria . Baseline mean values were as follows : m-WCAS of 5.7 points , heart rate ( HR ) of 166.7 beats/min , respiratory rate ( RR ) of 49.5 breaths/min and FiO(2 ) of 45.3 % . In the first hour m-WCAS fell 2.3 ± 1.5 points , HR 13.5 ± 14 beats/min , and RR 9.8 ± 10 breaths/min ( P < 0.01 ) . After institution of NIV therapy , 5 children required intubation due to increasing respiratory distress . There was one case of massive subcutaneous emphysema , with no other serious adverse effects associated with NIV . CONCLUSIONS These results show that NIV is a feasible therapy in children with SA unresponsive to conventional treatment . Pediatr . Pulmonol . 2011 ; 46:949 - 955 . © 2011 Wiley-Liss , Objective : To determine the factors that predict outcome of noninvasive ventilation ( NIV ) in critically ill children . Design : Prospect i ve observational study . Setting : Multidisciplinary pediatric intensive care unit of a university hospital in Malaysia . Patients : Patients admitted to the pediatric intensive care unit from July 2004 to December 2006 for respiratory support due to acute respiratory failure and those extubated from invasive mechanical ventilation . Interventions : NIV was used as an alternative means of respiratory support for all children . In patients who had prior invasive mechanical ventilation , NIV was used to facilitate extubation , or it was used after a failed extubation . The children were assigned to the nonresponders group ( intubation was needed ) or responders group ( intubation was avoided totally or for at least 5 days ) . The physiologic variables were monitored before , at 6 hrs , and 24 hrs of NIV . Measurements and Main Results : Of 278 patients , 129 were admissions for management of acute respiratory failure and 149 patients received NIV to facilitate extubation ( n = 98 ) or for a failed extubation ( n = 48 ) . Their median age and weight were 8.7 months ( interquartile range , 3.1–33.1 months ) and 5.5 kg ( interquartile range , 3.3–10.8 kg ) , respectively . Intubation was avoided for > 5 days in 79.1 % ( n = 220 ) . No significant difference in age or weight of responders and nonresponders was observed . The cardiorespiratory variables in all patients improved , but significant differences between the two groups were noted at 6 hrs and 24 hrs after NIV . Conclusions : NIV was a feasible strategy of respiratory support to avoid intubation in > 75 % of children in this study . A higher Pediatric Risk of Mortality II score , sepsis at initiation of NIV , an abnormal respiratory rate , and a higher requirement of Fio2 may be predictive factors of NIV failure BACKGROUND Noninvasive ventilation ( NIV ) is an emerging modality in the management of patients with acute respiratory failure . However , its role in severe acute asthma is not well defined . OBJECTIVE Evaluate the efficacy of NIV in severe acute asthma . METHODS Patients with severe acute asthma were r and omized to receive either st and ard medical therapy or NIV in addition to medical therapy . The primary outcomes were improvement in forced expiratory volume in the first second ( FEV1 ) , intensive care unit ( ICU ) stay , and hospital stay . The secondary outcomes were rate of improvement in respiratory rate , blood pH , ratio of PaO2 to fraction of inspired oxygen ( F(I)O2 ) , PaCO2 , requirement for inhaled medications , and failure of primary therapy . RESULTS Fifty-three patients with severe acute asthma ( 42 females and 11 males , mean + /- SD age 44 + /- 15 y , FEV1 < 30 % of predicted ) were r and omized to NIV ( n = 28 ) or st and ard medical therapy ( n = 25 ) . The baseline variables were similar in the 2 groups except for the mean duration of asthma , which was shorter in the st and ard-medical-therapy group . The median inspiratory and expiratory airway pressures applied were 12 cm H2O and 5 cm H2O , respectively . There was a significant improvement in respiratory rate , FEV1 , and PaO2/F(I)O2 ( but not pH or PaCO2 ) in both the groups , but no significant difference between the 2 groups . The number of patients who had a > or = 50 % improvement in FEV1 at 1 , 2 , and 4 hours was nonsignificantly greater in the NIV arm . ICU and hospital stay was significantly shorter in the NIV group . The mean dose of inhaled bronchodilator was significantly less in the NIV group . There were 4 instances of st and ard-medical-therapy failure , and all those patients improved with NIV . Two patients in the NIV arm required invasive ventilation . There was no mortality in either of the arms . CONCLUSION In patients with severe acute asthma , the addition of NIV to st and ard medical therapy probably accelerates the improvement in lung function , decreases the inhaled bronchodilator requirement , and shortens the ICU and hospital stay , but a larger study is required to settle this issue Background : Endotracheal intubation and mechanical ventilation ( MV ) are often needed in patients of chronic obstructive pulmonary disease ( COPD ) with acute hypercapnic respiratory failure . The rate of weaning failure is high and prolonged MV increases intubation associated complications . Objective : To evaluate the role of Noninvasive ventilation ( NIV ) in weaning patients of chronic obstructive pulmonary disease ( COPD ) from MV , after T piece trial failure . Design : A prospect i ve , r and omized , controlled study was conducted in a tertiary care centre . 30 patients of acute exacerbation of COPD with acute on chronic hypercapnic respiratory failure , who were mechanically ventilated , were included in the study A T-piece weaning trial was attempted once the patients achieved satisfactory clinical and biochemical parameters . After T-piece failure , defined as pH < 7.35 , PaCO2 > 50 mmHg , PaO2 < 50 mmHg , HR > 100/min , RR > 35 , patients were r and omized to receive either NIV or PSV . Results : Demography , severity of disease and clinical profiles were similar in both groups . No significant difference between the two groups in duration of MV ( 6.20 ± 5.20 days vs. 7.47 ± 6.38 days , P > 0.05 ) , duration of weaning ( 35.17 ± 16.98 and 47.05 ± 20.98 hours , P > 0.05 ) or duration of ICU stay ( 8.47 ± 4.79 and 10.80 ± 5.28 days , P > 0.05 ) in Gp I and Gp II , respectively . Five patients developed VAP in the PSV group , where as only one patient had pneumonia in the NIV group . Lesser number of deaths in the NIV group at discharge from ICU ( 3 vs. 5 patients , respectively ) and at 30 days ( 5 vs. 9 patients , respectively ) , it did not achieve statistical significance ( P > 0.05 ) . Conclusion : NIV is as useful as PSV in weaning and can be better in weaning failure especially in COPD for earlier weaning , decrease ICU stay , complications and mortality Objective : Noninvasive mask ventilation ( NIV ) is a treatment option in acute respiratory failure in adults . This study was performed to determine prognostic variables for the success of NIV in a group of infants and children with respiratory failure for a wide range of reasons . Design : Prospect i ve , clinical study . Setting : Multidisciplinary , neonatal – pediatric intensive care unit of a university teaching hospital . Methods : Descriptive study of infants and children ≤16 yrs of age with acute respiratory failure requiring assisted ventilation . During 2002–2003 , patients with hypoxemic or hypercarbic respiratory failure , signs of respiratory distress , and described by the attending critical care physician as likely to require intubation , were eligible to receive mask ventilation as an alternative means of respiratory support . Patients were not selected for their underlying disease contributing to the respiratory problems . Depending on whether they failed NIV and had to be intubated , the children were assigned to nonresponders or responders groups . The two groups were compared regarding physiologic variables prospect ively evaluated before NIV and at 1 , 8 , 24 , and 48 hrs of NIV . Results : A total of 42 patients were included . Their median age was 2.45 yrs ( range , 0.01–18 yrs ) . Twenty-one patients required mask ventilation only with continuous positive airway pressure and 21 with biphasic positive airway pressure . In both responders ’ and nonresponders ’ blood gas results , heart rate and respiratory rate improved significantly after initiation of NIV ( p < .0001 ) . The courses of these variables did not differentiate between the two groups . The overall success rate  of NIV was 57 % . After 1 hr of NIV , there was a significantly higher Fio2 in patients who failed NIV than in responders . An Fio2 of > 80 % after 1 hr of NIV predicted nonresponse with a sensitivity of 56 % , specificity of 83 % , and positive and negative predictive value of 71 % . Conclusion : NIV can be successfully applied to infants and children with acute respiratory failure in the setting of a pediatric intensive care unit . The level of Fio2 after 1 hr of NIV may be a predictive factor for the treatment success Abstract Objective : To evaluate the cost effectiveness of st and ard treatment with and without the addition of ward based non-invasive ventilation in patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease . Design : Incremental cost effectiveness analysis of a r and omised controlled trial . Setting : Medical wards in 14 hospitals in the United Kingdom . Participants : The trial comprised 236 patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease and mild to moderate acidosis ( pH 7.25 - 7.35 ) secondary to respiratory failure . The economic analysis compared the costs of treatment that these patients received after r and omisation . Main outcome measure : Incremental cost per in-hospital death . Results : 24/118 died in the group receiving st and ard treatment and 12/118 in the group receiving non-invasive ventilation ( P=0.05 ) . Allocation to the group receiving non-invasive ventilation was associated with a reduction in costs of £ 49 362 ( $ 78 741 ; € 73 109 ) , mainly through reduced use of intensive care units . The incremental cost effectiveness ratio was −£645 per death avoided ( 95 % confidence interval −£2310 to £ 386 ) , indicating a dominant ( more effective and less costly ) strategy . Modelling of these data indicates that a typical UK hospital providing a non-invasive ventilation service will avoid six deaths and three to nine admissions to intensive care units per year , with an associated cost reduction of £ 12 000–53 000 per year . Conclusions : Non-invasive ventilation is a highly cost effective treatment that both reduced total costs and improved mortality in hospital . What is already known on this topic Non-invasive ventilation  reduces the need for intubation and mortality in hospital in patients with acute exacerbations of chronic obstructive pulmonary disease and acute respiratory failure The procedure is feasible in the ward or intensive care environment What this study adds Non-invasive ventilation given on wards reduces the need for intubation by 44 % and halves mortality in hospital in patients with chronic obstructive pulmonary disease and mild to moderate acidosis The early use of non-invasive ventilation on the ward reduces costs and improves outcomes compared with traditional medical treatment The main cost saving is in preventing the use of intensive care Objectives To determine the effectiveness of noninvasive positive pressure ventilation ( NIPPV ) , and the factors predicting failure of NIPPV in acute respiratory failure ( ARF ) due to chronic obstructive pulmonary disease ( COPD ) versus other causes of ARF . Patients and methods This was a prospect i ve observational study and all patients with ARF requiring NIPPV over a one- and -a-half year period were enrolled in the study . We recorded the etiology of ARF and prospect ively collected the data for heart rate , respiratory rate , arterial blood gases ( pH , partial pressure of oxygen in the arterial blood [ PaO2 ] , partial pressure of carbon dioxide in arterial blood [ PaCO2 ] ) at baseline , one and four hours . The patients were further classified into two groups based on the etiology of ARF as COPD –ARF and ARF due to other causes . The primary outcome was the need for endotracheal intubation during the intensive care unit ( ICU ) stay . Results During the study period , 248 patients were admitted in the ICU and of these 63 ( 25.4 % ; 24 , COPD –ARF , 39 , ARF due to other causes ; 40 male and 23 female patients ; mean [ st and ard deviation ] age of 45.7 [ 16.6 ] years ) patients were initiated on  NIPPV .  Patients with ARF secondary to COPD were older , had higher APACHE II scores , lower respiratory rates , levels compared to other causes of ARF . After one hour there was lower pH and higher PaCO2 levels with increase a significant decrease in respiratory rate and heart rate and decline in PaCO2 levels in patients successfully managed with NIPPV . However , there was no in pH and PaO2 difference in improvement of clinical and blood gas parameters between the two groups except at one hour which was significantly the rate of decline of pH at one and four hours and PaCO2 faster in the COPD group . NIPPV failures were significantly higher in ARF due to other causes ( 15/39 ) than in ARF– COPD ( 3/24 ) ( p = 0.03 ) . The mean ICU and hospital stay and the hospital mortality were similar in the two groups . In the multivariate logistic regression model ( after and adjusting for gender , APACHE II scores and improvement in respiratory rate , pH , PaO2 at one hour ) only the etiology of ARF , ie , ARF– COPD , was associated with a decreased PaCO2 risk of  NIPPV  failure ( odds ratio 0.23 ; 95 % confidence interval , 0.58–0.9 ) . Conclusions NIPPV is more effective in preventing endotracheal intubation in ARF due to COPD than other causes , and the etiology of ARF is an important predictor of NIPPV failure Background : In low-income countries and those with a high prevalence of HIV , respiratory failure is a common cause of death in children . However , the role of non-invasive ventilation with bubble continuous positive airway pressure ( bCPAP ) in these patients is not well established . Methods : A prospect i ve observational study of bCPAP was undertaken between July and September 2012 in 77 Malawian children aged 1 week to 14 years with progressive acute respiratory failure despite oxygen and antimicrobial therapy . Results : Forty-one ( 53 % ) patients survived following bCPAP treatment , and an HIV-uninfected single-organ disease subgroup demonstrated bCPAP success in 14 of 17 ( 82 % ) . Compared with children aged ≧60 months , infants of 0–2 months had a 93 % lower odds of  bCPAP  failure ( odds ratio 0·07 , 95 % confidence interval 0·004–1·02 , P = 0·05 ) . Following commencement of bCPAP , respiratory physiology improved , the average respiratory rate decreased from 61 to 49 breaths/minute ( P = 0·0006 ) , and mean oxygen saturation increased from 92·1 % to 96·1 % ( P = 0·02 ) . Conclusions : bCPAP was well accepted by caregivers and patients and can be feasibly implemented into a tertiary African hospital with high-risk patients and limited re sources The aim of this paper is to assess the clinical efficacy of non-invasive ventilation ( NIV ) in avoiding endotracheal intubation ( ETI ) , to demonstrate clinical and gasometric improvement and to identify predictive risk factors associated with NIV failure . An observational prospect i ve clinical study was carried out . Included Patients with acute respiratory disease ( ARD ) treated with NIV , from November 2006 to January 2010 in a Pediatric Intensive Care Unit ( PICU ) . NIV was used in 151 patients with acute respiratory failure ( ARF ) . Patients were divided in two groups : NIV success and NIV failure , if ETI was required . Mean age was 7.2±20.3 months ( median : 1 min : 0,3 max . : 156 ) . Main diagnoses were bronchiolitis in 102 ( 67.5 % ) , and pneumonia in 44 ( 29 % ) patients . There was a significant improvement in respiratory rate ( RR ) , heart rate ( HR ) , pH , and pCO2 at 2 , 6 , 12 and 24 hours after NIV onset ( P<0.05 ) in both groups . Improvement in pulse oximetric saturation/fraction of inspired oxygen ( SpO2/FiO2 ) was verified at 2 , 4 , 6 , 12 and 24 hours after NIV onset in the success group ( P<0.001 ) . In the failure group , significant SpO2/FiO2 improvement was only observed in the first 4 hours .  NIV failure occurred in 34 patients ( 22.5 % ) . Risk factors for NIV failure were apnea , prematurity , pneumonia , and bacterial co-infection ( P<0.05 ) . Independent risk factors for NIV failure were apneia ( P<0.001 ; odds ratio 15.8 ; 95 % confidence interval : 3.42–71.4 ) and pneumonia ( P<0.001 , odds ratio 31.25 ; 95 % confidence interval : 8.33–111.11 ) . There were no major complications related with NIV . In conclusion this study demonstrates the efficacy of NIV as a form of respiratory support for children and infants with ARF , preventing clinical deterioration and avoiding ETI in most of the patients . Risk factors for failure were related with immaturity and severe infection Background : Use of noninvasive ventilation ( NIV ) outside guideline recommendations is common . We audited use of NIV in our tertiary care critical care unit ( CCU ) to evaluate appropriateness of use and patient outcomes when used outside level I recommendations . Material s and Methods : Prospect i ve observational study of all patients requiring NIV .  Clinical parameters and arterial blood gases were recorded at initiation of NIV and 2 h later ( or earlier if clinical ly warranted ) . NIV titration and decision to intubate were left to the discretion of treating intensivist . Patients were categorized into two groups : Group 1 : Those with level I indications for use of NIV and group 2 : All other levels of indications . Patients were followed until hospital discharge . Results : From January 2010 to June 2010 , 1120 patients were admitted to the CCU . Of these 106 patients required NIV support with 40.6 % ( n = 43/106 ) being in group 1 and 59.4 % ( n = 63/106 ) in group 2 . Of these 35.8 % patients ( 38/106 ) failed NIV and required endotracheal intubation . NIV failure rates ( 41.27 % vs. 27.91 % ; P = 0.02 ) and mortality ( 30.6 % vs. 18.6 % ; P = 0.03 ) were significantly higher in group 2 patients . In a logistic regression analysis Acute Physiology and Chronic Health Evaluation ( APACHE ) II score ( P = 0.02 ) , time on NIV before intubation ( P = 0.001 ) and baseline PaCO2 levels ( P = 0.01 ) were strongly associated with mortality . Conclusion :  Noninvasive ventilation failure and mortality rates were significantly higher when used outside level I recommendations . APACHE II score , baseline PaCO2 and duration on NIV prior to intubation were predictors of increased mortality Background Lack of appropriate reporting of method ological details has previously been shown to distort risk of bias assessment s in r and omized controlled trials . The same might be true for observational studies . The goal of this study was to compare the Newcastle-Ottawa Scale ( NOS ) assessment for risk of bias between review ers and authors of cohort studies included in a published systematic review on risk factors for severe outcomes in patients infected with influenza . Methods Cohort studies included in the systematic review and published between 2008–2011 were included . The corresponding or first authors completed a survey covering all NOS items . Results were compared with the NOS assessment applied by review ers of the systematic review . Inter-rater reliability was calculated using kappa ( K ) statistics . Results Authors of 65/182 ( 36 % ) studies completed the survey . The overall NOS score was significantly higher ( p < 0.001 ) in the review ers ’ assessment ( median = 6 ; interquartile range [ IQR ] 6–6 ) compared with those by authors ( median = 5 , IQR 4–6 ) . Inter-rater reliability by item ranged from slight ( K = 0.15 , 95 % confidence interval [ CI ] = −0.19 , 0.48 ) to poor ( K = −0.06 , 95 % CI = −0.22 , 0.10 ) . Reliability for the overall score was poor ( K = −0.004 , 95 % CI = −0.11 , 0.11 ) . Conclusions Differences in assessment and low agreement between review ers and authors suggest the need to contact authors for information not published in studies when applying the NOS in systematic review Noninvasive positive pressure ventilation ( NPPV ) refers to the delivery of mechanical respiratory support without the use of endotracheal intubation ( ETI ) . The present review focused on the effectiveness of NPPV in children > 1 month of age with acute respiratory failure ( ARF ) due to different conditions . ARF is the most common cause of cardiac arrest in children . Therefore , prompt recognition and treatment of pediatric patients with pending respiratory failure can be lifesaving . Mechanical respiratory support is a critical intervention in many cases of ARF . In recent years , NPPV has been proposed as a valuable alternative to invasive mechanical ventilation ( IMV ) in this acute setting . Recent physiological studies have demonstrated beneficial effects of NPPV in children with ARF . Several pediatric clinical studies , the majority of which were noncontrolled or case series and of small size , have suggested the effectiveness of NPPV in the treatment of ARF due to acute airway ( upper or lower ) obstruction or certain primary parenchymal lung disease , and in specific circumstances , such as postoperative or postextubation ARF , immunocompromised patients with ARF , or as a means to facilitate extubation . NPPV was well tolerated with rare major complications and was associated with improved gas exchange , decreased work of breathing , and ETI avoidance in 22 - 100 % of patients . High FiO2 needs or high PaCO2 level on admission or within the first hours after starting NPPV appeared to be the best independent predictive factors for the  NPPV failure in children with ARF . However , many important issues , such as the identification of the patient , the right time for NPPV application , and the appropriate setting , are still lacking . Further r and omized , controlled trials that address these issues in children with ARF are recommended STUDY OBJECTIVE To compare the efficacy of st and ard medical therapy ( ST ) and noninvasive mechanical ventilation additional to st and ard medical therapy in hypercapnic acute respiratory failure ( HARF ) . DESIGN Single center , prospect i ve , r and omized , controlled study . SETTING Pulmonary medicine directed critical care unit in a university hospital . PATIENTS Between March 1993 and November 1996 , 30 HARF patients were r and omized to receive ST or noninvasive positive pressure ventilation ( NPPV ) in addition to ST .  INTERVENTIONS NPPV was given with an air-cushioned face via a mechanical ventilator ( Puritan Bennett 7200 ) with initial setting of 5 cm H2O continuous positive airway pressure and 15 cm H2O pressure support . RESULTS At the time of r and omization , patients in the ST group had ( mean+/-SD ) PaO2 of 54+/-13 mm Hg , PaCO2 of 67+/-11 mm Hg , pH of 7.28+/-0.02 , and respiratory rate of 35.0+/-5.8 breaths/min . Patients in the NPPV group had PaO2 of 55+/-14 , PaCO2 of 69+/-15 , pH of 7.27+/-0.07 , and respiratory rate of 34.0+/-8.1 breaths/min . With ST , there was significant improvement of only respiratory rate ( p < 0.05 ) . However , with NPPV , PaO2 ( p < 0.001 ) , PaCO2 ( p < 0.001 ) , pH ( p < 0.001 ) , and respiratory rate ( p < 0.001 ) improved significantly compared with baseline . Six hours after r and omization , pH ( p < 0.01 ) and respiratory rate ( p < 0.01 ) in NPPV patients were significantly better than with ST . Hospital stay for NPPV vs ST patients was , respectively , 11.7+/-3.5 and 14.6+/-4.7 days ( p < 0.05 ) . One patient in the NPPV group required invasive mechanical ventilation . The conditions of six patients in the ST group deteriorated and they were switched to NPPV ; this was successful in four patients , two failures were invasively ventilated . CONCLUSION This study suggests that early application of NPPV in HARF patients facilitates improvement , decreases need for invasive mechanical ventilation , and decreases the duration of hospitalization BACKGROUND AND METHODS The role of noninvasive positive-pressure ventilation delivered through a face mask in patients with acute respiratory failure is uncertain . We conducted a prospect i ve , r and omized trial of noninvasive positive-pressure ventilation as compared with endotracheal intubation with conventional mechanical ventilation in 64 patients with hypoxemic acute respiratory failure who required mechanical ventilation . RESULTS Within the first hour of ventilation , 20 of 32 patients ( 62 percent ) in the noninvasive-ventilation group and 15 of 32 ( 47 percent ) in the conventional-ventilation group had an improved ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen ( PaO2:FiO2 ) ( P=0.21 ) . Ten patients in the noninvasive-ventilation group subsequently required endotracheal intubation . Seventeen patients in the conventional-ventilation group ( 53 percent ) and 23 in the noninvasive-ventilation group ( 72 percent ) survived their stay in the intensive care unit ( odds ratio , 0.4 ; 95 percent confidence interval , 0.1 to 1.4 ; P=0.19 ) ; 16 patients in the conventional-ventilation group and 22 patients in the noninvasive-ventilation group were discharged from the hospital . More patients in the conventional-ventilation group had serious complications ( 66 percent vs. 38 percent , P=0.02 ) and had pneumonia or sinusitis related to the endotracheal tube ( 31 percent vs. 3 percent , P=0.003 ) . Among the survivors , patients in the noninvasive-ventilation group had shorter periods of ventilation ( P=0.006 ) and shorter stays in the intensive care unit ( P=0.002 ) . CONCLUSIONS In patients with acute respiratory failure , noninvasive ventilation was as effective as conventional ventilation in improving gas exchange and was associated with fewer serious complications and shorter stays in the intensive care unit Aim : There is sparse data on the role of noninvasive ventilation ( NIV ) in acute respiratory distress syndrome ( ARDS ) from India . Herein , we report our experience with the use of NIV in mild to moderate ARDS . Material s and Methods : This was a prospect i ve observational study involving consecutive subjects of ARDS treated with NIV using an oronasal mask .  Patients were monitored clinical ly with serial arterial blood gas analysis . The success of NIV , duration of NIV use , Intensive Care Unit stay , hospital mortality , and improvement in clinical and blood gas parameters were assessed . The success of NIV was defined as prevention of endotracheal intubation . Results : A total of 41 subjects ( 27 women , mean age : 30.9 years ) were included in the study . Tropical infections followed by abdominal sepsis were the most common causes of ARDS . The use of NIV was successful in 18 ( 44 % ) subjects , while 23 subjects required intubation . The median time to intubation was 3 h. Overall , 19 ( 46.3 % ) deaths were encountered , all in those requiring invasive ventilation . The mean duration of ventilation was significantly higher in the intubated patients ( 7.1 vs. 2.6 days , P = 0.004 ) . Univariate analysis revealed a lack of improvement in PaO2/FiO2 at 1 h and high baseline Acute Physiology and Chronic Health Evaluation II ( APACHE II ) as predictors of NIV failure . Conclusions : Use of NIV in mild to moderate ARDS helped in avoiding intubation in about 44 % of the subjects . A baseline APACHE II score of > 17 and a PaO2/FiO2 ratio < 150 at 1 h predicts NIV failure Dengue hemorrhagic fever ( DHF ) is caused by dengue virus . Patients with DHF grade 3 - 4 , termed Dengue Shock Syndrome ( DSS ) , may develop acute respiratory failure after initial fluid resuscitation . Previously , these patients were treated with oxygen on a nasal cannula , or if necessary with tracheal intubation and mechanical ventilation . In the present prospect i ve r and omized study , we compared the effectiveness of oxygen treatment administered by a face mask vs. nasal continuous positive airway pressure ( NCPAP ) .  Morbidity , mortality , and supportive treatment was evaluated . Thirty-seven patients with DSS complicated by respiratory failure were enrolled . On admission and after 30 min of treatment , clinical and para clinical data were obtained . Chest X-ray revealed pleural effusion in 92 per cent and showed interstitial oedema in 33 per cent . After 30 min of treatment the respiratory rate decreased significantly in the NCPAP group ( p < 0.05 ) , while SaO2 and PaO2 increased in both groups ( p < 0.01 ) . However , subsequently a significant difference of unresponsiveness to treatment between the oxygen mask group and the NCPAP group ( 13/19 vs. 4/18,p < 0.01 ) was noted . Complications of NCPAP or oxygen mask treatment were not documented . We conclude that NCPAP is useful in improving the management of acute respiratory failure in children with DHF/DSS in dengue-endemic areas Outcomes : To compare the benefits of noninvasive ventilation ( NIV ) plus st and ard therapy vs. st and ard therapy alone in children with acute respiratory failure ; assess method effectiveness in improving gas exchange and vital signs ; and assess method safety . Design : Prospect i ve , r and omized , controlled study . Site : Two pediatric intensive care units in Santiago , Chile , at Clínica Santa María and Clínica Dávila , respectively . Patients and Methods : Fifty patients with acute respiratory failure admitted to pediatric intensive care units were recruited ; 25 patients were r and omly allocated to noninvasive inspiratory positive airway pressure and expiratory positive airway pressure plus st and ard therapy ( study group ) ; the remaining 25 were given st and ard therapy ( control group ) . Both groups were comparable in demographic terms . Interventions and Measurements : The study group received NIV under inspiratory positive airway pressure ranging between 12 cm and 18 cm H2O and expiratory positive airway pressure between 6 cm and 12 cm H2O . Vital signs ( cardiac and respiratory frequency ) , Po2 , Pco2 , pH , and Po2/Fio2 were recorded at the start and 1 , 6 , 12 , 24 , and 48 hrs into the study . Results : Heart rate and respiratory rate improved significantly with NIV . Heart rate and respiratory rate were significantly lower after 1 hr of treatment compared with admission ( p = 0.0009 and p = 0.004 , respectively ) . The trend continued over time , heart rate being significantly lower than control after the first hour and heart rate after 6 hrs . With NIV , Po2/Fio2 improved significantly from the first hour . The endotracheal intubation was significantly lower ( 28 % ) in the NIV group than in the control group ( 60 % ; p = 0.045 ) . Conclusions : NIV improves hypoxemia and the signs and symptoms of acute respiratory failure . NIV seems to afford these patients protection from endotracheal intubation . ( Pediatr Crit Care Med 2008 ; 9:484–489 BACKGROUND Acute respiratory distress syndrome ( ARDS ) is a clinical syndrome of severe dyspnoea of rapid onset , hypoxemia , and diffuse pulmonary infiltrates leading to respiratory failure in the absence of cardiac failure . We did the study to asses various aetiologies of ARDS , to determine the correlation between the diagnostic criteria , mortality predictors , need of mechanical ventilation and the outcome of patients . This was an observational , prospect i ve study in medical intensive care unit ( MICU ) of a tertiary care hospital , over a period of 15 months . METHODS AND MATERIAL This study encompassed 116 patients of ARDS admitted to an MICU at a tertiary care centre in Mumbai . We included all consecutive patients with ARDS in this study . We excluded patients with known ischemic heart diseases , valvular heart diseases or in congestive cardiac failure , chronic kidney diseases with fluid overload states and age below 18 years . RESULTS Males comprised almost 70 % ( 81 ) of the study population and the presentation was more common in younger age group with total mortality of 57.8 % ( 67 out of 116 ) . Factors attributable for ARDS were malaria in 31 patients ( 26.72 % ) , pneumonia in 23 ( 19.82 % ) , sepsis in 20 ( 17.2 % ) , dengue in 15 ( 12.96 % ) , undiagnosed fever in 13 ( 11.1 % ) , leptospirosis in 7 ( 6.03 % ) , pancreatitis in 3 ( 2.58 % ) , H1N1 infection in 2 ( 1.72 % ) , urinary tract infection ( UTI ) in 1 ( 0.86 % ) and UTI with pyelonephritis and Dengue in 1 ( 0.86 % ) patients . Tropical diseases in present study constituted 66 ( 56.89 % ) cases of which 31 ( 47 % ) died . This difference was statistically found to be significant . Mean PaO2/FiO2 was 178.32 amongst discharged and 127.69 amongst those who expired . Sixty patients had severe LIS , out of which 45 ( 75 % ) patients expired , as compared to 56 patients with moderate LIS out of which 22 ( 39.3 % ) expired . CONCLUSIONS Tropical diseases like malaria , dengue , and leptospirosis were the main factors responsible for ARDS . LIS , Modified LIS and PaO2/FiO2 ratio predicted outcome as well as need for mechanical ventilation . Renal failure , metabolic acidosis appeared to be good predictors of mortality OBJECTIVE Noninvasive positive pressure ventilation ( NIPPV ) has been shown to decrease the need for  invasive mechanical ventilation ( MV )  in patients presenting with acute respiratory failure ( ARF ) . We conducted a prospect i ve study to assess if NIPPV use , in a developing country , was associated with clinical and physiological improvements . DESIGN Prospect i ve observational study . MATERIAL S AND METHODS Forty patients admitted to a medical intensive care unit during a 2-year period who fulfilled criteria for inclusion formed the study cohort to receive NIPPV . FINDINGS Baseline ( mean + /- SD ) pH , PaCO 2 and PaO 2 were 7.25 + /- 0.08 , 76.6 + /- 20.9 and 79.18 + /- 40.56 mmHg respectively . The primary indication for NIPPV was hypercapnic respiratory failure ( n = 36 , 90 % ) . The success rate with NIPPV was 85 % , with 34 of 40 patients weaned successfully . Significant improvements were observed at 1 hour following institution of NIPPV in pH ( 7.31 + /- 0.09 , P 2 ( 65 + /- 17.9 , P 2 54.7 + /- 20 ) and maintained ( within 12 h ) postweaning from the ventilator ( pH 7.39 + /- 0.08 , PaCO 2 51.9 + /- 12.4 ) . No significant change in the PaO 2 was observed during NIPPV ; PaO 2 after 1 h , prior to weaning and after weaning was 90.53 + /- 42.85 , 84.80 + /- 33.76 , 78.71 + /- 43.81 respectively . CONCLUSION This study has demonstrated benefits of NIPPV in avoiding the need for invasive MV in patients presenting with ARF of diverse etiology , with results comparable to developed nations . Increased use of NIPPV in ARF is likely to impact favorably in nations with limited re sources BACKGROUND Within the intensive-care unit , non-invasive ventilation ( NIV ) can prevent the need for intubation and the mortality associated with severe episodes of chronic obstructive pulmonary disease ( COPD ) . The aim of this study was to find whether the introduction of NIV , early after the admission on a general respiratory ward , was effective at reducing the need for intubation and the mortality associated with acute exacerbations of COPD . METHODS We did a prospect i ve multicentre r and omised controlled study comparing NIV with st and ard therapy in patients with mild to moderate acidosis .  NIV was administered on the ward with a simple non-invasive ventilator and a st and ardised predefined protocol . Patients were recruited from 14 UK hospitals over 22 months . FINDINGS 236 patients were recruited , 118 received st and ard therapy alone and 118 additional NIV . The two groups had similar characteristics at enrolment . The use of NIV significantly reduced the need for intubation as defined by the failure criteria . 32/118 ( 27 % ) of the st and ard group failed compared with 18/118 ( 15 % ) of the NIV group ( p=0.02 ) . In-hospital mortality was also reduced by NIV , 24/118 ( 20 % ) died in the st and ard group compared with 12/118 ( 10 % ) in the NIV group ( p=0.05 ) . In both groups pH , PaCO2 , and respiratory rate improved at 4 h ( p<0.01 ) . However , NIV led to a more rapid improvement in pH in the first hour ( p=0.02 ) and a greater fall in respiratory rate at 4 h ( p=0.035 ) . The duration of breathlessness was also reduced by NIV ( p=0.025 ) . INTERPRETATION The early use of NIV for mildly and moderately acidotic patients with COPD in the general ward setting leads to more rapid improvement of physiological variables , a reduction in the need for invasive mechanical ventilation ( with objective criteria ) , and a reduction in in-hospital mortality OBJECTIVES To determine the outcomes of noninvasive ventilation ( NIV ) and the factors associated with NIV failure in patients with acute hypoxemic respiratory failure ( AHRF ) . METHODS This was a prospect i ve observational study and all patients with AHRF requiring NIV over a one- and -a-half-year period were enrolled in the study . We recorded the etiology of AHRF and prospect ively collected the data for heart rate , respiratory rate , arterial blood gases ( pH , P(aO2 ) , P(aCO2 ) ) at baseline , 1 hour , and 4 hours . The patients were further classified into 2 groups , based on the etiology of AHRF : either acute lung injury/acute respiratory distress syndrome [ ALI/ARDS ] , or AHRF due to other causes . The primary outcome was the need for endotracheal intubation during the ICU stay . RESULTS During the study period , 287 patients were admitted in the ICU , and of these 40 ( 13.9 % ) ( 21 ALI/ARDS , 19 AHRF due to other causes ; 16 male , 24 female patients ; mean + /- SD age 43.2 + /- 20.6 years ) patients with AHRF were initiated on NIV .  The baseline characteristics were similar in the 2 groups . After 1 hour there was a significant decrease in respiratory rate and heart rate , with increase in pH and P(aO2 ) ; however , there was no difference in improvement of clinical and blood-gas parameters between the 2 groups . The NIV failures , the mean ICU and hospital stay , and the hospital mortality were similar in the 2 groups . In the univariate logistic regression model the only factor associated with NIV failure was the baseline ratio of P(aO2 ) to fraction of inspired oxygen ( P(aO2)/F(IO2 ) ) ( odds ratio 0.97 , 95 % confidence interval 0.95 - 0.99 ) . CONCLUSIONS NIV should be judiciously used in patients with AHRF . A low baseline P(aO2)/F(IO2 ) ratio was associated with NIV failure Objective Identification of predictive factors for non-invasive ventilation ( NIV ) failure and determination of NIV characteristics . Design Prospect i ve observational study . Setting Paediatric Intensive Care Unit in a University Hospital . Patients and measurements A total of 116 episodes were included . Clinical data collected were respiratory rate ( RR ) , heart rate and FiO2 before NIV began . Same data and expiratory and support pressures were collected at 1 , 6 , 12 , 24 and 48 h. Conditions precipitating acute respiratory failure ( ARF ) were classified into two groups : type 1 ( 38 episodes ) and type 2 ( 78 episodes ) . Ventilation – perfusion impairment was the main respiratory failure mechanism in type 1 , and hypoventilation in type 2 . Factors predicting NIV failure were determined by multivariate analysis . Results Most common admission diagnoses were pneumonia ( 81.6 % ) in type 1 and bronchiolitis ( 39.7 % ) and asthma ( 42.3 % ) in type 2 . Complications secondary to NIV were detected in 23 episodes ( 20.2 % ) . NIV success rate was 84.5 % ( 68.4 % in type 1 and 92.3 % in type 2 ) . Type 1 patients showed a higher risk of NIV failure compared to type 2 ( OR 11.108 ; CI 95 % , 2.578–47.863 ) . A higher PRISM score ( OR 1.138 ; CI 95 % , 1.022–1.267 ) , and a lower RR decrease at 1 h and at 6 h ( OR 0.926 ; CI 95 % , 0.860–0.997 and OR 0.911 ; CI 95 % , 0.837–0.991 , respectively ) were also independently associated with NIV failure . Conclusions NIV is a useful respiratory support technique in paediatric patients . Type 1 group classification , higher PRISM score , and lower RR decrease during NIV were independent risk factors for NIV failure Non-invasive positive pressure ventilation ( NPPV ) is a well established therapy for acute respiratory failure in patients with chronic obstructive pulmonary disease , however its role in post-extubation period is uncertain . The objective of this study was to find the effect of NPPV on rate of re-intubation , intensive care unit and hospital stay , and physiological parameters in severe chronic obstructive pulmonary disease patients after planned extubation . Forty patients with severe chronic obstructive pulmonary disease were r and omised immediately after planned extubation to receive NPPV ( n=20 ) or conventional therapy ( n=20 ) . NPPV was delivered with mean levels of inspiratory positive-airway pressure of 12.10±1.37 cmH2O and expiratory positive-airway pressure of 6.50±1.00 cmH2O for a mean period of 34.75±10 hours for 7 to 11 hours/day . Patients in conventional therapy group received usual treatment . Reintubation rate  among NPPV ( 15 % ) and conventional ( 25 % ) were similar ( P=0.44 ) . The duration of intensive care unit stay after extubation ( 2.05±2.15 vs 1.55±0.82 days , P=0.34 ) and hospital stay ( 16.10±6.29 vs 18.25±7.91 days , P=0.34 ) in both groups were comparable . Given the load of chronic obstructive pulmonary disease patients and wide availability of NPPV , it is safe to recommend its use in these patients soon after extubation , although clear benefit is not documented in this study OBJECTIVE To describe the outcomes of infants and young children with respiratory distress when treated with a novel , low-cost , st and -alone bubble Continuous Positive Airway Pressure ( bCPAP ) system in a re source -limited setting . METHODS A non-r and omized , convenience sample study in a pediatric unit in Blantyre , Malawi , 2013 . Patients weighing ≤10 kg with respiratory distress were eligible . We compared outcomes for patients with bronchiolitis , pneumonia and Pneumocystis jiroveci pneumonia ( PJP ) after treatment with bCPAP . RESULTS Seventy percent of patients treated with bCPAP  survived . Outcomes were best for patients with bronchiolitis and worst for those with PJP . Most survivors ( 80 % ) showed improvement within 24 h. All treating physicians found bCPAP useful , leading to a change in practice . CONCLUSIONS Bubble CPAP was most beneficial to patients with bronchiolitis . Children , who were going to get well , tended to get well quickly . Physicians believed the bCPAP system provided a higher level of care than nasal oxygen Background and Aims : The 2009 p and emic influenza A ( H1N1 ) has taken its toll across most parts of India . We aim ed to study its epidemiology , clinical characteristics and outcomes from an Indian multidisciplinary intensive care unit ( ICU ) . Material s and Methods : All patients admitted to our ICU with a flu-like illness and who tested positive for the 2009 H1N1 by reverse -transcriptase polymerase- chain -reaction assay during a 3 month period were prospect ively studied . Results : Thirty one patients were admitted to the ICU during the study period . Patients were in the younger age group with a median age of 35 years ( IQR : 28.2 - 42.8 ) . Obesity was the commonest risk factor . Twenty six patients ( 83.9 % ) required ventilator support ; the median duration of ventilator support was 10 days ( IQR : 4 - 22 ) . Severe hypoxemia was the predominant feature in all patients . Circulatory failure requiring vasopressors occurred in 18 ( 58.1 % ) patients and acute kidney injury in 6 ( 3.2 % ) patients . Twenty six patients were alive at the end of 28 days ; subsequently all except one were discharged . The median duration of hospital stay was 15 ( IQR : 8 - 22.5 ) days . Increasing APACHE II scores were associated with an increased risk of death ( Hazard Ratio : 1.1 ; CI : 1.08 -1.2 ; P = 0.04 ) . Mean tidal volumes in non-survivors were significantly lower ; this was related to poor lung compliance in this group . Conclusions : 2009 H1N1 infection caused severe disease in relatively young patients without significant co-morbidities , characterized by severe hypoxemia and the requirement for prolonged mechanical ventilation . Extra-pulmonary organ failure included circulatory and renal failure OBJECTIVE Invasive mechanical ventilation is often not an option for children with acute respiratory infections in developing countries . An alternative is continuous positive airway pressure ( CPAP ) . The authors evaluated the effectiveness of CPAP in children presenting with acute respiratory distress in a developing country . STUDY DESIGN A r and omized , controlled trial was conducted in 4 rural hospitals in Ghana . Children , 3 months to 5 years of age , presenting with tachypnea and intercostal or subcostal retractions or nasal flaring were r and omly assigned to receive CPAP immediately or 1 hour after presentation . CPAP was applied by locally trained nurses . The primary outcome measure was change in respiratory rate at 1 hour . RESULTS The study was stopped after the enrollment of 70 subjects because of a predetermined stop value of P < .001 . Mean respiratory rate of children who received immediate CPAP fell by 16 breaths/min ( 95 % CI 10 - 21 ) in the first hour compared with no change in children who had CPAP delayed by 1 hour ( 95 % CI -2 to + 5 ) . Thirty-five of the patients had a positive malaria blood smear . There were 3 deaths as a result of severe malaria . No major complications of CPAP use were noted . CONCLUSIONS CPAP decreases respiratory rate in children with respiratory distress compared with children not receiving CPAP . The technology was successfully used by local nurses . No complications were associated with its use . CPAP is a relatively low-cost , low-technology that is a safe method to decrease respiratory rate in children with nonspecific respiratory distress OBJECTIVE Nasal bubble continuous positive airway pressure ( bCPAP ) is preferred in developing economies for easy applicability and low cost . Because its use in older children is unexplored , we sought to evaluate its utility in hypoxemic clinical pneumonia . METHODS Of 330 children ( 1 month-12 years ) with clinical pneumonia enrolled prospect ively over 1 year , those with increased work of breathing and /or SpO2 < 92 % received bCPAP delivered via an underwater ' T ' tube through nasal prongs . Proportion requiring intubation despite bCPAP constituted primary outcome . Incidence of complications , duration of bCPAP and emergency stay were secondary outcomes . RESULTS Oxygen was initiated by nasal prongs ( NPO2 ) in 204 ( 61.8 % ) , and by bCPAP in 110 ( 33.3 % ) . Sixteen ( 4.8 % ) were intubated at the outset . Fifty-three ( 25.9 % ) on NPO2 were shifted to bCPAP for worsening distress and hypoxemia . Only three ( 1.8 % ) from bCPAP group required intubation , of which one died . Failure rate and complications were negligent . The median emergency stay was 4 days . CONCLUSIONS Nasal bCPAP was safe and effective in children with hypoxemic clinical pneumonia IMPORTANCE Studies of mechanically ventilated critically ill patients that combine population s that are at high and low risk for reintubation suggest that conditioned high-flow nasal cannula oxygen therapy after extubation improves oxygenation compared with conventional oxygen therapy . However , conclusive data about reintubation are lacking . OBJECTIVE To determine whether high-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy for preventing reintubation in mechanically ventilated patients at low risk for reintubation . DESIGN , SETTING , AND PARTICIPANTS Multicenter r and omized clinical trial conducted between September 2012 and October 2014 in 7 intensive care units ( ICUs ) in Spain . Participants were 527 adult critical patients at low risk for reintubation who fulfilled criteria for planned extubation . Low risk for reintubation was defined as younger than 65 years ; Acute Physiology and Chronic Health Evaluation II score less than 12 on day of extubation ; body mass index less than 30 ; adequate secretions management ; simple weaning ; 0 or 1 comorbidity ; and absence of heart failure , moderate-to-severe chronic obstructive pulmonary disease , airway patency problems , and prolonged mechanical ventilation . INTERVENTIONS Patients were r and omized to undergo either high-flow or conventional oxygen therapy for 24 hours after extubation . MAIN OUTCOMES AND MEASURES The primary outcome was reintubation within 72 hours , compared with the Cochran-Mantel-Haenszel χ2 test . Secondary outcomes included postextubation respiratory failure , respiratory infection , sepsis and multiorgan failure , ICU and hospital length of stay and mortality , adverse events , and time to reintubation . RESULTS Of 527 patients ( mean age , 51 years [ range , 18 - 64 ] ; 62 % men ) , 264 received high-flow therapy and 263 conventional oxygen therapy . Reintubation within 72 hours was less common in the high-flow group ( 13 patients [ 4.9 % ] vs 32 [ 12.2 % ] in the conventional group ; absolute difference , 7.2 % [ 95 % CI , 2.5 % to 12.2 % ] ; P = .004 ) . Postextubation respiratory failure was less common in the high-flow group ( 22/264 patients [ 8.3 % ] vs 38/263 [ 14.4 % ] in the conventional group ; absolute difference , 6.1 % [ 95 % CI , 0.7 % to 11.6 % ] ; P = .03 ) . Time to reintubation was not significantly different between groups ( 19 hours [ interquartile range , 12 - 28 ] in the high-flow group vs 15 hours [ interquartile range , 9 - 31 ] in the conventional group ; absolute difference , -4 [ 95 % CI , -54 to 46 ] ; P = .66 ] . No adverse effects were reported . CONCLUSIONS AND RELEVANCE Among extubated patients at low risk for reintubation , the use of high-flow nasal cannula oxygen compared with conventional oxygen therapy reduced the risk of reintubation within 72 hours . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01191489 Background : Chronic obstructive pulmonary disease ( COPD ) patients frequently pose difficulty in weaning from invasive mechanical ventilation ( MV ) . Prolonged invasive ventilation brings along various complications . Non-invasive positive pressure ventilation ( NIPPV ) is proposed to be a useful weaning modality in such cases . Objective : To evaluate the usefulness of NIPPV in weaning COPD patients from invasive MV , and compare it with weaning by conventional pressure support ventilation ( PSV ) . Material s and Methods : For this prospect i ve r and omized controlled study , we included 50 COPD patients with type II respiratory failure requiring initial invasive MV .  Upon satisfying weaning criteria and failing a t-piece weaning trial , they were r and omized into two groups : Group I ( 25 patients ) weaned by NIPPV , and group II ( 25 patients ) weaned by conventional PSV . The groups were similar in terms of disease severity , demographic , clinical and biochemical parameters . They were compared in terms of duration of MV , weaning duration , length of intensive care unit ( ICU ) stay , occurrence of nosocomial pneumonia and outcome . Results : Statistically significant difference was found between the two groups in terms of duration of MV , weaning duration , length of ICU stay , occurrence of nosocomial pneumonia and outcome . Conclusion : NIPPV appears to be a promising weaning modality for mechanically ventilated COPD patients and should be tried in re source -limited setting s especially in developing countries
Purpose : We systematic ally review ed the effects of NIV for acute respiratory failure ( ARF ) in low‐ and low‐middle income countries .
HighlightsAcute respiratory failure is a common indication for hospital admission in children and adults in low/middle‐income countries .