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Intubation after noninvasive ventilation failure in chronic obstructive pulmonary disease: associated factors at emergency department presentation

van Gemert, Johanna P.a; Brijker, Folkertb; Witten, Marja A.c; Leenen, Loek P.H.d

European Journal of Emergency Medicine: February 2015 - Volume 22 - Issue 1 - p 49–54
doi: 10.1097/MEJ.0000000000000141

Objective Noninvasive ventilation (NIV) is a common practice in acute hypercapnic respiratory failure (AHRF) because of exacerbation of chronic obstructive pulmonary disease (COPD). However, a recent study has shown that patients who require invasive mechanical ventilation (IMV) after failure of NIV experience high mortality rates (up to 30%). Therefore, the aim of this study is to determine the parameters, specifically for emergency department (ED) presentation, associated with the transition from NIV to IMV because of NIV failure.

Patients and methods This is a 4-year retrospective cohort study in the EDs of two Dutch hospitals. International Classification of Disease codes were used to identify 139 COPD patients treated with NIV. Those with AHRF (pH limits: 7.25–7.35), a full resuscitation order, and those without a pneumonia were selected for the study (n=40 with 50 NIV episodes). Parameters in patients treated successfully with NIV were compared with those in patients requiring transition to IMV due to NIV failure. Univariable regression analysis was used and, if P-value less than 0.20, analyses were entered into a multivariable logistic regression analysis model.

Results NIV was successful in 33 (66%) patients, 10 (20%) required transition to IMV, and seven (14%) died. Age over 65 years and a Glasgow Coma Score less than 15 were associated significantly with the transition from NIV to IMV in multivariable analysis (P<0.05).

Conclusion Older age and a low Glasgow Coma Score at ED presentation are factors associated with the transition from NIV to IMV in COPD patients with AHRF.

aDepartment of Internal Medicine, Academic Medical Center, Amsterdam

bDepartment of Pulmonology, Diakonessenhuis, Utrecht

Departments of cEmergency Medicine

dSurgery, University Medical Centre, Utrecht, The Netherlands

Correspondence to Johanna P. van Gemert, MD, Department of Internal Medicine, Academic Medical Center, Room No. F4-222, PO Box 22660, 1100 DD Amsterdam, The Netherlands Tel: +31 062 495 7208; fax: +31 20 566 4440; e-mail:

Received November 28, 2013

Accepted February 18, 2014

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.