• F S F Ram, J Picot, J Lightowler, and J A Wedzicha.
• National Collaborating Centre for Women and Children's Health, 27 Sussex Place, Regent's Park, London, UK, NW1 4RG. fsfram@yahoo.co.uk
• Cochrane Db Syst Rev. 2004 Jan 1(3):CD004104.

BackgroundNon-invasive positive pressure ventilation (NPPV) is being used increasingly in the management of patients admitted to hospital with acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease (COPD).ObjectivesTo determine the efficacy of NPPV in the management of patients with respiratory failure due to an acute exacerbation of COPD.Search StrategyAn initial search was performed using the Cochrane Airways Group trials register and other relevant electronic databases. An updated search was conducted in September 2003 and another in April 2004.Selection CriteriaRandomised controlled trials comparing NPPV plus usual medical care (UMC) versus UMC alone were selected. Trials needed to recruit adult patients admitted to hospital with respiratory failure due to an exacerbation of COPD and with PaCO2 > 6 kPa (45 mmHg).Data Collection And AnalysisTwo reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted the data.Main ResultsFourteen studies were included in the review. NPPV resulted in decreased mortality (Relative Risk 0.52; 95%CI 0.35 to 0.76), decreased need for intubation (RR 0.41; 95%CI 0.33 to 0.53), reduction in treatment failure (RR 0.48; 95%CI 0.37 to 0.63), rapid improvement within the first hour in pH (Weight Mean Difference 0.03; 95%CI 0.02 to 0.04), PaCO2 (WMD -0.40 kPa; 95%CI -0.78 to -0.03) and respiratory rate (WMD -3.08 bpm; 95%CI -4.26 to -1.89). In addition, complications associated with treatment (RR 0.38; 95%CI 0.24 to 0.60) and length of hospital stay (WMD -3.24 days; 95%CI -4.42 to -2.06) was also reduced in the NPPV group.Reviewers' ConclusionsData from good quality randomised controlled trials show benefit of NPPV as first line intervention as an adjunct therapy to usual medical care in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD. NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, as a means of reducing the likelihood of endotracheal intubation, treatment failure and mortality.

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