Acute respiratory failure in patients with severe community-acquired pneumonia - A prospective randomized evaluation of noninvasive ventilation

In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) w as found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe community-acquired pneumonia (CA P). We conducted a prospective, randomized study comparing standard treatme nt plus NPPV delivered through a face mask to standard treatment alone in p atients with severe CAP and ARF. Patients fitting the American Thoracic Soc iety criteria for severe CAP were included in presence of ARF (refractory h ypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscit ation, home mechanical ventilation or oxygen long-term supplementation, con comitant severe disease with a low expectation of life, inability to expect orate or contraindications to the use of the mask. Fifty-six consecutive pa tients (28 in each arm) were enrolled, and the two groups were similar at s tudy entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubatio n (21% versus 50%; p = 0.03), and duration of intensive care unit (ICU) sta y (1.8 +/- 0.7 d Versus 6 +/- 1.8 d; p = 0.04). The two groups had a simila r intensity of nursing care workload, time interval from study entry to end otracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those ran domized to NPPV had a lower intensity of nursing care workload (p = 0.04) a nd improved 2-mo survival (88.9% versus 37.5%; p = 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated wit h a significant reduction in the rate of endotracheal intubation and durati on of ICU stay. A 2-mo survival advantage was seen in patients with COPD.