Efficacy of noninvasive CPAP in COPD with acute respiratory failure

Dynamic hyperinflation and the development of intrinsic positive end-expiratory pressure (PEEPi) are commonly observed in patients with severe chronic obstructive pulmonary disease (COPD) in acute respiratory failure. Previous studies have shown that externally applied PEEP reduces PEEPi and its adverse effects in mechanically-ventilated COPD patients. The purpose of this study was to determine the effects of graded amounts of continuous positive airway pressure (CPAP) on the degree of inspiratory effort, pattern of breathing, gas exchange, and level of dyspnoea in a group of spontaneously breathing, nonintubated COPD patients in acute hypercapnic respiratory failure. Ten COPD patients admitted to the intensive care unit in acute hypercapnic respiratory failure were studied. Inspiratory effort was measured by the tidal excursions of oesophageal (Poes) and transdiaphragmatic (Pdi) pressure. Inspiratory effort and both the pressure-time product for the diaphragm (integral of Pdi-dt) and for the inspiratory muscles (integral of Poes.dt) were measured during the application of 5, 7.5, and 10 cmH2O of CPAP. Dyspnoea, gas exchange and pattern of breathing were also assessed. Inspiratory effort and the pressure-time product both for the diaphragm and the inspiratory muscles fell significantly with CPAP in a dose-dependent fashion. Both the pattern of breathing and level of dyspnoea improved with CPAP. End-expiratory lung volume remained stable at the lower levels of CPAP, with only modest increases at the higher levels. Arterial oxygen tension (Pa,O2) and arterial carbon dioxide tension (Pa,CO2) either improved or remained stable with CPAP. We conclude that the noninvasive application of CPAP to spontaneously breathing patients with severe COPD in acute respiratory failure decreases inspiratory effort and dyspnoea whilst improving breathing pattern. It is conceivable that the early institution of CPAP in this setting may obviate the need for intubation and conventional mechanical ventilation.