Quality statement 7: Non‑invasive ventilation

Quality statement

People with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy have non‑invasive ventilation. [2011, updated 2016]

Rationale

Non‑invasive ventilation is used to treat persistent hypercapnic ventilatory failure and acidosis during an exacerbation of COPD, when a person's arterial blood gases (especially the pH and carbon dioxide levels) are not responding (or worsening) despite optimal medical management. Non‑invasive ventilation should be delivered in a dedicated setting by staff trained and experienced in its use because of safety concerns with using the equipment.

Quality measures

Structure

Evidence of local arrangements to ensure that people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non‑invasive ventilation.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme.

Process

Proportion of people with an exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment who have non‑invasive ventilation.

Numerator – the number in the denominator who have non‑invasive ventilation.

Denominator – the number of people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy.

Outcome

Mortality rates.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme.

What the quality statement means for different audiences

Service providers (secondary care services and A&E departments) ensure that people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non‑invasive ventilation.

Healthcare professionals ensure that people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non‑invasive ventilation. Healthcare professionals are trained and experienced in using non‑invasive ventilation.

Commissioners (clinical commissioning groups) ensure that they commission services in which people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non‑invasive ventilation.

People with COPD who have 'ventilatory failure' during a sudden flare up of their symptoms (called an acute exacerbation) are given an emergency treatment called non‑invasive ventilation if they do not improve after 1 hour of treatment with medicine and oxygen. Ventilatory failure happens when a person can't breathe deeply enough and waste carbon dioxide builds up in the blood causing acid to form. Non‑invasive ventilation involves wearing a mask connected to a machine that pumps oxygen into the lungs.

Source guidance

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018, updated 2019) NICE guideline NG115, recommendation 1.3.33

Definitions of terms used in this quality statement

Acute exacerbation

An acute exacerbation is a sustained worsening of a person's symptoms from their stable state, and which is beyond usual day‑to‑day variations and acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour.

[Adapted from NICE's guideline on chronic obstructive pulmonary disease]

Persistent acidotic hypercapnic ventilatory failure

Acute acidotic hypercapnic respiratory failure results from an inability of the respiratory system to provide sufficient alveolar ventilation to maintain a normal arterial PCO2 and blood pH level. Co‑existent hypoxaemia is usually mild and easily corrected. Conventionally, a pH <7.35 and a PCO2 >6.5 kPa, persisting after initial medical therapy, define acute respiratory acidosis and have been used as threshold values for considering the use of non‑invasive ventilation. More severe degrees of acidosis, such as pH <7.25, have been used as a threshold for considering provision of invasive mechanical ventilation.

[Adapted from NICE's guideline on chronic obstructive pulmonary disease and expert consensus]

Non‑invasive ventilation

Non‑invasive ventilation is a method of providing ventilatory support that does not require an endotracheal tube. It is usually delivered through a mask that covers the nose or a mask covering the nose and the mouth.

[NICE's guideline on chronic obstructive pulmonary disease]

Non‑invasive ventilation should be given once it is recognised that a person is not responding to 1 hour of optimal medical therapy.

[Expert consensus]

Optimal medical treatment

Controlled oxygen therapy, nebulised bronchodilator therapy, systemic corticosteroids and antibiotics if indicated, in line with the NICE guideline.

[NICE's guideline on chronic obstructive pulmonary disease]