Noninvasive Ventilation for Patients With COPD Exacerbation and a Do-Not-Intubate Order

Background: In patients with an acute exacerbation of COPD, NIV has been shown to reduce hospital length of stay, the need for intubation, and mortality. Patients with do-not-intubate (DNI) order are on the rise due to increasing awareness of advanced care planning, including those with advanced age, multiple co-morbidities and poor baseline functional status. The role of NIV in COPD exacerbation patients with DNI order remains contentious. We aimed to find predictors of success in this group of patients treated with NIV at our facility. Methods: Single-center, prospective observational study of all COPD exacerbation patients with a DNI order treated with NIV from April 2014 to December 2015, in a tertiary care teaching hospital. NIV was initiated in in patients with respiratory acidosis (pH Results: A total of 36 COPD exacerbation patients with respiratory acidosis and a DNI order received NIV during this period. Median age was 77.0 (71.0 - 84.8) y, and 29 (80.6%) were males. Overall survival to hospital discharge was 66.7%. There was no significant difference in age, BMI, severity of airflow obstruction, and baseline function status between survivors and non-survivors. A greater proportion of survivors were on long-term oxygen therapy compared to non-survivors (83.3% vs. 25%; P=0.001). Non-survivors had a higher proportion of hypertension (83.3% vs. 45.8%; P=0.04) and a lower median pH prior to NIV initiation [7.29 (7.22-7.33) vs. 7.22 (7.13-7.27); P=0.038]. There was no statistical difference in the duration of NIV between survivors and non-survivors [2 (1-4) vs. 1.5 d (1-4.8); P=0.779]. Conclusions: Our study shows that the survival to discharge of COPD exacerbation patients with a DNI order was 66.7%. Conventional predictors of long-term mortality in COPD did not predict outcomes for them. Valid concerns of NIV potentially prolonging the dying process in this subpopulation are perhaps mitigated by short median duration of NIV in the study. There may be a role of NIV in DNI patients with COPD exacerbation complicated by respiratory acidosis, but more studies are needed to elucidate the predictors of poor outcome to better select patients for this intervention.