Managing acute hypercapnic respiratory failure in adults: where do we need to get to?

The concept of augmenting spontaneous breathing effort by a close fitting face mask has evolved from initial case reports, nearly two decades ago, to become part of mainstream acute clinical care. Indeed, it has become the preferred option to invasive ventilation in many cases of acute hypercapnic respiratory failure (AHRF). In the UK, service development has been driven largely by respiratory physicians and this has resulted in an unintended, and unhelpful, dichotomy of responsibility for patient care. NIV guidelines that have been published have, by being concerned with the practicalities of delivery of a new service, failed to promote appropriate integration between those providing the acute NIV service and intensivists, the gate keepers to the intensive care unit (ICU) and who manage the invasively ventilated patient. The joint British Thoracic Society (BTS) and Intensive Care Society guideline for ‘the ventilatory management of acute hypercapnic respiratory failure in adults’, a supplement to this edition of Thorax , instead aims to promote shared clinical responsibility and reviews the evidence base for both invasive and NIV in the variety of conditions that may present as AHRF. Hypercapnic respiratory failure is less common than hypoxic respiratory failure but is still a frequent cause of emergency hospital admission. It complicates around 20% of acute exacerbations of COPD (AECOPD), signalling advanced disease, a high risk of future hospital admission and limited long-term prognosis. Its presence increases the mortality of an exacerbation from 8% to as much as 30%, depending on the degree of respiratory acidosis.1 Morbid obesity is now the second most common cause of AHRF …