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Non-invasive ventilation (NIV) has been shown to be of benefit in the treatment of decompensated respiratory acidosis due to an exacerbation of chronic obstructive pulmonary disease (COPD).1–3 The reduction in the need for intubation and in mortality offered by this treatment make it at least a useful initial therapy in this situation, and in some cases represents the only option available if the patient is deemed unsuitable for invasive ventilation. Plant et al4 specify ward based NIV in their paper, yet there is no reason why NIV could not be initiated in the emergency department, provided that the equipment is available and the nursing and medical staff are given the necessary training.
NIV has previously been assessed in this role and found to be of use as an initial treatment, with the option of intubation should treatment fail.5 Plant et al4 concur with previous studies that the most important initial data predicting the need for intubation and mortality are the degree of acidosis and level of hypercapnia.6–8 It seems reasonable to assume that the earlier NIV is commenced, provided it is used appropriately, the better the outcome will be. I therefore feel that NIV should be routinely available in the emergency department in order to offer the best initial treatment at the earliest opportunity. Since intubation may well be needed should an initial trial of NIV fail, ICU staff should always be involved at an early stage with frequent reassessment of progress being part of a strict protocol of care.