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We read the BTS guideline on non-invasive ventilation (NIV) in acute respiratory failure1 with great interest. The paper is an excellent summary and a very good reference for a number of situations related to this novel approach. We have, however, some questions which we wish to raise.
Nowadays it is widely accepted that NIV is superior to both invasive mechanical ventilation and standard medical treatment in selected patients with exacerbations of hypercapnic chronic obstructive pulmonary disease (COPD). The skills required for NIV are easily learnt and the equipment required is relatively inexpensive. The complication rate is very low compared with invasive ventilation, and it has been shown by Plant et al2 that NIV is cheaper with a lower mortality rate than standard medical treatment in patients with COPD. The use of NIV outside the ICU and by physicians, nurses, or respiratory care practitioners is also beneficial, allowing early intervention to prevent further respiratory deterioration, access to respiratory support for patients who would not otherwise be admitted to the ICU, and the provision of support in a less intimidating setting. Success rates of NIV in such patients can be higher than 90%,3 depending on appropriate selection of patients, close monitoring in the first 4–6 hours, and the experience of the staff. However, according to the BTS guideline,1 NIV does not appear to be a suitable treatment modality for low income countries because of the limited availability of ICU facilities. Although there is no doubt that the best settings in which to use NIV are those stated in the guideline, it is not always possible for a low income country to set up a countrywide ICU service. The number of patients with acute COPD exacerbations is no lower than in developed countries, so shouldn’t we use NIV in selected COPD patients with acute exacerbations even if there is no ICU service in the near area? Would it be ethical not to use this simple and inexpensive device in those selected patients if you have a well trained staff but no ICU service?
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Author’s reply
In response to the criticism that it is unnecessary to transfer all patients on non-invasive ventilation (NIV) to the care of a respiratory physician as soon as possible, these are guidelines not rules. I am unhappy with the suggestion that NIV should be managed by surgeons, although clearly there may be hospitals where the surgeons have sufficient training and experience in NIV for this to be acceptable. I agree that NIV can be used to palliate breathlessness, but I did not specifically address this area of use in the guideline.
In answer to the question as to whether it would be ethical to use NIV if there is no intensive care service available, I agree that in special circumstances this would be entirely reasonable.