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What is the key question?
What do guidelines say about how to deliver non-invasive ventilation (NIV) and how are they applied in clinical practice?
What is the bottom line?
Guidelines provide consistent recommendations but NIV is delivered inconsistently.
Why read on?
Understanding how practice can be improved will help to deliver improved care and outcomes for these high-risk patients.
The British Thoracic Society (BTS) first produced a guideline on acute non-invasive ventilation (NIV) in 2002.1 Earlier studies had established a survival benefit and reduced hospital stay for selected patients with chronic obstructive pulmonary disease (COPD).2 3 Patients with milder acute hypercapnic respiratory failure (AHRF) due to COPD (pH 7.30–7.35) could be treated in a ward setting. No benefit was found when ward-based NIV was used for patients with pH<7.30.3 Initially, there was limited availability of NIV in clinical practice,4 though new services developed as the evidence base grew. In 2004, the National Institute for Health and Clinical Excellence (NICE) recommended that NIV should be available in all hospitals admitting patients with COPD.5 The 2002 BTS NIV guideline defined the indications for NIV, described the optimal delivery of NIV and set standards of care. It comprised 41 recommendations (2 at grade A). Key recommendations are shown in table 1.
The 2002 guideline also recommended regular audit of acute NIV services. National audits were emerging and a collaboration between the Royal College of Physicians of London (RCP) and BTS led to a series of national audits of acute hospital COPD care. The 2003 COPD audit showed that NIV was available in 89% of hospitals.6 However, only 31% of patients who presented with AHRF received NIV.7 An updated NIV guideline was produced in 2008, focused on the use of acute NIV to manage patients with AHRF …
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