IntroductionNon-invasive ventilation (NIV) in the management of acute type II respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. The National Institute for Health and Clinical Excellence (NICE) recommend that NIV be available in all hospitals admitting patients with COPD. 1 This has led to a rapid expansion in the provision of NIV services with over 90% of UK admitting hospitals offering this intervention. The UK national audit of acute hospital COPD care in 2003, however, suggested that treatment was often applied to patients outside the existing British Thoracic Society (BTS) inclusion criteria. 2,3 This document updates the 2002 BTS guidance and provides a specific focus on the use of NIV in COPD patients with acute type 2 respiratory failure. While there are a variety of ventilator units available most centres now use bi-level positive airways pressure (BiPAP) units and this guideline refers specifically to this form of ventilatory support although many of the principles encompassed are applicable to other forms of NIV. The guideline has been produced for the clinician caring for COPD patients in the emergency and ward areas of acute hospitals. Guideline development was in accordance with the AGREE principles and is summarised in the online version of this guideline (www.rcplondon. ac.uk/pubs/brochure.aspx?e=258). An extended version of this guideline encompassing service provision is available on the BTS website. Clinical contextNon-invasive ventilation, within the intensive care unit and the ward environment, has been shown in randomised controlled trials and systematic reviews to reduce intubation rate and mortality in COPD patients with decompensated respiratory acidosis (pH <7.35 and PaCO 2 >6 kPa) following immediate medical therapy. 5-14 It should therefore be considered within the first 60 minutes of hospital arrival in all patients with an acute exacerbation of COPD in whom a respiratory acidosis persists despite maximum standard medical treatment, which includes:• controlled oxygen to maintain SaO 2 88-92% • nebulised salbutamol 2.5-5 mg • nebulised ipratroprium 500 µg • prednisolone 30 mg • antibiotic agent (when indicated).A clearly documented treatment plan for NIV, including how potential failure will be dealt with and whether escalation to intubation and mechanical ventilation is indicated, should be documented in the case notes at the outset of treatment. Whenever possible the patient and carers should be involved in these discussions. Once started, patient comfort, breathing synchrony and enhanced compliance are key factors in determining outcome. Low starting pressures increase patient compliance but should be quickly adjusted upwards to achieve therapeutic effect. If effective, treatment will usually be required until the acute cause has resolved, commonly about two to three days.s CONCISE GUIDELINES

The use of a positive expiratory pressure (PEP) mask was compared with postural drainage in the treatment of 10 patients with cystic fibrosis. The patients were allocated randomly in a crossover fashion to the two regimens and evaluated initially by a physiotherapist and over a 4 week treatment period by use of a diary card. There was no significant difference in sputum production or change in lung function between each technique as assessed by the physiotherapist. Diary card evaluation also failed to demonstrate a difference in sputum production, symptom score or peak expiratory flow rate between the 4 week treatment periods. It was concluded that PEP mask therapy is an acceptable and effective alternative to postural drainage in interval therapy of patients with cystic fibrosis, although the patients have tended to revert to postural drainage during acute exacerbations.

A 4.5 year old boy with cerebral palsy presented with seizures associated with facial flushing and tachycardia following the instillation of 1% cyclopentolate, a commonly used mydriatic in paediatric practice. He had no prior history of convulsions. This case demonstrates the uncommon, though serious, atropine-like side effect of cyclopentolate eyedrops (Cyclogyl, Alcon) in usual dosage in a brain damaged child without an epileptic focus.

CL. Exercise capacity reflects airflow limitation rather than hypoxaemia in patients with pulmonary arteriovenous malformations. QJM. 2019 In Press Exercise capacity reflects airflow limitation rather than hypoxaemia in patients with pulmonary arteriovenous malformations

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