This document has been developed by an international committee and has been endorsed by both the ATS and the ERS. It places pulmonary rehabilitation within the concept of integrated care. The World Health Organization has defined integrated care as "a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion" (1). Integration of services improves access, quality, user satisfaction, and efficiency of medical care. As such, pulmonary rehabilitation provides an opportunity to coordinate care and focus on the entire clinical course of an individual's disease.Building on previous statements (2, 3), this document presents recent scientific advances in our understanding of the multisystemic effects of chronic respiratory disease and how pulmonary rehabilitation addresses the resultant functional limitations. It was created as a comprehensive statement, using both a firm evidence-based approach and the clinical expertise of the writing committee. As such, it is complementary to two current documents on pulmonary rehabilitation: the American College of Chest Physicians and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) evidence-based guidelines (4), which formally grade the level of scientific evidence, and the AACVPR Guidelines for Pulmonary Rehabilitation Programs (5), which give practical recommendations.

The study was designed to assess the patterns of use of home mechanical ventilation (HMV) for patients with chronic respiratory failure across Europe.A detailed questionnaire of centre details, HMV user characteristics and equipment choices was sent to carefully identified HMV centres in 16 European countries.A total of 483 centres treating 27,118 HMV users were identified. Of these, 329 centres completed surveys between July 2001 and June 2002, representing up to 21,526 HMV users and a response rate of between 62% and 79%. The estimated prevalence of HMV in Europe was 6.6 per 100,000 people. The variation in prevalence between countries was only partially related to the median year of starting HMV services. In addition, there were marked differences between countries in the relative proportions of lung and neuromuscular patients using HMV, and the use of tracheostomies in lung and neuromuscular HMV users. Lung users were linked to a HMV duration of ,1 yr, thoracic cage users with 6-10 yrs of ventilation and neuromuscular users with a duration of o6 yrs.In conclusion, wide variations exist in the patterns of home mechanical ventilation provision throughout Europe. Further work is needed to monitor its use and ensure equality of provision and access.

Chronic obstructive pulmonary disease (COPD) patients with chronic ventilatory failure (CVF) are more likely to develop exacerbations, which are an important determinant of health-related quality of life (HRQL). Long-term noninvasive positive-pressure ventilation (NPPV) has been proposed in addition to long-term oxygen therapy (LTOT) to treat CVF but little information is available on its effects on HRQL and resource consumption. Therefore, the current authors undertook a 2-yr multicentric, prospective, randomised, controlled trial to assess the effect of NPPVz LTOT on: 1) severity of hypercapnia; 2) use of healthcare resources, and 3) HRQL, in comparison with LTOT alone.One hundred and twenty-two stable hypercapnic COPD patients on LTOT for o6 months were consecutively enrolled. After inclusion and 1-month run-in, 90 patients were randomly assigned to NPPVzLTOT (n=43) or to LTOT alone (n=47). Arterial blood gases, hospital and intensive care unit (ICU) admissions, total hospital and ICU length of stay and HRQL were primary outcome measures; survival and drop-out rates, symptoms (dyspnoea and sleep quality) and exercise tolerance were secondary outcome measures. Follow-up was performed at 3-month intervals up to 2 yrs.Lung function, inspiratory muscle function, exercise tolerance and sleep quality score did not change over time in either group. By contrast the carbon dioxide tension in arterial blood on usual oxygen, resting dyspnoea and HRQL, as assessed by the Maugeri Foundation Respiratory Failure Questionnaire, changed differently over time in the two groups in favour of NPPVzLTOT. Hospital admissions were not different between groups during the follow-up. Nevertheless, overall hospital admissions showed a different trend to change in the NPPVzLTOT (decreasing by 45%) as compared with the LTOT group (increasing by 27%) when comparing the follow-up with the followback periods. ICU stay decreased over time by 75% and 20% in the NPPVzLTOT and LTOT groups, respectively. Survival was similar.Compared with long-term oxygen therapy alone, the addition of noninvasive positivepressure ventilation to long-term oxygen therapy in stable chronic obstructive pulmonary disease patients with chronic ventilatory failure: 1) slightly decreased the trend to carbon dioxide retention in patients receiving oxygen at home and 2) improved dyspnoea and health-related quality of life. The results of this study show some significant benefits with the use of nocturnal, home noninvasive positive-pressure ventilation in patients with chronic ventilatory failure due to advanced chronic obstructive pulmonary disease patients. Further work is required to evaluate the effect of noninvasive positive-pressure ventilation on reducing the frequency and severity of chronic obstructive pulmonary disease exacerbation. Eur Respir J 2002; 20: 529-538.

Noninvasive pressure support ventilation during weaning reduces weaning time, shortens the time in the intensive care unit, decreases the incidence of nosocomial pneumonia, and improves 60-day survival rates.

Background -Non-invasive mechanical ventilation is increasingly used in the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). The Non-invasive mechanical ventilation is increasingly being used in the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). To date, controlled studies comparing non-invasive mechanical ventilation with endotracheal intubation are lacking, so the use of non-invasive mechanical ventilation as an alternative to intubation might, if unsuccessful, unduly delay endotracheal intubation.l The aim of this study was to identify simple measures which could be used to predict whether patients with COPD could be successfully treated with noninvasive mechanical ventilation, and also to avoid unnecessary delay in intubation of those who deteriorate on non-invasive mechanical ventilation. MethodsWe retrospectively reviewed the data of 47 patients with COPD (31 men) undergoing 59 consecutive episodes of acute respiratory failure. All were chronically hypoxaemic and hypercapnic and on long term oxygen therapy. Patients with relevant concomitant diseases were excluded. All had undergone acute relapses of their primary disease and had been given non-invasive mechanical ventilation and met the following criteria: rapid deterioration in neurological status,5 acute onset of severe hypercapnia (Paco2 >8-5 kPa), acute decrease in pH (<7 35), tachypnoea and/or abdominal paradox. The attending physicians considered that all these patients were likely to require mechanical ventilation and performed a short (1-2 hours) trial of non-invasive mechanical ventilation before endotracheal intubation when, according to their own clinical judgement, the clinical and functional status deteriorated despite non-invasive mechanical ventilation.Mechanical ventilation was added to standard medical and oxygen therapy. Modalities of non-invasive mechanical ventilation were either pressure support ventilation (NPSV) (25 episodes) or intermittent positive pressure ventilation (NIPPV) in assisted/controlled mode (34 episodes) delivered through either nasal or facial masks. The ventilatory settings were as previously described.3 The following data were considered from the case records: