One year period prevalence study of respiratory acidosis in acute exacerbations of COPD: implications for the provision of non-invasive ventilation and oxygen administration

Abstract

Background-Non-invasive ventilation (NIV) reduces mortality and intubation rates in patients with chronic obstructive pulmonary disease (COPD) admitted to hospital with respiratory acidosis. This study aimed to determine the prevalence of respiratory acidosis in patients admitted with COPD, to draw inferences about oxygen therapy, and to determine the need for NIV services for acute COPD in typical UK hospitals. Methods-This one year prospective prevalence study identified patients with COPD aged 45-79 years inclusive who were admitted to Leeds General Infirmary, St James's University, and Killingbeck Hospitals, Leeds between 1 March 1997 and 28 February 1998. The prevalence of respiratory acidosis and the relationship with oxygenation are described. Other outcomes included intensive care use and in hospital mortality. From this data population prevalence estimates were determined for respiratory acidosis, from which the need for NIV in a typical district general hospital was modelled. Results-983 patients were admitted, 11 of whom required immediate intubation. 20% of the remaining 972 had a respiratory acidosis. Acidosis was associated with subsequent admission to the intensive care unit (ICU): pH<7.25, OR 6.10 (95% confidence interval (CI) 1.19 to 31.11); pH 7.25-7.30, OR 8.73 (95% CI 2.11 to 36.06). pH was inversely correlated with arterial oxygen tension (PaO 2 ) in the 47% of patients who were hypercapnic, with a PaO 2 of >10 kPa being associated with acidosis in most hypercapnic patients. 80% remained acidotic after initial treatment, giving an age/sex specific prevalence for England and Wales of 75 (95% CI 61 to 90)/ 100 000/year for men aged 45-79 years and 57 (95% CI 46 to 69)/100 000/year for women. Modelling the need for NIV for all COPD patients indicates that a typical UK hospital will admit 90 patients per year with acidosis of which 72 will require NIV. Conclusions-In patients with acute COPD the PaO 2 should be maintained at 7.3-10 kPa (SaO 2 85-92%) to avoid the dangers of hypoxia and acidosis. If all COPD patients with a respiratory acidosis (pH<7.35) after initial treatment are offered NIV, a typical UK hospital will treat 72 patients per year.

Respiratory failure in chronic obstructive pulmonary disease

“…Either way, nursing care is needed to ensure that treatment is used appropriately and blood gas levels should be monitored after treatment to ensure satisfactory therapy without risk of CO 2 retention. Ignoring these simple principles has led to many patients being rendered needlessly acidotic, at least as seen in a large survey of practise in a UK metropolitan area [32].…”

One and half year prevalence study of respiratory acidosis in acute exacerbation of chronic obstructive pulmonary disorders

“…Each can be encountered alone, as a simple disorder, or can be a part of a mixed disorder, defined as the simultaneous presence of two or more simple, acid-base disturbances. Mixed acid-base disorders are frequently observed in hospitalized patients, especially in the critically ill [13][14][15][16][17][18][19].…”

“…Total admission rates fall in the summer but the rate of respiratory acidosis was more constant at 18 per month (range [10][11][12][13][14][15][16][17][18][19][20][21][22].…”

The art and science of non-invasive ventilation

“…In this setting, the main priority is optimizing medical treatment. Around 20% patients with COPD exacerbation have initial respiratory acidosis, and in 20% of them arterial pH can be normalised by simply optimizing medical treatment (23), since hyperoxygenation is a common cause of hypercapnic acidosis. An australian study showed a higher mortality rate in COPD patients that received uncontrolled oxygen therapy in the ambulance compared with those in whom oxygen was titrated to achieve an arterial O2 saturation (SaO2) of 88-92% (24).…”