Question 11

You are asked to review a 74-year-old female in the Emergency Department who has presented with an infective exacerbation of her Chronic Obstructive Pulmonary Disease (COPD).

On examination she is conscious, but unable to speak in sentences. She has a respiratory rate of 36 breaths/min and oxygen saturations of 88% on high flow nasal prongs (HFNP) with FiO2 = 0.4, and 50 L/min of flow. Heart rate is 108 beats/min and blood pressure 156/84 mmHg.

Her blood gas shows:

pH                 7.34

PaO2              58 mmHg (7.73 kPa)

CO2               52 mmHg (6.93 kPa)

Lactate           3.2 mmol/L

What factors would influence your decision to choose non-invasive ventilation or invasive ventilation in this patient?

[Click here to toggle visibility of the answers]

College answer

Not available.


Suitability for intubation:

  • Presence of reversible physiological factors which intubation might address, such as:
    • Respiratory acidosis
    • Decreased level of consciousness
    • Fatigue due to high respiratory workload
  • Absence of existing treatment limitation orders
  • Absence of features which might suggest futility, i.e. where chances of success are impossibly small (eg. multiorgan system failure, severe shock, extreme frailty, etc)
    Insufficient information to guide robust end-of-life decisionmaking (Wildman et al, 2007; prognostic pessimism may deny intubation to potentially salvageable patients)

Factors which favour a beneficial effect from invasive ventilation:

  • Acute exacerbation of COPD as the cause of respiratory failure -Nevins et al (2001) found that the in-hospital mortality was only 12% for these people, as compared to 28% for the rest of the cohort
  • Higher premorbid FEV(over 1.2) - this is the GOLD score (Mannino et al, 2006); GOLD stage 3 or 4 (FEV1/FVC<0.70 and FEV1<50% predicted) is associated with a mortality of around 35% at ten years.
  • Good baseline function  -low BODE index (Celli et al, 2004)
  • Pneumonia as the cause of this exacerbation would favour HFNP or invasive ventilation instead of NIV, as NIV may even be counterproductive (by impairing the clearance of secretions, for example)

Factors which predict a poor outcome from intubation:

  • Failure of NIV, particularly if the patient is elderly - Chandra et al (2012) found that the in-hospital mortality for these people was 33%; non-survivors were largely elderly (over 55% of them were aged 75 or older)
  • Poor baseline function indices - BODE index 7-10 (Low BMI, breathless at rest and unable to walk more than 150m over six minutes, with an FEV1 below 35% of the predicted value) =  20% chance of surviving the next 48 months.
  • Poor global assessment of function -  Menzies et al (1989) found that if the patient is unable to leave their house because of their symptoms, their ICU mortality was with intubation 71%, going up to 75% if they were chronically bedbound or chairbound.
  • Dependence on home oxygen: according to Hajizadeh et al (2015) there is 23% in-hospital mortality, 45% 1-year mortality and  26.8% were discharged to a nursing home within 30 days.
  • Comorbidities (Menzies et al, 1989):
    • Malignancy
    • Cor pulmonale
    • Chronic hypercapnia
    • Left ventricular failure

Patient and family preferences

  • The patient's autonomy needs to be respected (they may have strong views on the matter)
  • It is important to remain objective - physicians can influence patient opinion significantly depending on how they "spin" their explanation of intubation and mechanical ventilation ( Sullivan et al, 1996)
  • For some scenarios, invasive ventilation has a good chance of success (ICU mortality for the "pure" COPD cohort from Nevins et al (2001) was actually lower than for other acute respiratory pathologies - 9% ICU mortality and 17% hospital mortality).
  • Survivors of short ICU stay with invasive ventilation rate their post-discharge health as same or better, and 96% responded that they would be willing to undergo similar treatment again (Wildman et al, 2009). These patients stayed in ICU for 6-9 days on average.


Chandra, Divay, et al. "Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998–2008." American journal of respiratory and critical care medicine 185.2 (2012): 152-159.

Simonds, A. K. "Ethics and decision making in end stage lung disease.Thorax 58.3 (2003): 272-277.

Gadre, Shruti K., et al. "Acute respiratory failure requiring mechanical ventilation in severe chronic obstructive pulmonary disease (COPD)." Medicine 97.17 (2018).

Lindenauer, Peter K., et al. "Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease." JAMA internal medicine 174.12 (2014): 1982-1993.

Nevins, Michael L., and Scott K. Epstein. "Predictors of outcome for patients with COPD requiring invasive mechanical ventilation." Chest 119.6 (2001): 1840-1849.

Stefan, Mihaela S., et al. "Comparative effectiveness of noninvasive and invasive ventilation in critically ill patients with acute exacerbation of COPD." Critical care medicine 43.7 (2015): 1386.

Rinaudo, Mariano, et al. "Impact of COPD in the outcome of ICU-acquired pneumonia with and without previous intubation." Chest 147.6 (2015): 1530-1538.

Sullivan, Karen E., et al. "What do physicians tell patients with end-stage COPD about intubation and mechanical ventilation?." Chest 109.1 (1996): 258-264.

Wildman, Martin J., et al. "Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study." Bmj 335.7630 (2007): 1132.

Jerpseth, Heidi, et al. "Considerations and values in decision making regarding mechanical ventilation for older patients with severe to very severe COPD." Clinical Ethics 11.4 (2016): 140-148.

Mannino, David M., Dennis E. Doherty, and A. Sonia Buist. "Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study." Respiratory medicine 100.1 (2006): 115-122.

Celli, Bartolome R., et al. "The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease." New England Journal of Medicine 350.10 (2004): 1005-1012.

Menzies, Richard, William Gibbons, and Peter Goldberg. "Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure." Chest 95.2 (1989): 398-405.

Wildman, Martin James, et al. "Survival and quality of life for patients with COPD or asthma admitted to intensive care in a UK multicentre cohort: the COPD and Asthma Outcome Study (CAOS)." Thorax 64.2 (2009): 128-132.

Wakatsuki, Mai, and Paul Sadler. "Invasive Mechanical Ventilation in Acute Exacerbation of COPD: Prognostic Indicators to Support Clinical Decision Making.Journal of the Intensive Care Society 13.3 (2012): 238-243.

National Institute for Health and Clinical Excellence. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) London: National Clinical Guideline Centre; 2018

Quinnell, Timothy G., et al. "Prolonged invasive ventilation following acute ventilatory failure in COPD: weaning results, survival, and the role of noninvasive ventilation." Chest 129.1 (2