Background: While the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients.Materials and methods: The European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients.Results: The task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode.Conclusions: Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.

To develop a severity assessment tool to predict mortality in community-acquired pneumonia (CAP) patients in intensive care unit (ICU), comparing its performance with Acute Physiology and Chronic Health Evaluation (APACHE) II score and American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) criteria as a prognostic index in CAP patients requiring ICU admission. Secondary analysis of prospective observational cohort study. Thirty-three ICUs. Five hundred and twenty-nine adult patients with CAP requiring ICU admission. A severity assessment score was developed based on the PIRO (predisposition, insult, response, and organ dysfunction) concept including the presence of the following variables: Comorbidities (chronic obstructive pulmonary disease, immunocompromise); age >70 years; multilobar opacities in chest radiograph; shock, severe hypoxemia; acute renal failure; bacteremia and acute respiratory distress syndrome. PIRO score was obtained at ICU within 24 hours from admission, and one point was given for each present feature (range, 0-8 points). The mean PIRO score was significantly higher in nonsurvivors than in survivors (4.6 +/- 1.2 vs. 2.3 +/- 1.4). Considering the observed mortality for each PIRO score, the patients were stratified in four levels of risk: a) Low, 0-2 points; b) Mild, 3 points; c) high, 4 points; and d) Very high, 5-8 points. Mild-risk (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.1-2.9; p < 0.05), high-risk (HR 3.1; 95% CI = 2.0-4.7; p < 0.001), and very high risk levels (HR 6.3; 95% CI = 4.2-9.4; p < 0.001) were significantly associated with higher risk of death in Cox proportional hazards regression analysis. Furthermore, analysis of variance showed that higher levels of PIRO score were significantly associated with higher mortality (p < 0.001), prolonged length of stay in the ICU (p < 0.001), and days of mechanical ventilation (p < 0.001). Receiver operating characteristic curves showed that PIRO score (area under the curve [AUC] = 0.88) performed better than APACHE II (AUC = 0.75, p < 0.001) and ATS/IDSA criteria (AUC = 0.80, p < 0.001) to predict 28-day mortality. The PIRO score performed well as 28-day mortality prediction tool in CAP patients requiring ICU admission with a better performance than APACHE II and ATS/IDSA criteria in this subset of patients. Furthermore, PIRO score also is associated with increased healthcare resource utilization in CAP patients admitted in the ICU.

To evaluate the effect of discordant empirical therapy on outcome in bacteremic pneumococcal community-acquired pneumonia. Prospective observational study. A 600-bed teaching hospital with a reference area of 400,000 inhabitants. All patients aged ≥18 yrs with a diagnosis of community-acquired pneumonia whose blood cultures, obtained within the first 48 hrs of hospitalization, demonstrated growth of Streptococcus pneumoniae were included in the study. Discordant therapy was defined as failure to administer an antibiotic with in vitro activity against the isolated strain within 24 hrs of hospital admission. The 2002 breakpoints recommended for respiratory infections by the National Committee for Clinical Laboratory Standards were used to classify therapy. A total of 100 patients with bacteremic pneumococcal pneumonia were identified. Penicillin- and macrolide-resistant strains were identified in 29 and 18 cases, respectively. Only two strains had minimum inhibitory concentrations of >2 μg/mL for cephalosporins. Discordant therapy was documented in ten patients, five of whom died. Mortality in patients receiving concordant therapy was 14% (13 of 90). Nursing home residence (odds ratio [OR] = 14.8) and immunocompromise (OR = 11.5) were independently (p < .05) associated with discordant therapy. Risk of discordant therapy was significantly higher (p < .05) when empirical therapy did not include cefotaxime or ceftriaxone (OR = 10.4). Discordant therapy (OR = 27.3), multilobar involvement (OR = 14.2), underlying chronic obstructive pulmonary disease (OR = 9.1), and hospitalization during the previous 12 wks (OR = 7.9) were independently associated (p < .05) with death. The excess mortality for initial discordant therapy was estimated to be 35.6% (95% confidence interval, 3.73–67.4). Survival in patients with bacteremic community-acquired pneumococcal pneumonia can be improved by avoiding suboptimal therapy. Using the 2002 breakpoints, it is very unlikely that discordant therapy would be given with ceftriaxone or cefotaxime. Clinical outcome is worse in those patients receiving antimicrobial therapy that in vitro testing suggests would be ineffective.

Episodes of patient-ventilator asynchrony (PVA) occur during acute and chronic non-invasive positive pressure ventilation (NIV). In long-term NIV, description and quantification of PVA is not standardised, thus limiting assessment of its clinical impact. The present report provides a framework for a systematic analysis of polygraphic recordings of patients under NIV for the detection and classification of PVA validated by bench testing. The algorithm described uses two different time windows: rate asynchrony and intracycle asynchrony. This approach should facilitate further studies on prevalence and clinical impact of PVA in long-term NIV.

The influence of infecting serotype group on outcome in bacteraemic pneumococcal pneumonia remains unclear.We performed a prospective, 10-yr observational study in an 800-bed teaching hospital. 299 adults diagnosed with pneumonia whose blood cultures showed growth ofStreptococcus pneumoniaewere included in the study. High invasive disease potential (H) serotypes included serotypes 1, 5 and 7F, which served as a reference category, were compared with low invasive disease potential (L) serotypes (3, 6A, 6B, 8, 19F, and 23F) and other (O) serotypes (non-H, non-L). The influence on outcome was determined for each group of serotypes after adjusting for underlying conditions and severity of illness at admission.Overall, 30-day mortality was 11%. H serotypes (n = 93) infected primarily younger people and presented a higher risk of complicated parapneumonic effusion or empyema (17.2versus5.1%; p = 0.01), with lower mortality (3.2%). The isolation of L serotypes (n = 78) was an independent risk factor for 30-day mortality (OR 7.02, 95% CI 1.72–28.61), as were Charlson score (OR 1.30, 95% CI 1.08–1.58), alcohol abuse (OR 3.99, 95% CI 1.39–11.39) and severity of illness measured by American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) criteria (OR 4.80, 95% CI 1.89–12.13).A vaccination strategy including serotypes 3, 6A, 6B, 8, 19F and 23F may improve survival in adults.