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In the early 1990s, noninvasive ventilation (NIV) emerged as a potential useful addition in the management of patients with ventilatory failure due to an acute exacerbation of chronic obstructive pulmonary disease (COPD). That it was an effective alternative to standard medical therapy and oxygen (1, 2), and indeed to endotracheal intubation and mechanical ventilation (3), was confirmed in a number of randomized controlled trials (RCTs), systematic reviews, and meta-analyses (4). A reduction in infectious complications was a consistent finding, and in some studies this translated into reduced ICU and hospital lengths of stay. Cost is one barrier to the implementation of any new treatment in medicine. However, NIV was more cost effective than standard therapy (5) and the savings were even greater when performed outside the ICU (6). In enthusiastic units, as confidence and skill grows, outcomes improve and NIV can be used in sicker patients and lower-dependency settings. Despite this overwhelming evidence that NIV is more effective than standard therapy and can be provided at lower cost, the technique has been underutilized.
In this issue of the Journal, Chandra and coworkers (pp. 152- 159) report the pattern and outcomes of NIV use for acute exacerbations of COPD between 1998 and 2008 (7). It was only in 2008 that NIV overtook invasive mechanical ventilation as the most frequently used form of support in these patients. What are the main reasons for the "late adoption" of NIV? One survey performed in the United States (8) identified lack of physician knowledge as the main reason, followed by inadequate staff training and poor previous experiences. The importance of these "human" factors underscored the need for more education and training, as experience and confidence with the technique are important for NIV success. Geographical reasons may also explain the inhomogeneous pattern of NIV utilization around the world. In Europe NIV seems to be more popular than it is in North America (9), at least for treating COPD exacerbation. This may be due to the fact that the first RCTs were performed in France (1) and in the United Kingdom (2), and under the direct responsibility of a physician in ordering and directly applying NIV with the support of all the staff, including nurses and respiratory therapists, while in the United...