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British Thoracic Society/Intensive Care Society Guideline for the ventilatory management of acute hypercapnic respiratory failure in adults
  1. Craig Davidson1,
  2. Steve Banham2,
  3. Mark Elliott3,
  4. Daniel Kennedy4,
  5. Colin Gelder5,
  6. Alastair Glossop6,
  7. Colin Church7,
  8. Ben Creagh-Brown8,
  9. James Dodd9,
  10. Tim Felton10,
  11. Bernard Foëx11,
  12. Leigh Mansfield12,
  13. Lynn McDonnell13,
  14. Robert Parker14,
  15. Caroline Patterson15,
  16. Milind Sovani16 and
  17. Lynn Thomas17
  18. BTS Standards of Care Committee Member, British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group, On behalf of the British Thoracic Society Standards of Care Committee
  1. 1British Thoracic Society, London, UK
  2. 2British Thoracic Society, London, UK
  3. 3St James's University Hospital, Leeds, UK
  4. 4Barts Health NHS Trust, London, UK
  5. 5Department of Respiratory Research, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
  6. 6Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
  7. 7Department of Respiratory, Scottish Pulmonary Vascular Unit, Glasgow, UK
  8. 8Royal Surrey County Hospital NHS Foundation Trust and Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
  9. 9Academic Respiratory Unit, University of Bristol, Bristol, UK North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
  10. 10University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
  11. 11Emergency Department, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, Manchester M13 9WL, UK
  12. 12University of Plymouth, Plymouth, UK
  13. 13Department of Physiotherapy, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
  14. 14Aintree University Hospital, Liverpool, UK
  15. 15CLAHRC, Imperial College, London, UK
  16. 16Queen's Medical Centre, Nottingham, UK
  17. 17Royal College of Physicians, London, UK
  1. Correspondence to Dr Craig Davidson; craigdavidson{at}

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The British Thoracic Society (BTS) published the guideline ‘The use of non-invasive ventilation in acute respiratory failure’ in 2002.1 This was in response to trials that had demonstrated that non-invasive ventilation (NIV) was an alternative to invasive mechanical ventilation (IMV) in life-threatening respiratory acidosis due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD). It drew attention to evidence that, when NIV was used in the less severely unwell patient, it also limited progression to more severe respiratory failure.2 The trial also demonstrated the feasibility, of delivering NIV on general medical or admission wards that had enhanced support and when staff were provided with ongoing training.

In subsequent years, NIV has been shown to deliver better rather than equivalent outcomes to invasive ventilation in AECOPD and better evidence has accumulated for the use of NIV in non-COPD disease in the intervening years. Repeated national audits have, however, raised concerns that expected patient benefit is not being delivered and have pointed to a number of process deficiencies.3–5 There is also the risk, in the absence of justifying trial evidence, that the preferred use of NIV in AECOPD might be extended to all hypercapnic patients, irrespective of circumstance or underlying disease process. That this is a real risk might be inferred from the BTS audits where the indication for NIV was not COPD in over 30% of cases.3 ,4

NIV development in the UK has been largely outside the organisational ‘umbrella’ of critical care. This may have adversely affected resource allocation and contributed to a lack of integration in NIV and IMV patient pathways. Other unintended consequences might be a restriction on access to invasive ventilation and delay in the development of extended applications of NIV, such as accelerating extubation and its use in the management of …

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