Clinical decision-making and mechanical ventilation in patients with respiratory failure due to an exacerbation of COPD

This paper reports a study undertaken to determine whether differences exist in practice between respiratory physicians, general physicians and intensivists or between individual clinicians in initiating mechanical ventilation in respiratory failure due to chronic obstructive pulmonary disease (COPD), the factors influencing decisionmaking and their relation to the evidence base. Of 725 questionnaires sent to clinicians, 350 (48%) were completed and analysed. Twenty-five variables were included which clinicians scored 0–3 according to their perceived relevance in the decision. The sum of all the responses was calculated for each clinician: respiratory 15–68, general 12–65, intensivists 16–64. The most important variables in withholding ventilation were lung cancer inoperable due to COPD, and nursing home resident. The least important variables were treated depression and osteoporosis. No significant differences existed in practice between specialties but there were great differences between individuals’ practices. Clinicians were influenced by similar factors, but these did not reflect documented poor outcome predictors. Guidelines are needed.