REBUTTAL FROM DR. HILL

Nicholas S. Hill

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Dr. Rossi is to be commended for attempting to make a silk purse out of a sow's ear, but it's still a sow's ear, and the data simply do not support the contention that NIV is effective for severe stable COPD. Dr. Rossi's argument boils down to: (1) NIV for other indications is not supported by high grade evidence, yet they are accepted; why not accept them for stable COPD? (2) Mortality is not the only worthwhile end-point, (3) The physiologic rationale for use of noninvasive ventilation in severe stable COPD is strong, and (4) The trials yielding negative results were flawed and should not be given more weight than the single controlled trial yielding positive results (1). I agree with all of these points except that the data supporting use of NIV in severe stable COPD should not be equated with that supporting other applications. Even though it is not supported by randomized controlled trials, NIV for restrictive thoracic disorders has gained wide acceptance because virtually all published studies have been favorable and clinical experience has been confirmatory, similar to the use of antibiotics for pneumonia. This is certainly not the case with severe stable COPD, where data have been conflicting. Further, we should demand a high level of evidence before accepting NIV as routine therapy for severe stable COPD, because it is expensive and cumbersome, and the number of patients with COPD would impose a large financial burden. If we accepted a physiologic rationale as a justification for the use of a therapy, IPPB would still be used for every COPD patient with an exacerbation and no controlled trial (2) would have been done. The simple fact is that only one controlled trial (1) has obtained favorable results of arguably minor magnitude in a special subpopulation of patients, several others have yielded negative findings, and the data are far from conclusive. Dr. Rossi is an honorable man, but if he had to convince the Romans that NIV is effective in severe stable COPD based on currently available evidence, even someone with the persuasive powers of a Mark Anthony would have been tossed into the Tiber.

	References

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1. Meecham-Jones, D. J., E. A. Paul, and P. W. Jones. 1995. Nasal pressure support ventilation plus oxygen compared with the oxygen therapy alone in hypercapnic COPD. Am. J. Respir. Crit. Care Med. 152: 538-544 [Abstract].

2. Intermittent Positive Pressure Breathing Trial Group. 1983. Intermittent positive pressure breathing therapy of chronic obstructive pulmonary disease. Ann. Intern. Med. 99: 612-620 .