https://doi.org/10.4081/monaldi.2026.4092
Immediate versus gradual noninvasive ventilatory pressure-or-duration step-down in chronic obstructive pulmonary disease patients: a randomized trial
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Accepted: 25 August 2026
Published: 15 October 2026
Despite the proven role of noninvasive ventilation (NIV) as an effective treatment for acute hypercapnic respiratory failure (AHRF) in patients with chronic obstructive pulmonary disease (COPD), no clear agreement has been reached regarding the ideal weaning strategy. This study aimed to compare three NIV weaning strategies in terms of efficiency and safety among COPD patients with AHRF. A total of 105 COPD patients stabilized on NIV were enrolled in this randomized clinical trial and equally distributed into three groups (n=35 each): duration step-down (group A), pressure step-down (group B), and immediate withdrawal (group C). The primary endpoint was successful weaning within 48 hours. Secondary outcomes included duration of NIV use, lengths of ICU and hospital stay, predictors of weaning failure, and complication rates. The results of this study indicated that successful weaning rates differed significantly among the groups, being highest in group A (82.9%), followed by group B (74.3%), and lowest in group C (54.3%) (p<0.01). Compared with other strategies, immediate withdrawal was associated with higher rates of weaning failure. Although NIV duration was significantly shorter in group C (p<0.001), complication rates and post-discharge outcomes were similar across the three groups. In this trial, gradual duration- and pressure-based step-down strategies were associated with higher rates of successful NIV weaning than immediate withdrawal, with the highest observed success rate in the duration-based step-down group.
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Plant PK, Owen J, Elliott MW. One year period prevalence study of respiratory acidosis in acute exacerbation of COPD: implications for the provision of non-invasive ventilation and oxygen administration. Thorax 2000;55:550-4. DOI: https://doi.org/10.1136/thorax.55.7.550
British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:192-211. DOI: https://doi.org/10.1136/thorax.57.3.192
Davidson AC, Banham S, Elliott M, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016;71:ii1-35. DOI: https://doi.org/10.1136/thoraxjnl-2015-208209
Keenan SP, Powers CE, McCormack DG. Noninvasive positive-pressure ventilation in patients with milder chronic obstructive pulmonary disease exacerbations: a randomized controlled trial. Respir Care 2005;50:610-6. DOI: https://doi.org/10.4187/respcare.05500610
Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish lung failure collaborative group. N Engl J Med 1995;332:345-50. DOI: https://doi.org/10.1056/NEJM199502093320601
Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilator support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994;150:896-903. DOI: https://doi.org/10.1164/ajrccm.150.4.7921460
Wysocki M, Tric L, Wolff MA, et al. Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy. Chest 1995;107:761-8. DOI: https://doi.org/10.1378/chest.107.3.761
Girault C, Daudenthun I, Chevron V, et al. Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med 1999;160:86-92. DOI: https://doi.org/10.1164/ajrccm.160.1.9802120
Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease: a randomized, controlled trial. Ann Intern Med 1998;128:721-8. DOI: https://doi.org/10.7326/0003-4819-128-9-199805010-00004
Duan J, Tang X, Huang S, et al. Protocol-directed versus physician-directed weaning from noninvasive ventilation: the impact in chronic obstructive pulmonary disease patients. J Trauma Acute Care Surg 2012;72:1271-5. DOI: https://doi.org/10.1097/TA.0b013e318249a0d5
Faverio P, Stainer A, De Giacomi F, et al. Noninvasive ventilation weaning in acute hypercapnic respiratory failure due to COPD exacerbation: a real-life observational study. Can Respir J 2019;2019:3478968. DOI: https://doi.org/10.1155/2019/3478968
Sellares J, Ferrer M, Anton A, et al. Discontinuing noninvasive ventilation in severe chronic obstructive pulmonary disease exacerbations: a randomized controlled trial. Eur Respir J 2017;50:1601448. DOI: https://doi.org/10.1183/13993003.01448-2016
Lun CT, Chan VL, Leung WS, et al. A pilot randomized study comparing two methods of non-invasive ventilation withdrawal after acute respiratory failure in chronic obstructive pulmonary disease. Respirology 2013;18:814-9. DOI: https://doi.org/10.1111/resp.12080
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2024 report. Available from: https://goldcopd.org/2024-gold-report/.
Knaus WA, Zimmerman JE, Wagner DP, et al. APACHE—acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981;9:591-7. DOI: https://doi.org/10.1097/00003246-198108000-00008
Coleman JM, Wolfe LF, Kalhan R. Noninvasive ventilation in chronic obstructive pulmonary disease. Ann Am Thorac Soc 2019;16:1091-8. DOI: https://doi.org/10.1513/AnnalsATS.201810-657CME
Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J 2007;29:1033-56. DOI: https://doi.org/10.1183/09031936.00010206
Purohit S, Madan M, Kumar R, et al. Comparison of immediate withdrawal and stepwise reduction in duration of non-invasive ventilation in chronic obstructive pulmonary disease patients presenting with acute hypercapnic respiratory failure. Monaldi Arch Chest Dis 2023;94:2755. DOI: https://doi.org/10.4081/monaldi.2023.2755
Venkatnarayan K, Khilnani GC, Hadda V, et al. A comparison of three strategies for withdrawal of noninvasive ventilation in chronic obstructive pulmonary disease with acute respiratory failure: a randomized trial. Lung India 2020;37:3-7. DOI: https://doi.org/10.4103/lungindia.lungindia_335_19
Docci M, Rezoagli E, Teggia-Droghi M, et al. Individual response in patient’s effort and driving pressure to variations in assistance during pressure support ventilation. Ann Intensive Care 2023;13:132. DOI: https://doi.org/10.1186/s13613-023-01231-9
Schellenberg MD, Imach S, Iberl G, et al. Clinical characterization and possible pathophysiological causes of the deventilation syndrome in COPD. Sci Rep 2022;12:1099. DOI: https://doi.org/10.1038/s41598-022-05118-w
Lüthgen M, Rüller S, Herzmann C. Characteristics of the deventilation syndrome in COPD patients treated with non-invasive ventilation: an explorative study. Respir Res 2022;23:13. DOI: https://doi.org/10.1186/s12931-022-01924-y
Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333:817-22. DOI: https://doi.org/10.1056/NEJM199509283331301
Gadallah D, Esmaeel HM, Mahmoud HA, Khalaf AR. Integrating validated scores with clinical parameters to predict NIV weaning outcomes: a prospective study in the respiratory ICU. Sci Rep 2026;16:23698. DOI: https://doi.org/10.1038/s41598-026-63797-1
Carrillo A, Ferrer M, Gonzalez-Diaz G, et al. Noninvasive ventilation in acute hypercapnic respiratory failure caused by obesity hypoventilation syndrome and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2012;186:1279-85. DOI: https://doi.org/10.1164/rccm.201206-1101OC
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