This 60-year-old man had been a heavy smoker for more than 40 years, with very severe chronic airflow obstruction with a “pink-puffer” clinical aspect. Two years previously, he had been intubated and mechanically ventilated for acute respiratory failure, probably due to bronchopulmonary superinfection. The course of mechanical ventilation had been difficult (air trapping) and prolonged; the patient had been extubated after 22 days, and the weaning period had been poorly tolerated. One week before admission, the patient had become febrile and dyspneic, and it was obvious that a new episode of acute-on-chronic respiratory failure had occurred.
At the time of admission, the patient was exhausted and severely hypercapnic (PaC02, 10.9 kPa [82 mm Hg]), and the decision to intubate and ventilate this patient was obvious; however, the patient strongly opposed this treatment, while accepting an attempt at NPPV. This technique was therefore applied for two days, but we were unable to ventilate the patient more than during short periods of 20 to 30 min, because of poor tolerance; this was probably related to the high inflation pressures required (>30 cm H20). Finally, after a total of 10 h of NPPV, and despite the fact that the PlaCO could be reduced to 8.5 to 9 kPa (64 to 68 mm Hg), the patient was exhausted, requesting intubation and mechanical ventilation. Unfortunately, the patient died five days later from irreversible shock due to P aeruginosa septicemia.