Effectiveness of Early Non-Invasive Ventilation in the Management of Acute Exacerbation of COPD in the Emergency Department: A Systematic Review

Abstract

Background: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) frequently results in acute hypercapnic respiratory failure requiring ventilatory support. Early initiation of non-invasive ventilation (NIV) has been proposed to reduce the need for intubation, improve gas exchange, and shorten hospitalization; however, the timing and setting of initiation remain variable across clinical practice. Objective: This systematic review aimed to evaluate the effectiveness of early initiation of NIV, defined as initiation within two hours of emergency department (ED) or prehospital presentation, in improving clinical outcomes among adult patients with AECOPD. Methods: A systematic search of PubMed, Cochrane Library, Scopus, and Web of Science (January 2015–October 2025) was performed following PRISMA 2020 guidelines. Eligible studies included randomized controlled trials, cohort studies, and quasi-experimental designs comparing early NIV with conventional oxygen therapy, delayed NIV, or invasive ventilation. Data on mortality, intubation rate, length of stay, and NIV failure were extracted and appraised using RoB 2 and JBI tools. Due to heterogeneity, findings were synthesized narratively. Results: Nine studies (n ≈ 1,300) met inclusion criteria. Early NIV reduced intubation rates by 40–60%, improved pH and PaCO₂ within two hours of initiation, and decreased hospital length of stay by up to three days. Mortality reduction was consistent across higher-quality studies. Conclusion: Early initiation of NIV in the ED or prehospital setting significantly improves survival and reduces invasive ventilation needs in AECOPD. Timely recognition and protocol-driven implementation should be standard in acute respiratory care pathways.