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Objective: older patients usually receive less invasive and costly hospital care, even if they meet the criteria for Intensive Care Unit admission or have a ‘do not intubate’(DNI) order. The aim of this randomised, controlled trial was to assess the effectiveness of non-invasive mechanical ventilation (NIV) versus the standard medical therapy (SMT) in reducing the need of intubation, improving survival and reducing respiratory distress in very old patients with acute hypercapnic respiratory failure (AHRF).Participants and design: eighty-two patients aged >75 years (mean age 81.3 ± 3.5 years) were randomised to receive NIV or SMT.Settings: three respiratory units.Measurements: the primary outcome was the rate of meeting the endotracheal intubation (ETI) criteria. Secondary outcomes were the mortality rate, the respiratory rate, dyspnoea score, arterial blood gases.Results: the rate of meeting the ETI criteria was lower in the NIV group compared with the SMT group (7.3 versus 63.4%, respectively; P < 0.001), as was the mortality rate [(odds ratios) OR = 0.40; 95% CI: 0.19–0.83; P = 0.014]. Twenty-two of 41 SMT patients with DNI orders received NIV as a rescue therapy. The mortality rate in this subgroup was comparable with the NIV group and significantly lower compared with patients receiving ETI (OR = 0.60, 95% CI: 0.18–1.92 versus 4.03, 95% CI: 2.35–6.94, respectively; P = 0.009). Arterial blood gases, respiratory rate and dyspnoea improved significantly faster with NIV than with SMT.Conclusions: compared with SMT, NIV decreased the rate of meeting the ETI criteria and the mortality rate of very old patients with AHRF. NIV should be offered as an alternative to patients considered poor candidates for intubation and those with a DNI order.