Noninvasive positive pressure ventilation (NPPV) via nasal mask is well known to be effective in the treatment of acute respiratory failure (ARF) secondary to chronic obstructive pulmonary disease (COPD). A case of ARF with hypercapnic coma due to exacerbation of COPD is described. Six hours of conservative therapy with oxygen and medical treatment did not show any result. As endotracheal intubation (ET) was avoided on the basis of advanced age, poor life expectancy of the patient and family wish, NPPV was set up using a pressure triggered ventilator. After 61 hours of uninterrupted NPPV, the acid-base alteration and the lethargic status was fully reversed. The conclusions is drawn that NPPV may be useful also in the treatment of patients affected by severe decompensated hypercapnic respiratory failure in whom ET is not indicated.