BACKGROUND The current frequency of noninvasive (NIV) and invasive mechanical ventilation use in asthma exacerbations (AEs) and the relationship to outcomes are unknown. METHODS We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients discharged with a principal diagnosis of AE. For each discharge, we determined whether NIV or invasive mechanical ventilation was initiated during the first 2 hospital days. Using multivariate logistic regression to adjust for potential confounders, we determined whether use of mechanical ventilation and in-hospital mortality changed between 2000 and 2008. RESULTS The number of AEs increased by 15.8% from 2000 to 2008. The proportion of admissions for which invasive mechanical ventilation was used during the first 2 days decreased from 1.4% in 2000 to 0.73% in 2008, whereas NIV use increased from 0.34% to 1.9%. The adjusted mortality from AEs requiring NIV or invasive mechanical ventilation was unchanged from 2000 to 2008. The hospital stay was also unchanged. CONCLUSIONS There was a substantial increase in the use of mechanical ventilation, accompanied by a shift from invasive mechanical ventilation to NIV. Although we could not determine the clinical reasons for this increase, hospital stay and mortality were unchanged. A randomized trial is needed to determine whether NIV can improve outcomes in AEs before widespread adoption makes it impossible to conduct such a trial.

O besity is a growing epidemic in the United States, with a current prevalence estimated to be about 32% and 36% in the male and female populations, respectively. 1 Approximately 7% of patients requiring admission to the ICU are morbidly obese (BMI. 40 kg/m 2). 2 Investigations focusing on outcomes of critically ill obese adults have demonstrated confl icting results. Although some studies suggest increased mortality, 3,4 others have found a protective effect and lower risk of death. 5-7 Conclusions from most studies are limited by heterogeneous populations and varying defi nitions. Few specifi cally address outcomes of obese patients requiring invasive mechanical ventilation (IMV), especially the morbidly obese. 8-10 Secondary to its delete-rious effects on pulmonary physiology, obesity 11 in the critically ill has been independently associated with prolonged lengths of mechanical ventilation (MV) and ICU stay. 3,4,12 A few recent analyses found that although the risk of developing ARDS was higher in obese and severely obese patients who are mechanically Background: Critically ill, morbidly obese patients (BMI 40 kg/m 2) are at high risk of respiratory failure requiring invasive mechanical ventilation (IMV). It is not clear if outcomes of critically ill, obese patients are affected by obesity. Due to limited cardiopulmonary reserve, they may have poor outcomes. However, literature to this effect is limited and confl icted. Methods: We used the Nationwide Inpatient Sample from 2004 to 2008 to examine the outcomes of morbidly obese people receiving IMV and compared them to nonobese people. We identifi ed hospitalizations requiring IMV and morbid obesity using International Classifi cation of Diseases, 9th Revision, Clinical Modifi cation codes. Primary outcomes studied were inhospital mortality, rates of prolonged mechanical ventilation (96 h), and tracheostomy. Multivariable logistic regression was used to adjust for potential confounding variables. We also examined outcomes stratifi ed by number of organs failing. Results: Of all hospitalized, morbidly obese people, 2.9% underwent IMV. Mean age, comorbidity score, and severity of illness were lower in morbidly obese people. The adjusted mortality was not signifi cantly different in morbidly obese people (OR 0.89; 95% CI, 0.74-1.06). When stratifi ed by severity of disease, there was a stepwise increase in risk for mortality among morbidly obese people relative to nonobese people (range: OR, 0.77; 95% CI, 0.58-1.01 for only respiratory failure, to OR, 4.14; 95% CI, 1.11-15.3 for four or more organs failing). Rates of prolonged mechanical ventilation were similar, but rate of tracheostomy (OR 2.19; 95% CI, 1.77-2.69) was signifi cantly higher in patients who were morbidly obese. Conclusions: Morbidly obese people undergoing IMV have a similar risk for death as nonobese people if only respiratory failure is present. When more organs fail, morbidly obese people have increased risk for mortality compared with nonobese people. CHEST 2013; 144(1):48-54

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A structured sign-out process compared with usual sign-out significantly reduced the occurrence of non-routine events in an academic MICU.

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