Epidemiology of noninvasive mechanical ventilation in acute respiratory failure - a retrospective population-based study

Abstract

BackgroundNoninvasive mechanical ventilation (NIV) is a front-line therapy for the management of acute respiratory failure (ARF) in the intensive care units. However, the data on factors and outcomes associated with the use of NIV in ARF patients is lacking. Therefore, we aimed to determine the utilization of NIV for ARF in a population-based study.MethodsWe conducted a populated-based retrospective cohort study, where in all consecutively admitted adults (≥18 years) with ARF from Olmsted County, Rochester, MN, at the Mayo Clinic medical and surgical ICUs, during 2006 were included. Patients without research authorization or on chronic NIV use for sleep apnea were excluded.ResultsOut of 1461 Olmsted County adult residents admitted to the ICUs in 2006, 364 patients developed ARF, of which 146 patients were initiated on NIV. The median age in years was 75 (interquartile range, 60–84), 48% females and 88.7% Caucasians. Eighteen patients (12%) were on Continuous Positive Airway Pressure (CPAP) mode and 128 (88%) were on noninvasive intermittent positive-pressure ventilation (NIPPV) mode. Forty-six (10%) ARF patients were put on NIV for palliative strategy to alleviate dyspnea. Seventy-six ARF patients without treatment limitation were given a trial of NIV and 49 patients succeeded, while 27 had to be intubated. Mortality was similar between the patients initially supported with NIV versus invasive mechanical ventilation (33% vs 22%, P=0.289). In the multivariate analysis, the development of acute respiratory distress syndrome (ARDS) and higher APACHE III scores were associated with the failure of initial NIV treatment.ConclusionsOur results have important implications for a future planning of NIV in a suburban US community with high access to critical care services. The higher APACHE III scores and the development of ARDS are associated with the failure of initial NIV treatment.

Where is Noninvasive Ventilation Actually Delivered for Acute Respiratory Failure?

“…Factors that were associated with the site of NIV initiation in our study included the causal diagnosis of ARF. NIV was started most commonly in the ED for patients with ACLD, APE, or DNI/DNR status and in the ICU for cases with 'de novo' ARF, consistent with other studies [28,33]. Patients in our study who started NIV in the ED were more tachypneic, tachycardic, acidotic, and hypercarbic than those started in other units.…”

“…In our study, ICU transfers were more tachypneic, acidotic, and hypercapnic with higher SAPSII scores and less often had a DNI status than ward transfers, thus having a higher perceived need for intensive monitoring. In our study as in others [6,25,28], location of NIV initiation was related to NIV success and in-hospital mortality. NIV success rate was lowest in the ICU (60 %), undoubtedly reflecting the more common diagnosis of ''de novo'' ARF as opposed to the more common diagnoses of ACLD and APE encountered among patients started in the ED or on general wards where success rates were 77 and 68 %, respectively.…”

“…Evidence of benefits of NIV for selected patients with ARF has accrued over the past couple of decades, not only for patients treated in ICUs, but also outside of the ICU [6,12,[21][22][23][24][28][29][30]. Although ICUs provide an appropriate, safe environment for NIV use, bed availability is limited and cost is much higher [14].…”

Use and performance of non-invasive ventilation in Internal Medicine ward: a real-life study

“…[32][33][34][35] Few studies 36,37 have been published on use of NIV Yet it is precisely the Internal Medicine wards that, due to their greater spread in all hospitals, can provide an easier and more widespread accessibility to a broader population, as well as its application in early phase of evolution of ARF with mild or mild to moderate respiratory acidosis, with greater chance of success.…”

Evolving Epidemiology and Definitions of the Acute Respiratory Distress Syndrome and Early Acute Lung Injury

“…This inclusion is in line with increasing use of noninvasive ventilation worldwide 27 and will likely facilitate further study of noninvasive ventilation for mild ARDS, which continues to be a debated area of research. [28][29][30] Importantly the Berlin criteria were empirically derived and validated based on a pooled cohort of patients that comprised separate clinical 5,16,31,32 and physiologic [33][34][35] databases. Of note, 4 proposed ancillary variables (radiographic severity, respiratory system compliance, level of PEEP, and exhaled minute ventilation) were dropped from the empirical definition because they did not enhance the predictive value of the severe ARDS classification.…”