Assessing mortality differences across acute respiratory failure management strategies in Covid-19

Krishnan, Jamuna; Rajan, Mangala; Baer, Benjamin R.; Hoffman, Katherine L.; Alshak, Mark N.; Aronson, Kerri I.; Goyal, Parag; Ezeomah, Chiomah; Hill, Shanna S.; Martínez, Fernando J.; Turetz, Meredith L.; Wells, Martin T.; Safford, Monika M.; Schenck, Edward J.

doi:10.1016/j.jcrc.2022.154045

Cited by 8 publications

(11 citation statements)

References 36 publications

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“…This interpretation is supported by prior work showing a mortality benefit with invasive ventilation for patients with acute respiratory distress syndrome and an arterial-to-inspired oxygen ratio less than 150 mmHg, or patients with COVID-19 pneumonia and higher baseline severity as measured by Sequential Organ Failure Assessment (SOFA) score. 53,54 The optimal physiologic thresholds for invasive ventilation are unknown 55 , but our analysis suggests that finding disease-specific thresholds for invasive ventilation could improve outcomes for white patients at lower severity, and for Asian, Black, and Hispanic patients at higher severity.…”

Section: Discussionmentioning

confidence: 93%

Association between patient race/ethnicity and invasive ventilation in hypoxemic respiratory failure

Abdelmalek

Angriman

Moore

et al. 2022

Preprint

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Importance: Differential use of therapies for respiratory failure according to patient race/ethnicity may represent health inequity and could impact patient survival. Objective: Measure the association between patient race/ethnicity and the use of invasive ventilation, and the impact of any association on survival. Design: Retrospective cohort analysis using a Bayesian multistate model that adjusted for baseline covariates and time-varying severity. Setting: Multicenter study using the Medical Information Mart for Intensive Care IV (MIMIC-IV) and Phillips eICU (eICU) databases from the USA. Participants: Non-intubated adults receiving oxygen within the first 24 hours of ICU admission. Exposure: Patient race/ethnicity (Asian, Black, Hispanic, white). Main outcomes and measures: Primary output was the cause-specific hazard ratio (HR) of invasive ventilation for patient race/ethnicity. Secondary output was change in 28-day survival mediated by differences in invasive ventilation rate. We reported posterior means and 95% credible intervals (CrI). Results: We studied 38,263 patients, 52% (20,033) from MIMIC-IV and 48% (18,230) from eICU, 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% white (31,923). Invasive ventilation occurred in 3,511 (9.2%), and 2,869 (7.5%) died. The rate of invasive ventilation was lower in Asian (HR 0.82, CrI 0.70 to 0.95), Black (HR 0.78, CrI 0.71 to 0.86), and Hispanic (HR 0.70, CrI 0.61 to 0.79) patients as compared to white patients. For the average patient, lower rates of invasive ventilation did not mediate differences in survival. For a reference patient with inspired oxygen (FiO2) varied from 0.5 to 1.0, the change in survival mediated by lower rates of invasive ventilation ranged from probable benefit (probability 0.82 for Asian patients, 0.91 for Black patients, and 0.93 for Hispanic patients) at FiO2 0.5 to probable harm (probability 0.87 for Asian patients, 0.92 for Black patients, and 0.97 for Hispanic patients) at FiO2 1.0, although the mean absolute changes in mortality were all less than 1.5%. Conclusions: Asian, Black, and Hispanic patients had a lower rate of invasive ventilation than white patients. The changes in 28-day survival mediated by this difference ranged from slight benefit at lower inspired oxygen fractions to slight harm at inspired oxygen fraction of 1.0, and there was no difference in survival for the average patient.

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Section: Discussionmentioning

confidence: 93%

Association between patient race/ethnicity and invasive ventilation in hypoxemic respiratory failure

Abdelmalek

Angriman

Moore

et al. 2022

Preprint

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“…In an observational study, ARDS patients with arterial-to-inspired oxygen ratio less than 150 mmHg managed using invasive as opposed to noninvasive ventilation had lower mortality [ 21 ]. In patients with COVID-19, higher baseline sequential organ failure assessment scores were associated with better outcomes when patients were managed with invasive ventilation as opposed to noninvasive oxygen strategies [ 57 ]. For patients with higher predicted mortality, invasive ventilation thresholds triggered at a lower severity of illness could confer benefits by avoiding catastrophic deteriorations, emergency intubations, or patient self-inflicted lung injury [ 58 , 59 ].…”

Section: Discussionmentioning

confidence: 99%

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

et al. 2023

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Background The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation. Methods This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008–2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003–2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation. Results We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8). Conclusion Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.

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“…We thank Dr. Mukherjee and colleagues for their thoughtful comments regarding our recently published study [ 1 ]. We have given their comments careful consideration and hope our responses provide further clarification.…”

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confidence: 99%

Author's response: “Assessing mortality differences across acute respiratory failure management strategies in Covid-19”

Krishnan

Schenck

2023

Journal of Critical Care

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Assessing mortality differences across acute respiratory failure management strategies in Covid-19

Cited by 8 publications

References 36 publications

Association between patient race/ethnicity and invasive ventilation in hypoxemic respiratory failure

Association between patient race/ethnicity and invasive ventilation in hypoxemic respiratory failure

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

Author's response: “Assessing mortality differences across acute respiratory failure management strategies in Covid-19”

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