Outcomes of Patients Treated With Noninvasive Ventilation by a Medical Emergency Team on the Wards

Abstract

BACKGROUND: Initiation of noninvasive ventilation (NIV) on the wards is not universally accepted. Medical emergency teams (METs) provide acute care and monitoring to deteriorating patients on the general wards. Whether it is safe for an MET to start NIV in ward patients with respiratory distress remains unclear. METHODS: We evaluated 1,123 MET calls in 30,217 ward patients between January 2009 and June 2011 from the prospectively maintained MET database in our tertiary care hospital. We identified ward patients with acute desaturation (< 90%) and tachypnea (breathing frequency > 28 breaths/min), for whom an MET was called. Subjects transferred to the ICU at the end of an MET call were excluded. The remaining ward subjects were divided into 2 groups: patients who were not started on NIV by the MET; versus patients who were started on NIV by the MET. The primary outcome was endotracheal intubation or ICU transfer within 48 hours of MET activation. Secondary outcome measures were 28-day mortality and ICU mortality. RESULTS: Two hundred thirty-eight MET subjects met the study criteria, and 109 immediate ICU transfers were excluded. Of the remaining 129 ward subjects, 54 were in the NIV group, and 75 in the no-NIV group. The NIV group subjects were sicker (mean Acute Physiology and Chronic Health Evaluation II score 17.6 ؎ 5.1 versus 14.4 ؎ 5, P < .001). Subjects with pulmonary edema, COPD exacerbation, or asthma exacerbation were more likely, while those with pneumonia were less likely to be placed on NIV. The primary outcome was reached in 2/54 (3.7%) of the NIV subjects and 12/75 (16%) of the no-NIV subjects (P ‫؍‬ .03). There was no significant difference (P > .30) between the groups in 28-day mortality (7.4% vs 13.3%) or ICU mortality (3.7% vs 8%). CONCLUSIONS: In selected ward patients, especially those with COPD or pulmonary edema, NIV can be safely initiated by an MET.

Does Noninvasive Ventilation Delivery in the Ward Provide Early Effective Ventilation?

“…This earlier usage allows for safe application outside a more closely monitored setting. 1,3,[5][6][7][8] Compared with both ICU and HDU, general wards are characterized by reduced house staff availability, especially during the SEE THE RELATED EDITORIAL ON PAGE 144 night shift. The possibility of detecting NIV-related adverse events, such as air leaks, accidental disconnection, oxygen desaturation, and mask intolerance, is then arguably lower than in ICU and HDU, and adequate NIV application may not be guaranteed, especially overnight.…”

Noninvasive Ventilation and Medical Emergency Team in Ward Departments: Will It Be a Safe and Practical Battlefield?

“…2 However, application of NIV outside ICU settings is still infrequent. 3 We read with great interest the study by Khalid et al, 4 describing outcomes during NIV by medical emergency team (MET). This article opens a greatly controversial topic with important clinical implications.…”

Outcome of Patients Treated With Noninvasive Ventilation by a Medical Emergency Team on the Wards: Is It Really Scarce Monitoring?

“…1 In this study, the authors prospectively evaluated 238 patients with an S pO 2 of Ͻ 90% and a breathing frequency of Ͼ 28 breaths/min identified by a medical emergency team (MET). Fifty-four of these patients received noninvasive ventilation (NIV), whereas another 75 patients did not; both groups were evaluated in the general medicine ward.…”