Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study.
TL;DR: In hypoxemic ARF, NPPV can be successful in selected populations, but when patients have a higher severity score, an older age, ARDS or pneumonia, or fail to improve after 1 h of treatment, the risk of failure is higher.
Abstract: Context: In patients with hypoxemic acute respiratory failure (ARF), randomized studies have shown noninvasive positive pressure ventilation (NPPV) to be associated with lower rates of endotracheal intubation. In these patients, predictors of NPPV failure are not well characterized. Objective: To investigate variables predictive of NPPV failure in patients with hypoxemic ARF. Design: Prospective, multicenter cohort study. Setting: Eight Intensive Care Units (ICU) in Europe and USA. Patients: Of 5,847 patients admitted between October 1996 and December 1998, 2,770 met criteria for hypoxemic ARF. Of these, 2,416 were already intubated and 354 were eligible for the study. Results: NPPV failed in 30% (108/354) of patients. The highest intubation rate was observed in patients with ARDS (51%) or community-acquired pneumonia (50%). The lowest intubation rate was observed in patients with cardiogenic pulmonary edema (10%) and pulmonary contusion (18%). Multivariate analysis identified age >40 years (OR 1.72, 95% CI 0.92–3.23), a simplified acute physiologic score (SAPS II) ≥35 (OR 1.81, 95% CI 1.07–3.06), the presence of ARDS or community-acquired pneumonia (OR 3.75, 95% CI 2.25–6.24), and a PaO2:FiO2 ≤146 after 1 h of NPPV (OR 2.51, 95% CI 1.45–4.35) as factors independently associated with failure of NPPV. Patients requiring intubation had a longer duration of ICU stay (P<0.001), higher rates of ventilator-associated pneumonia and septic complications (P<0.001), and a higher ICU mortality (P<0.001). Conclusions: In hypoxemic ARF, NPPV can be successful in selected populations. When patients have a higher severity score, an older age, ARDS or pneumonia, or fail to improve after 1 h of treatment, the risk of failure is higher.
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McMaster University1, Northwestern University2, University of Texas Health Science Center at San Antonio3, Johns Hopkins University4, University of Mississippi5, LDS Hospital6, University of Utah7, Centers for Disease Control and Prevention8, Baylor College of Medicine9, United States Department of Veterans Affairs10, Stony Brook University11, Winthrop-University Hospital12, University of Barcelona13
TL;DR: This work presents a meta-analyses of the immune system’s response to chronic obstructive pulmonary disease and shows clear patterns of decline in the immune systems of elderly patients with compromised immune systems.
Abstract: Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.
5,558 citations
Cites background from "Predictors of failure of noninvasiv..."
...Within the first 1–2 h of NIV, failure to improve respiratory rate and oxygenation [114, 289, 290] or failure to decrease carbon dioxide partial pressure (pCO2) in patients with initial hypercarbia [114] predicts NIV failure and warrants prompt intubation....
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...NIV provides no benefit for patients with ARDS [289], which may be nearly indistinguishable from CAP among patients with bilateral alveolar infiltrates....
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...Patients with CAP who have severe hypoxemia (PaO2/FiO2 ratio, !150) are also poor candidates for NIV [290]....
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...Patients who do not require immediate intubation but who have either hypoxemia or respiratory distress should receive a trial of NIV [114, 288, 289]....
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...Prompt recognition of a failed NIV trial is critically important, because most studies demonstrate worse outcomes for patients who require intubation after a prolonged NIV trial [288, 290]....
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McMaster University1, St. Michael's Hospital2, University of Toronto3, St James's University Hospital4, Harvard University5, Tufts Medical Center6, University of Bologna7, Magna Græcia University8, Sapienza University of Rome9, University of Barcelona10, Baylor College of Medicine11, French Institute of Health and Medical Research12, University of British Columbia13, Royal Columbian Hospital14, Hospital de Sant Pau15, Lenox Hill Hospital16, Hofstra University17
TL;DR: This document provides European Respiratory Society/American Thoracic Society and ERS/ATS evidence-based recommendations for the use of noninvasive ventilation in acute respiratory failure based on the most current literature.
Abstract: Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature. The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material. This guideline committee developed recommendations for 11 actionable questions in a PICO (population–intervention–comparison–outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation. This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.
922 citations
TL;DR: Non-invasive mechanical ventilation has been increasingly used to avoid or serve as an alternative to intubation and in some instances with invasive mechanical ventilation, it improves survival and reduces complications in selected patients with acute respiratory failure.
842 citations
TL;DR: Continuous positive airway pressure may decrease the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery.
Abstract: ContextHypoxemia complicates the recovery of 30% to 50% of patients after abdominal
surgery; endotracheal intubation and mechanical ventilation may be required
in 8% to 10% of cases, increasing morbidity and mortality and prolonging intensive
care unit and hospital stay.ObjectiveTo determine the effectiveness of continuous positive airway pressure
compared with standard treatment in preventing the need for intubation and
mechanical ventilation in patients who develop acute hypoxemia after elective
major abdominal surgery.Design and SettingRandomized, controlled, unblinded study with concealed allocation conducted
between June 2002 and November 2003 at 15 intensive care units of the Piedmont
Intensive Care Units Network in Italy.PatientsConsecutive patients who developed severe hypoxemia after major elective
abdominal surgery. The trial was stopped for efficacy after 209 patients had
been enrolled.InterventionsPatients were randomly assigned to receive oxygen (n = 104)
or oxygen plus continuous positive airway pressure (n = 105).Main Outcome MeasuresThe primary end point was incidence of endotracheal intubation; secondary
end points were intensive care unit and hospital lengths of stay, incidence
of pneumonia, infection and sepsis, and hospital mortality.ResultsPatients who received oxygen plus continuous positive airway pressure
had a lower intubation rate (1% vs 10%; P = .005;
relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had
a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95%
CI, 0.07-0.94; P = .03), and sepsis (2%
vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03)
than did patients treated with oxygen alone. Patients who received oxygen
plus continuous positive airway pressure also spent fewer mean (SD) days in
the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09)
than patients treated with oxygen alone. The treatments did not affect the
mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus
continuous positive airway pressure died in the hospital while 3 deaths occurred
among those treated with oxygen alone (P = .12).ConclusionContinuous positive airway pressure may decrease the incidence of endotracheal
intubation and other severe complications in patients who develop hypoxemia
after elective major abdominal surgery.
597 citations
TL;DR: The COVID-19 Treatment Guidelines Panel recommends using an N95 respirator (or equivalent or higher-level respirator) rather than surgical masks, in addition to other personal protective equipment (PPE) (i.e., gloves, gown, and eye protection such as a face shield or safety goggles).
Abstract: Recommendations Infection Control • For health care workers who are performing aerosol-generating procedures on patients with COVID-19, the COVID-19 Treatment Guidelines Panel (the Panel) recommends using an N95 respirator (or equivalent or higher-level respirator) rather than surgical masks, in addition to other personal protective equipment (PPE) (i.e., gloves, gown, and eye protection such as a face shield or safety goggles) (AIII). • The Panel recommends minimizing the use of aerosol-generating procedures on intensive care unit patients with COVID-19 and carrying out any necessary aerosol-generating procedures in a negative-pressure room, also known as an airborne infection isolation room, when available (AIII). • For health care workers who are providing usual care for nonventilated patients with COVID-19, the Panel recommends using an N95 respirator (or equivalent or higher-level respirator) or a surgical mask in addition to other PPE (i.e., gloves, gown, and eye protection such as a face shield or safety goggles) (AII). • For health care workers who are performing non-aerosol-generating procedures on patients with COVID-19 who are on closed-circuit mechanical ventilation, the Panel recommends using an N95 respirator (or equivalent or higher-level respirator) in addition to other PPE (i.e., gloves, gown, and eye protection such as a face shield or safety goggles) because ventilator circuits may become disrupted unexpectedly (BIII). • The Panel recommends that endotracheal intubation in patients with COVID-19 be performed by health care providers with extensive airway management experience, if possible (AIII). • The Panel recommends that intubation be performed using video laryngoscopy, if possible (CIII).
587 citations