Noninvasive ventilation safe in general, but not for CAP

SAN JUAN, P.R.  – Noninvasive ventilation can be safely initiated and monitored on a general medical ward, taking some of the pressure off intensive care units, investigators reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

A retrospective study comparing outcomes for patients started on noninvasive ventilation (NIV) on general floors with those of patients put on NIV in the ICU showed that patients on the general wards were less likely to need intubation and had a shorter length of stay, but with mortality similar to that of ICU-treated patients, reported Dr. Edison Gavilanes, a resident in internal medicine at New York Hospital Queens.

If the patients started on noninvasive ventilation have community-acquired pneumonia (CAP), however, there is a high likelihood that they will eventually need to be intubated, cautioned Dr. Anwar Murad, an internal medicine resident at McGill University Health Centre, Montreal.

"Even though current evidence does not support NIV use in CAP, our data demonstrate that it is commonly employed in critical care units," Dr. Murad said in a poster presentation.

NIV in general

The New York researchers noted that, although current guidelines recommend that patients be started on NIV in the ICU and transferred to a step-down unit when they are stable, there are "little data to suggest that NIV on general wards is unsafe or that it could have an effect on mortality."

To see whether it was safe to start patients on NIV in general wards, they took a retrospective look at the records of 647 patients treated with NIV in 2011, collecting both clinical and demographic parameters as well as physiologic measures, including pH levels, carbon dioxide partial pressure (pCO₂), oxygen partial pressure (pO₂), and serum bicarbonate.

They found that, compared with the 184 patients in whom NIV was initiated in the ICU, the group of 463 patients started on NIV on the general wards had a higher mean age (77.8 vs. 73.1 years), more females than males (56.6% vs. 41.8%), higher mean pCO₂ (51.4 vs. 42.9 mm Hg; P less than .0001), and was more likely to have respiratory failure from pulmonary causes rather than heart failure (69.8% vs. 51.1%; P less than .007).

Patients in the general wards had a significantly lower incidence of intubation (14.5% vs. 47.3%; P less than .0001) and shorter length of stay (11.6 vs. 15.9 days; P = .0001), Dr. Gavilanes reported.

There was no significant difference in mortality.

Variables associated with failure of an NIV trial on the floor and transfer to the ICU included the presence of metabolic acidosis, vasopressor requirement, and need for intubation. Patients who required transfer to the ICU had a higher mortality rate than did those who did not require it (62.9% vs. 27.6%; P less than .0001).

The investigators noted that "93% of the patients in whom NIV was started on the general medical wards did not require eventual ICU transfer or have increased mortality. However, patients with hemodynamic instability and metabolic acidosis can fail NIV and might benefit from ICU level monitoring."

NIV common for CAP

The Canadian researchers examined whether NIV was safe in patients with community-acquired pneumonia.

"Despite a lack of data supporting its use, NIV is commonly used in the management of patients with CAP. It is unclear which patients benefit from NIV and avoid endotracheal intubation," Dr. Murad said.

He and his associates conducted a retrospective cohort study of records on patients admitted to three critical care units from 2007 to 2012 with a diagnosis of CAP who were started on either noninvasive or invasive ventilation.

They identified 229 patients – 93 were intubated and 136 were started on NIV. Patients on NIV tended to be older (median age, 73 vs. 68 years), but there were no significant differences in baseline characteristics.

There were no significant differences in mortality for the overall cohort (46% vs. 33%), cardiac care unit length of stay (9 days in each group), or hospital length of stay (20 days vs. 17 days).

However, 101 (74%) patients failed NIV and required endotracheal intubation. Of the 101 patients in the NIV failure group, 50 (49.5%) required vasopressors, compared with 4 of the 35 patients (11.4%) who were successfully maintained on NIV.

As in the study by Dr. Gavilanes and his colleagues, there were significantly more deaths among patients who failed NIV (53 vs. 8; P = .002), as well as hemodynamic instability (54 vs. 8; P less than .001), and lactic acidosis (31 vs. 2; P =.003).

"Patients with CAP treated with NIV have a high likelihood of requiring intubation and developing significant complications. Patients started on NIV for severe CAP should be considered for early intubation if found to require vasopressor or have persistent hypoxemia/acidosis," Dr. Murad said.

Both studies were internally funded. Dr. Gavilanes and Dr. Murad each reported having no financial disclosures.

[email protected]

SAN JUAN, P.R.  – Noninvasive ventilation can be safely initiated and monitored on a general medical ward, taking some of the pressure off intensive care units, investigators reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

A retrospective study comparing outcomes for patients started on noninvasive ventilation (NIV) on general floors with those of patients put on NIV in the ICU showed that patients on the general wards were less likely to need intubation and had a shorter length of stay, but with mortality similar to that of ICU-treated patients, reported Dr. Edison Gavilanes, a resident in internal medicine at New York Hospital Queens.

If the patients started on noninvasive ventilation have community-acquired pneumonia (CAP), however, there is a high likelihood that they will eventually need to be intubated, cautioned Dr. Anwar Murad, an internal medicine resident at McGill University Health Centre, Montreal.

"Even though current evidence does not support NIV use in CAP, our data demonstrate that it is commonly employed in critical care units," Dr. Murad said in a poster presentation.

NIV in general

The New York researchers noted that, although current guidelines recommend that patients be started on NIV in the ICU and transferred to a step-down unit when they are stable, there are "little data to suggest that NIV on general wards is unsafe or that it could have an effect on mortality."

To see whether it was safe to start patients on NIV in general wards, they took a retrospective look at the records of 647 patients treated with NIV in 2011, collecting both clinical and demographic parameters as well as physiologic measures, including pH levels, carbon dioxide partial pressure (pCO₂), oxygen partial pressure (pO₂), and serum bicarbonate.

They found that, compared with the 184 patients in whom NIV was initiated in the ICU, the group of 463 patients started on NIV on the general wards had a higher mean age (77.8 vs. 73.1 years), more females than males (56.6% vs. 41.8%), higher mean pCO₂ (51.4 vs. 42.9 mm Hg; P less than .0001), and was more likely to have respiratory failure from pulmonary causes rather than heart failure (69.8% vs. 51.1%; P less than .007).

Patients in the general wards had a significantly lower incidence of intubation (14.5% vs. 47.3%; P less than .0001) and shorter length of stay (11.6 vs. 15.9 days; P = .0001), Dr. Gavilanes reported.

There was no significant difference in mortality.

Variables associated with failure of an NIV trial on the floor and transfer to the ICU included the presence of metabolic acidosis, vasopressor requirement, and need for intubation. Patients who required transfer to the ICU had a higher mortality rate than did those who did not require it (62.9% vs. 27.6%; P less than .0001).

The investigators noted that "93% of the patients in whom NIV was started on the general medical wards did not require eventual ICU transfer or have increased mortality. However, patients with hemodynamic instability and metabolic acidosis can fail NIV and might benefit from ICU level monitoring."

NIV common for CAP

The Canadian researchers examined whether NIV was safe in patients with community-acquired pneumonia.

"Despite a lack of data supporting its use, NIV is commonly used in the management of patients with CAP. It is unclear which patients benefit from NIV and avoid endotracheal intubation," Dr. Murad said.

He and his associates conducted a retrospective cohort study of records on patients admitted to three critical care units from 2007 to 2012 with a diagnosis of CAP who were started on either noninvasive or invasive ventilation.

They identified 229 patients – 93 were intubated and 136 were started on NIV. Patients on NIV tended to be older (median age, 73 vs. 68 years), but there were no significant differences in baseline characteristics.

There were no significant differences in mortality for the overall cohort (46% vs. 33%), cardiac care unit length of stay (9 days in each group), or hospital length of stay (20 days vs. 17 days).

However, 101 (74%) patients failed NIV and required endotracheal intubation. Of the 101 patients in the NIV failure group, 50 (49.5%) required vasopressors, compared with 4 of the 35 patients (11.4%) who were successfully maintained on NIV.

As in the study by Dr. Gavilanes and his colleagues, there were significantly more deaths among patients who failed NIV (53 vs. 8; P = .002), as well as hemodynamic instability (54 vs. 8; P less than .001), and lactic acidosis (31 vs. 2; P =.003).

"Patients with CAP treated with NIV have a high likelihood of requiring intubation and developing significant complications. Patients started on NIV for severe CAP should be considered for early intubation if found to require vasopressor or have persistent hypoxemia/acidosis," Dr. Murad said.

Both studies were internally funded. Dr. Gavilanes and Dr. Murad each reported having no financial disclosures.

[email protected]

SAN JUAN, P.R.  – Noninvasive ventilation can be safely initiated and monitored on a general medical ward, taking some of the pressure off intensive care units, investigators reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

A retrospective study comparing outcomes for patients started on noninvasive ventilation (NIV) on general floors with those of patients put on NIV in the ICU showed that patients on the general wards were less likely to need intubation and had a shorter length of stay, but with mortality similar to that of ICU-treated patients, reported Dr. Edison Gavilanes, a resident in internal medicine at New York Hospital Queens.

If the patients started on noninvasive ventilation have community-acquired pneumonia (CAP), however, there is a high likelihood that they will eventually need to be intubated, cautioned Dr. Anwar Murad, an internal medicine resident at McGill University Health Centre, Montreal.

"Even though current evidence does not support NIV use in CAP, our data demonstrate that it is commonly employed in critical care units," Dr. Murad said in a poster presentation.

NIV in general

The New York researchers noted that, although current guidelines recommend that patients be started on NIV in the ICU and transferred to a step-down unit when they are stable, there are "little data to suggest that NIV on general wards is unsafe or that it could have an effect on mortality."

To see whether it was safe to start patients on NIV in general wards, they took a retrospective look at the records of 647 patients treated with NIV in 2011, collecting both clinical and demographic parameters as well as physiologic measures, including pH levels, carbon dioxide partial pressure (pCO₂), oxygen partial pressure (pO₂), and serum bicarbonate.

They found that, compared with the 184 patients in whom NIV was initiated in the ICU, the group of 463 patients started on NIV on the general wards had a higher mean age (77.8 vs. 73.1 years), more females than males (56.6% vs. 41.8%), higher mean pCO₂ (51.4 vs. 42.9 mm Hg; P less than .0001), and was more likely to have respiratory failure from pulmonary causes rather than heart failure (69.8% vs. 51.1%; P less than .007).

Patients in the general wards had a significantly lower incidence of intubation (14.5% vs. 47.3%; P less than .0001) and shorter length of stay (11.6 vs. 15.9 days; P = .0001), Dr. Gavilanes reported.

There was no significant difference in mortality.

Variables associated with failure of an NIV trial on the floor and transfer to the ICU included the presence of metabolic acidosis, vasopressor requirement, and need for intubation. Patients who required transfer to the ICU had a higher mortality rate than did those who did not require it (62.9% vs. 27.6%; P less than .0001).

The investigators noted that "93% of the patients in whom NIV was started on the general medical wards did not require eventual ICU transfer or have increased mortality. However, patients with hemodynamic instability and metabolic acidosis can fail NIV and might benefit from ICU level monitoring."

NIV common for CAP

The Canadian researchers examined whether NIV was safe in patients with community-acquired pneumonia.

"Despite a lack of data supporting its use, NIV is commonly used in the management of patients with CAP. It is unclear which patients benefit from NIV and avoid endotracheal intubation," Dr. Murad said.

He and his associates conducted a retrospective cohort study of records on patients admitted to three critical care units from 2007 to 2012 with a diagnosis of CAP who were started on either noninvasive or invasive ventilation.

They identified 229 patients – 93 were intubated and 136 were started on NIV. Patients on NIV tended to be older (median age, 73 vs. 68 years), but there were no significant differences in baseline characteristics.

There were no significant differences in mortality for the overall cohort (46% vs. 33%), cardiac care unit length of stay (9 days in each group), or hospital length of stay (20 days vs. 17 days).

However, 101 (74%) patients failed NIV and required endotracheal intubation. Of the 101 patients in the NIV failure group, 50 (49.5%) required vasopressors, compared with 4 of the 35 patients (11.4%) who were successfully maintained on NIV.

As in the study by Dr. Gavilanes and his colleagues, there were significantly more deaths among patients who failed NIV (53 vs. 8; P = .002), as well as hemodynamic instability (54 vs. 8; P less than .001), and lactic acidosis (31 vs. 2; P =.003).

"Patients with CAP treated with NIV have a high likelihood of requiring intubation and developing significant complications. Patients started on NIV for severe CAP should be considered for early intubation if found to require vasopressor or have persistent hypoxemia/acidosis," Dr. Murad said.

Both studies were internally funded. Dr. Gavilanes and Dr. Murad each reported having no financial disclosures.

[email protected]