Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications

Abstract

BackgroundNoninvasive positive-pressure ventilation (NIPPV) use has increased in the treatment of patients with respiratory failure. However, despite decreasing the need for intubation in some patients, there are no data regarding the risk of intubation-related complications associated with delayed intubation in adult patients who fail NIPPV. The objective of this study is to evaluate the odds of a composite complication of intubation following failed NIPPV compared to patients intubated primarily in the medical intensive care unit (ICU).MethodsThis is a single-center retrospective cohort study of 235 patients intubated between 1 January 2012 and 30 June 2013 in a medical ICU of a university medical center. A total of 125 patients were intubated after failing NIPPV, 110 patients were intubated without a trial of NIPPV. Intubation-related data were collected prospectively through a continuous quality improvement (CQI) program and retrospectively extracted from the medical record on all patients intubated on the medical ICU. A propensity adjustment for the factors expected to affect the decision to initially use NIPPV was used, and the adjusted multivariate regression analysis was performed to evaluate the odds of a composite complication (desaturation, hypotension, or aspiration) with intubation following failed NIPPV versus primary intubation.ResultsA propensity-adjusted multivariate regression analysis revealed that the odds of a composite complication of intubation in patients who fail NIPPV was 2.20 (CI 1.14 to 4.25), when corrected for the presence of pneumonia or acute respiratory distress syndrome (ARDS), and adjusted for factors known to increase complications of intubation (total attempts and operator experience). When a composite complication occurred, the unadjusted odds of death in the ICU were 1.79 (95% CI 1.03 to 3.12).ConclusionsAfter controlling for potential confounders, this propensity-adjusted analysis demonstrates an increased odds of a composite complication with intubation following failed NIPPV. Further, the presence of a composite complication during intubation is associated with an increased odds of death in the ICU.

Effectiveness of Noninvasive Ventilation in Acute Respiratory Failure

“…In agreement with our results, A recent single center study by Mosier et al, [24] had suggested that in patients who fail on NIV and subsequently, ventilated have poorer outcomes.…”

Critical care of patients with cancer

“…More recent studies did not confirm those earlier reports of a benefit from early NIV compared with oxygen therapy . NIV failure is more frequent in patients with cancer and is accompanied by a higher rate of intubation‐associated complications and a worse prognosis, whereas early intubation is correlated with a better outcome . Infection as the cause of acute respiratory failure, high respiratory rate under NIV, a longer delay between admission and initiation of NIV, a need for vasopressors or renal replacement therapy, and acute respiratory distress syndrome were identified as independent factors associated with NIV failure .…”

“…184,185 NIV failure is more frequent in patients with cancer and is accompanied by a higher rate of intubation-associated complications and a worse prognosis, whereas early intubation is correlated with a better outcome. 9,183,[186][187][188][189][190] Infection as the cause of acute respiratory failure, high respiratory rate under NIV, a longer delay between admission and initiation of NIV, a need for vasopressors or renal replacement therapy, and acute respiratory distress syndrome were identified as independent factors associated with NIV failure. 176,183,190 In an analysis by Azoulay et al, patients who received NIV without subsequent invasive mechanical ventilation had a mortality rate of only 15%, whereas patients with late NIV failure had a mortality rate of 93% versus 78% in patients who received first-line invasive ventilation.…”

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

“…Early predictors of NIV failure include higher severity score, older age, ARDS or pneumonia as the aetiology for respiratory failure, or a failure to improve after 1 h of treatment [89]. Although the reasons for a poorer outcome are not completely understood, patients with NIV failure have higher tidal volumes before intubation [71] and develop more complications after intubation [90]. Studies have shown that NIV failure is an independent risk factor for mortality specifically in this population, although careful patient selection seems to reduce this risk [91,92].…”