Inter-country variability over time in the mortality of mechanically ventilated patients

Abstract

Purpose: Variations in clinical characteristics and management and in the mortality of mechanically ventilated patients have not been sufficiently evaluated. We hypothesized that mortality shows a variability associated with country after adjustment for clinical characteristics and management. Methods: Analysis of four studies carried out at 6-year intervals over an 18-year period. The studies included 26,024 patients (5183 in 1998, 4968 in 2004, 8108 in 2010, and 7765 in 2016) admitted to 1253 units from 38 countries. The primary outcome was 28-day mortality. We performed analyses using multilevel logistic modeling with mixed-random effects, including country as a random variable. To evaluate the effect of management strategies on mortality, a mediation analysis was performed. Results: Adjusted 28-day mortality decreased significantly over time (first study as reference): 2004: odds ratio 0.82 (95% confidence interval [CI] 0.72-0.93); 2010: 0.63 (95% CI 0.53-0.75); 2016: 0.49 (95% CI 0.39-0.61). A protective ventilatory strategy and the use of continuous sedation mediated a moderate fraction of the effect of time on mortality in patients with moderate hypoxemia and without hypoxemia, respectively. Logistic multilevel modeling showed a significant effect of country on mortality:

Invasive Mechanical Ventilation in Chronic Obstructive Pulmonary Disease Exacerbations

“…32 Weaning strategies in patients with AECOPD are quite limited at present (►Table 1). A subanalysis of 189 patients with AECOPD receiving invasive mechanical ventilation who were included in an international observational study of mechanical ventilation in the ICU in 2016 15 showed a significantly higher use of gradual reduction of pressure support as weaning method than the spontaneous breathing trial (56.1 vs. 43.9%, p < 0.001). Weaning was defined as difficult in 25.4% of patients and prolonged in 2.1%.…”

“…11 AECOPD is among the most common cause of medical admission to hospital, and patients with frequent exacerbations have accelerated lung function decline, worse quality of life, and greater mortality. [12][13][14][15][16][17] About half of COPD exacerbations are caused or triggered primarily by bacterial and viral infections (especially from rhinovirus), but air pollution may also be an important trigger. 14 Among patients with AECOPD, admission to an intensive care unit (ICU) is common.…”

“…14 Among patients with AECOPD, admission to an intensive care unit (ICU) is common. According to a recent observational and international study that included four cohort studies (1998,2004,2010, and 2016) performed using the same methodological approach, and that enrolled critically ill patients who received mechanical ventilation longer than 12 hours, 15 the incidence rate for AECOPD as the reason to start mechanical ventilation has significantly decreased from 1998 until 2016 (in 1998, incidence 10.0%, 95% CI: 9.2-10.8%; in 2004, 5.3%, 95% CI: 4.7-6.0%; in 2010, 6.4%, 95% CI: 5.8-6.9%; in 2016, 6.8%, 95% CI: 6.3-7.4%, p < 0.001) and interestingly has shown an increased rate of noninvasive ventilation as first ventilatory support at ICU admission overtime (►Fig. 1).…”

How to ventilate obstructive and asthmatic patients

“…They also have a major economic impact. According to cohort studies that enrolled unselected critically ill patients receiving mechanical ventilation (invasive or non-invasive) for more than 12 h [1], the proportion of patients managed for COPD exacerbation decreased from 10% in 1998 to 7% in 2016 ( Fig. 1).…”

“…Severe asthma exacerbation causing respiratory failure may lead to major mechanical ventilation-associated complications (e.g., barotrauma, cardiovascular collapse, atelectasis, and pneumonia) that can impact on morbidity and mortality. Severe asthma exacerbation accounts for approximately 1% of mechanically ventilated patients admitted to the ICU [1]. NIV use in these patients increased from 3% in 1998 to 34% in 2016 [2].…”