Trends in assisted ventilation and outcome for obstructive pulmonary disease exacerbations. A nationwide study

Abstract

BackgroundNon-invasive ventilation (NIV) has been used for decades in treatment of exacerbations of chronic obstructive pulmonary disease (COPD). The impact of the changing use of assisted ventilation in acute exacerbations on outcomes has not been fully elucidated and we aimed to describe these changes in the Danish population and describe their consequences for mortality.MethodsA register-based study was conducted of a cohort of 12,847 patients admitted for acute exacerbation of COPD (AECOPD) from 2004 through 2011, treated with invasive mechanical ventilation (IMV) or NIV for the first time. Age, sex, in-hospital mortality rates, time to death or readmission for AECOPD were established and changes over time tracked.ResultsThe number of admissions for AECOPD where assisted ventilation was used was 1,130 in 2004 and had increased by 145% in 2011. First time ventilations increased by 88%. This was mainly due to an increase in use of NIV accounting for 36% of the total number of assisted ventilations in 2004 and 67% in 2011. The number of IMV with or without NIV treatments remained constant. The mean age of NIV patients increased from 71.5 to 73.6 years, but remained constant at 70.0 years in IMV patients. Mortality rates both in hospital and after discharge for patients receiving NIV remained constant throughout the period. In-hospital mortality following IMV increased from 30% to 38%, but mortality after discharge remained stable.ConclusionAssisted ventilation has been increasingly used in a broader spectrum of AECOPD patients since the introduction of NIV. The changes in treatment strategies have been followed by shifts in in-hospital mortality rates following IMV.

Impact of Macrolide Antibiotics on Hospital Readmissions and Other Clinically Important Outcomes in Critically Ill Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Propensity Score–Matched Cohort Study

“…These agents are known to confer antiinflammatory properties that may have confounded our attempts to isolate the antiinflammatory effects of the macrolides over other antimicrobial agents . The in‐hospital mortality rate in this study was much lower than that reported previously for patients with both hospital and ICU admissions for AECOPD and partially reflects our exclusion of over 1000 patients who died in the first 2 hospital days . In turn, this may have impaired our ability to detect significant differences between treatment groups.…”

“…32 The inhospital mortality rate in this study was much lower than that reported previously for patients with both hospital and ICU admissions for AECOPD and partially reflects our exclusion of over 1000 patients who died in the first 2 hospital days. 33,34 In turn, this may have impaired our ability to detect significant differences between treatment groups. However, long-term outcomes in patients hospitalized in the ICU for AECOPD are poor, with relatively high mortality rates.…”

Is positive airway pressure therapy underutilized in chronic obstructive pulmonary disease patients?

“…Despite such accumulating evidence in the late 1990s and early 2000s, there was an implementation gap with a disproportionately small number of hospitalized patients with acute exacerbation of COPD receiving NIPPV [12]. Such an implementation gap has begun to narrow over the years, with recent trends suggesting that the use of NIPPV has more than doubled between 2004 and 2011 [13]. In this claims-based analysis of the Danish national registry, there was a 4.1 fold increase in NIPPV use alone and 3.1 fold increase in the combination of NIPPV and IMV in hospitalized patients, whereas, the use of IMV alone reduced by 40% during the same time [13].…”

Observational cohort study of outcomes in patients admitted to the intensive care unit for acute exacerbation of chronic obstructive pulmonary disease

“…This is a resource intensive therapy, and local guidelines published jointly by the Thoracic Society of Australia and New Zealand and the Lung Foundation of Australia do not provide specific criteria to aid the decision to admit to ICU for AECOPD. 11 Decisions related to ICU versus ward-based care may also be informed by data demonstrating in-hospital mortality of 4-25% and 1-year mortality of 23-51% for AECOPD patients receiving NIV for hypercapnia, 9,[12][13][14][15][16][17] with the latter comparing unfavourably to many malignancies. 11 Decisions related to ICU versus ward-based care may also be informed by data demonstrating in-hospital mortality of 4-25% and 1-year mortality of 23-51% for AECOPD patients receiving NIV for hypercapnia, 9,[12][13][14][15][16][17] with the latter comparing unfavourably to many malignancies.…”

“…8 The lack of robust prognostic tools to guide patient selection for ICU admission and the influence of nonmodifiable pre-morbid conditions 9,10 may at times result in a reluctance to admit patients with AECOPD to ICU. 11 Decisions related to ICU versus ward-based care may also be informed by data demonstrating in-hospital mortality of 4-25% and 1-year mortality of 23-51% for AECOPD patients receiving NIV for hypercapnia, 9,[12][13][14][15][16][17] with the latter comparing unfavourably to many malignancies. 18,19 Different views between intensivists and respiratory physicians on the likely clinical trajectory of AECOPD and the need for ICU admission are not uncommon.…”