A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure

Mihaela S Stefan,Jay S Steingrub,Karthik Raghunathan,Penelope S Pekow,Peter K Lindenauer,Tara Lagu,Aruna Priya,Anusha G Bhat,Nicholas S Hill

doi:10.1186/s12890-021-01421-w

Abstract

ObjectiveTo develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients.DesignRetrospective cohort study of a multihospital electronic health record database.PatientsNon-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization.MeasurementPrimary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010–2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016.Main resultsOf all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%–2.8%] for low risk group; 9.3% [6.3%–13.5%] for intermediate risk category; and 35.7% [31.0%–45.8%] for high risk category.ConclusionsIn patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.

Highlights

Noninvasive ventilation (NIV) plays a key role in the treatment of acute respiratory failure (ARF) and its use is supported by multiple randomized controlled trials [1,2,3,4]
In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation
The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV

Summary

Introduction

Noninvasive ventilation (NIV) plays a key role in the treatment of acute respiratory failure (ARF) and its use is supported by multiple randomized controlled trials [1,2,3,4]. NIV failure rates range from 5 to 50% and patients who are intubated have an increased risk of death compared to those treated with IMV from the outset [9, 11, 15,16,17]. Prior studies have identified several risk factors associated with NIV failure including coexistent pneumonia, tachypnea, hypotension, severe acidemia, higher severity of illness score, or failure to improve in one hour. Most of these studies were small, were developed in cohorts from randomized trials, or were geared towards specific diagnoses [15, 21,22,23,24]

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Conclusion