Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors

Arnaud W Thille,Chiara Fragnoli,Damien Contou,Ana Córdoba-Izquierdo,Florence Boissier,Christian Brun-Buisson

doi:10.1186/cc13103

Abstract

IntroductionWe assessed rates and predictive factors of non-invasive ventilation (NIV) failure in patients admitted to the intensive care unit (ICU) for non-hypercapnic acute hypoxemic respiratory failure (AHRF).MethodsThis is an observational cohort study using data prospectively collected over a three-year period in a medical ICU of a university hospital.ResultsAmong 113 patients receiving NIV for AHRF, 82 had acute respiratory distress syndrome (ARDS) and 31 had non-ARDS. Intubation rates significantly differed between ARDS and non-ARDS patients (61% versus 35%, P = 0.015) and according to clinical severity of ARDS: 31% in mild, 62% in moderate, and 84% in severe ARDS (P = 0.0016). In-ICU mortality rates were 13% in non-ARDS, and, respectively, 19%, 32% and 32% in mild, moderate and severe ARDS (P = 0.22). Among patients with moderate ARDS, NIV failure was lower among those having a PaO2/FiO2 >150 mmHg (45% vs. 74%, p = 0.04). NIV failure was associated with active cancer, shock, moderate/severe ARDS, lower Glasgow coma score and lower positive end-expiratory pressure level at NIV initiation. Among intubated patients, ICU mortality rate was 46% overall and did not differ according to the time to intubation.ConclusionsWith intubation rates below 35% in non-ARDS and mild ARDS, NIV stands as the first-line approach; NIV may be attempted in ARDS patients with a PaO2/FiO2 > 150. By contrast, 84% of severe ARDS required intubation and NIV did not appear beneficial in this subset of patients. However, the time to intubation had no influence on mortality.

Highlights

We assessed rates and predictive factors of non-invasive ventilation (NIV) failure in patients admitted to the intensive care unit (ICU) for non-hypercapnic acute hypoxemic respiratory failure (AHRF)
It is well-demonstrated that non-invasive ventilation (NIV) can reduce intubation and mortality rates in patients with severe acute exacerbation of chronic obstructive pulmonary disease [1,2,3] or cardiogenic pulmonary edema [4]
The beneficial effects of NIV remain unclear in patients with de novo acute hypoxemic respiratory failure (AHRF), that is, non-hypercapnic patients having acute respiratory failure in the absence of a cardiac origin or underlying chronic pulmonary disease

Summary

Introduction

We assessed rates and predictive factors of non-invasive ventilation (NIV) failure in patients admitted to the intensive care unit (ICU) for non-hypercapnic acute hypoxemic respiratory failure (AHRF). It is well-demonstrated that non-invasive ventilation (NIV) can reduce intubation and mortality rates in patients with severe acute exacerbation of chronic obstructive pulmonary disease [1,2,3] or cardiogenic pulmonary edema [4]. In unselected patients admitted to ICUs for AHRF, the rate of intubation is Despite these concerns, surveys show that NIV is increasingly used in patients having AHRF and is initiated as first-line ventilatory support in 20% to 30% of such patients [5,7]. The increasing popularity of NIV in AHRF patients is supported by some studies showing that NIV markedly reduced intubation and mortality rates in immunosuppressed patients [11,12] or in selected surgical patients with AHRF [13,14]

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