PREDICTORS OF NONINVASIVE VENTILATION FAILURE IN PATIENTS WITH COPD EXACERBATIONS IN THE ICU

Abstract

SESSION TITLE: Identifying Successes and Failures of NIV and Airway Clearance: From COPD to Neuromuscular Disease SESSION TYPE: Original Investigations PRESENTED ON: 10/21/2019 1:30 PM - 2:30 PM PURPOSE: Acute exacerbation of COPD is a major mortality and morbidity. Noninvasive ventilation (NIV) is proven to be effective in majority of patients with acute COPD exacerbation. NIV could be lifesaving but also can delay mechanical ventilation if its efficacy is not assessed in a timely manner. In this study we analyzed predictors that can be associated with failure of NIV in acute exacerbation of COPD in a large tertiary care ICU. In particular, we wondered whether duration of NIV among those who failed may be associated with poorer outcomes. METHODS: A retrospective review of consecutive patients with a primary diagnosis of acute exacerbation of COPD requiring NIV admitted to the Cleveland Clinic Main Campus medical ICU was conducted for the period between 2012 and 2017. Baseline data included demographics, APACHE score, albumin level, blood lactate and blood gas elements. Additional chart review was performed to collect NIV setting parameters on presentation to the ICU. Clinical outcome variables collected included outcome and duration of NIV, duration of invasive mechanical ventilation, ICU length of stay, hospital length of stay, and patient survival status. Multivariate regression analysis was performed to determine independent variables associated with clinical outcomes. RESULTS: There were 370 patients who met the inclusion criteria. 53.4% were male. Mean age was 64.7 ± 11.2 years old. Average baseline FEV1 was34 ±17% of predicted. Patients had mean pH of 7.20 ± 0.54 and PaCO2 of 70.3 ± 28.7 on presentation. 323 patients (87.3%) were successfully weaned off NIV. 47 patients (12.7%) failed NIV and required invasive mechanical ventilation. 12 patients (3.2 %)died, 8 in NIV success and 4 in failure groups ,APACHE III score was higher among patients who failed NIV (68.3±18.9 versus 48.8± 15.2, p-value <0.001). In the subset of 47 patients who failed NIV requiring intubation, duration of NIV was 25.0 ± 58.8 hours. Multivariate regression analysis yielded a model consisting of APACHE III score, having had an ABG at baseline and BMI as predictive variables for NIV success. ROC curve revealed c-statistic of 0.815 for the final model; Duration of NIV did not predict clinical outcomes among patients who failed NIV. CONCLUSIONS: NIV is successful in preventing mechanical ventilation in majority of patients with acute respiratory failure due to COPD. Patients with worse clinical status at presentation are more likely to fail noninvasive ventilation and require mechanical ventilation. In the subgroup of patients who failed NIV, duration of NIV prior to intubation was not associated with clinical outcomes. CLINICAL IMPLICATIONS: Clinical outcomes of NIV can be accurately predicted by baseline clinical parameters on presentation. Duration of the trial of NIV was not associated with clinical outcomes in the subgroup of patients who failed NIV. DISCLOSURES: No relevant relationships by Erin Covert, source=Web Response No relevant relationships by Tanya Devnani, source=Web Response No relevant relationships by Abhijit Duggal, source=Web Response No relevant relationships by Katelyn Edwards, source=Web Response No relevant relationships by Andrew Fiore, source=Web Response No relevant relationships by Laith Ghazala, source=Web Response No relevant relationships by Justin Hanks, source=Web Response No relevant relationships by Umur Hatipoglu, source=Web Response