Ward-based Non-invasive ventilation (NIV) as Ceiling of Care in Acute Hypercapnic Respiratory Failure (AHRF)

Abstract

Introduction: Ward-based NIV Units consistently admit more severely acidotic patients than recommended by the guidelines. It is hypothesised that the majority of such patients may have NIV as their ceiling of care. Even within Intensive care units (ICU), “Do-not-intubate” status was present among one-fifth of patients who received NIV (Azoulay et al. Intensive Care Med (2013) 39: 292-301) We assessed the proportion of patients receiving acute NIV as their “ceiling of care” and their outcomes. Methods: Retrospective registry analysis of all patients commenced on acute NIV for all-cause AHRF 01 January 2016 and 30 June 2017. Data relating to documentation of ceiling of care for patients, initial pH at commencement of NIV and NIV success (discharge from hospital alive) was collected. Results: Out of 228 acute NIV episodes, 145 (63.6%) had NIV as the ceiling of care, it was successful in reversing AHRF (patient discharged from hospital alive) in 123 (84.8%) of the 145. The median initial pH was 7.26. Conclusions: The results show that half of the patients receiving ward-based NIV as ceiling of care have an initial pH (strong mortality predictor) below the lower limit of the pH range (7.26) for ward-based acute NIV as per British guidelines with 15.2% in-hospital mortality (expected: about 30%). With limited availability of ICU beds, the admission of debilitated patients with underlying end-stage chronic illness may deprive other critically ill candidates who may derive more benefit from ICU resources but Ward-based NIV seems to be an effective alternative in the treatment of AHRF due to any cause in this patient population which should be tried before end-of-life care.