NIV Treatment Research Articles

Use of CPAP Ventilation in Non-ICU Wards May Influence Outcomes in Patients with Severe Respiratory COVID-19.

Background and Objectives: The COVID-19 disease has significantly burdened the healthcare system, including all units of severe patient treatment. Non-intensive care units were established to rationalize the capacity within the Intensive Care Unit (ICU) and to create a unit where patients with Acute Respiratory Distress Syndrome (ARDS) could be treated with non-invasive Continuous Positive Air Pressure (CPAP) outside the ICU. This unicentric retrospective study aimed to assess the efficacy of NIV Treatment in Patients of the fourth pandemic wave and how its application affects the frequency and mortality of ICU-treated patients at University Hospital Rijeka compared to earlier waves of the COVID-19 pandemic. Furthermore, the study showcases the effect of the Patient/Nurse ratio (P/N ratio) on overall mortality in the ICU. Materials and Methods: The study was conducted on two groups of patients with respiratory insufficiency in the second and third pandemic waves, treated in the COVID Respiratory Centre (CRC) (153 patients). We also reviewed a cohort of patients from the fourth pandemic wave who were initially hospitalized in a COVID-6 non-intensive unit from 1 October 2021 to 1 November 2022 (102 patients), and some of them escalated to CRC. Results: The introduction of the CPAP non-invasive ventilation method as a means of hypoxic respiratory failure treatment in non-intensive care units has decreased the strain, overall number of admissions, and CRC patient mortality. The overall fourth wave mortality was 29.4%, compared to the 58.2% overall mortality of the second and third waves. Conclusions: As a result, this has decreased CRC patient admissions and, by itself, overall mortality.

Clinical practice of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease

BackgroundNon-invasive ventilation (NIV) is an evidence-based treatment for acute respiratory failure in chronic obstructive pulmonary disease (COPD). However, suboptimal application of NIV in clinical practice, possibly due to poor guideline adherence, can impact patient outcomes. This study aims to evaluate guideline adherence to NIV for acute COPD exacerbations and explore its impact on mortality.MethodsThis retrospective study was performed in two Dutch medical centers from 2019 to 2021. All patients admitted to the pulmonary ward or intensive care unit with a COPD exacerbation were included. An indication for NIV was considered in the event of a respiratory acidosis.ResultsA total of 1162 admissions (668 unique patients) were included. NIV was started in 154 of the 204 admissions (76%) where NIV was indicated upon admission. Among 78 admissions where patients deteriorated later on, NIV was started in 51 admissions (65%). Considering patients not receiving NIV due to contra-indications or patient refusal, the overall guideline adherence rate was 82%. Common reasons for not starting NIV when indicated included no perceived signs of respiratory distress, opting for comfort care only, and choosing a watchful waiting approach. Better survival was observed in patients who received NIV when indicated compared to those who did not.ConclusionsThe adherence to guidelines regarding NIV initiation is good. Nevertheless, further improving NIV treatment in clinical practice could be achieved through training healthcare professionals to increase awareness and reduce reluctance in utilizing NIV. By addressing these factors, patient outcomes may be further enhanced.

NONINVASIVE MECHANICAL VENTILATION MANAGEMENT AND HACOR SCORE IN ACUTE HYPOXEMIC RESPIRATORY FAILURE INDUCED BY INFLUENZA A (H1N1): A CASE REPORT

Influenza is a highly contagious, acute viral infection that affects the respiratory system, and causes global outbreak in humans. It is usually self-limited, may progress to severe acute respiratory syndrome (SARS), and eventually leads to acute hypoxemic respiratory failure (AHRF). The main objective was to describe a case report of careful management of NIV in SARS caused by influenza A H1N1 virus, using the HACOR score. The patient exhibited clinical, radiological and laboratory improvement after 4 days of NIV treatment. She was discharged from ICU after 7 days and from the hospital after 10 days. NIV in AHRF is feasible in well-selected patients. Special attention to ventilator settings should be taken particularly to the expired tidal volume, allowing less hospitalization time, orotracheal intubation complications, and therefore, reducing hospital costs. Under these conditions, the new HACOR score can be very useful to avoid unduly delay of intubation time and increased mortality.

Non-invasive Home-Ventilation: Pathophysiology, Initiation and Follow-up

COPD is the most common reason for hypercapnia. However, it is - by far - not the only reason. In fact, numerous neuromuscular disorders (not only ALS) as well as restrictive thoracic disorders do also lead to clinically highly relevant hypercapnia. Early diagnosis of hypercapnic ventilatory failure usually takes place at nighttime. NIV devices work with a periodic interplay of alternating IPAP and EPAP which results in a ventilation of the lungs, thereby elimination CO2 to treat hypercapnic respiratory failure. Firstline settings for a NIV therapy to treat "stable hypercapnia" are as follows: Pressure Support Ventilation Modus, EPAP 5 cm H2O, IPAP 15 cm H2O, Back Up rate 15/Minute. The overall goal of NIV treatment is a successful reduction in CO2. This can be achieved by changing the following variables of the ventilator settings: increase in IPAP ± increase in back up respiratory rate ± use of assisted pressure controlled ventilation mode (APCV)-.

A multicenter, randomized controlled, non-inferiority trial, comparing nasal continuous positive airway pressure with nasal intermittent positive pressure ventilation as primary support before minimally invasive surfactant administration for preterm infants with respiratory distress syndrome (the NIV-MISA-RDS trial): Study protocol.

BackgroundNon-invasive ventilation (NIV) treatment has been developed to minimize lung damage and to avoid invasive mechanical ventilation (IMV) in preterm infants, especially in those with a gestational age of <30 weeks. Our hypothesis is that for preterm infants <30 weeks with potential to develop respiratory distress syndrome (RDS), nasal continuous positive airway pressure (NCPAP) is non-inferior to the nasal intermittent positive pressure ventilation (NIPPV) as primary respiratory support before minimal invasive surfactant administration (MISA).Methods and designThe NIV-MISA-RDS trial is planned as an unblinded, multicenter, randomized, non-inferiority trial at 14 tertiary neonatal intensive care units (NICUs) in China. Eligible infants are preterm infants of 24–29+6 weeks of gestational age who have spontaneous breaths at birth and require primary NIV support for RDS. Infants are randomized 1:1 to treatment with either NCPAP or NIPPV once admitted into NICUs. If an infant presents progressively aggravated respiratory distress and is clinically diagnosed as having RDS, pulmonary surfactant will be supplemented by MISA in the first 2 h of life. The primary outcome is NIV treatment failure within 72 h after birth. With a specified non-inferiority margin of 10%, using a two-sided 95% CI and 80% power, the study requires 480 infants per group (in total 960 infants).DiscussionCurrent evidence shows that NIV and MISA may be the most effective strategy for minimizing IMV in preterm infants with RDS. However, there are few large randomized controlled trials to compare the effectiveness of NCPAP and NIPPV as the primary respiratory support after birth and before surfactant administration. We will conduct this trial to test the hypothesis that NCPAP is not inferior to NIPPV as the initial respiratory support in reducing the use of IMV in premature infants who have spontaneous breaths after birth and who do not require intubation in the first 2 h after birth. The study will provide clinical data for the selection of the initial non-invasive ventilation mode in preterm infants with a gestational age of <30 weeks with spontaneous breaths after birth.Clinical trial registrationhttps://register.clinicaltrials.gov, identifier: NCT05137340.

Noninvasive ventilation and high-flow nasal cannula in patients with acute hypoxemic respiratory failure by covid-19: A retrospective study of the feasibility, safety and outcomes

BackgroundNoninvasive ventilation (NIV) and High-flow nasal cannula (HFNC) are the main forms of treatment for acute respiratory failure. This study aimed to evaluate the effect, safety, and applicability of the NIV and HFNC in patients with acute hypoxemic respiratory failure (AHRF) caused by COVID-19. MethodsIn this retrospective study, we monitored the effect of NIV and HFNC on the SpO2 and respiratory rate before, during, and after treatment, length of stay, rates of endotracheal intubation, and mortality in patients with AHRF caused by COVID-19. Additionally, data regarding RT-PCR from physiotherapists who were directly involved in assisting COVID-19 patients and non−COVID-19. Results62.2 % of patients were treated with HFNC. ROX index increased during and after NIV and HFNC treatment (P < 0.05). SpO2 increased during NIV treatment (P < 0.05), but was not maintained after treatment (P = 0.17). In addition, there was no difference in the respiratory rate during or after the NIV (P = 0.95) or HFNC (P = 0.60) treatment. The mortality rate was 35.7 % for NIV vs 21.4 % for HFNC (P = 0.45), while the total endotracheal intubation rate was 57.1 % for NIV vs 69.6 % for HFNC (P = 0.49). Two adverse events occurred during treatment with NIV and eight occurred during treatment with HFNC. There was no difference in the physiotherapists who tested positive for SARS−COV-2 directly involved in assisting COVID-19 patients and non−COVID-19 ones (P = 0.81). ConclusionThe application of NIV and HFNC in the critical care unit is feasible and associated with favorable outcomes. In addition, there was no increase in the infection of physiotherapists with SARS-CoV-2.

Non-invasive Home-Ventilation: Pathophysiology, Initiation and Follow up

COPD is the most common reason for hypercapnia. However, it is -by far- not the only reason. In fact, numerous neuromuscular disorders (not only ALS) as well as restrictive thoracic disorders do also lead to clinically highly relevant hypercapnia. Early diagnosis of hypercapnic ventilatory failure usually takes place at nighttime. NIV devices work with a periodic interplay of alternating IPAP and EPAP which results in a ventilation of the lungs, thereby elimination CO2 to treat hypercapnic respiratory failure. Firstline settings for a NIV therapy to treat "stable hypercapnia" are as follows: Pressure Support Ventilation Modus, EPAP 5 cmH2O, IPAP 15 cmH2O, Back Up rate 15/Minute. The overall goal of NIV treatment is a successful reduction in CO2. This can be achieved by changing the following variables of the ventilator settings: increase in IPAP ± increase in back up respiratory rate ± use of assisted pressure controlled ventilation mode (APCV).

Cardiovascular changes in children with obstructive sleep apnea and obesity after treatment with noninvasive ventilation.

Adults with obesity and obstructive sleep apnea (OSA) are at risk for cardiometabolic disease, and this risk likely extends to children with both conditions. Noninvasive ventilation (NIV; including continuous and bilevel positive airway pressure) is often used to treat OSA in children with obesity. The aim of this study was to examine the impact of NIV treatment on heart rate variability (HRV), as a marker of cardiovascular risk, in children with obesity and newly diagnosed OSA. A prospective multicenter cohort study was conducted in children with obesity prescribed NIV therapy for newly diagnosed moderate-severe OSA. Measurements of HRV were derived from polysomnography recordings at baseline and after 12 months of treatment. HRV parameters were examined by sleep stage, before and after arousal and oxygen desaturation events. HRV parameters were compared between time points using pair t tests as well as mixed model analysis. Twelve children had appropriate data for analysis at baseline and 12 months. Heart rate decreased by 4.5 beats/min after NIV treatment, with no change in HRV parameters. HRV parameters differed by sleep stage and showed an increase in arousal-related sympathetic-parasympathetic balance after 12 months of NIV treatment. HRV parameters did not differ before and after oxygen desaturation events. NIV for the treatment in children with obesity and OSA resulted in a small decrease in heart rate and an increase in arousal-related sympathetic-parasympathetic balance. These findings suggest small, potentially positive impacts of NIV on cardiovascular risk in children with concurrent obesity and OSA.

COVID-19: The Intensive Care Point-of-View

Approx. 93 % of COVID-19 infections are mild, and not all severely ill patients are transferred to the intensive care unit. But the Corona crisis implies high demands on intensive care medicine. Many treatment modalities of COVID patients are "best practice", but some aspects remain unclear at present. This article deals with diagnostics, monitoring and therapy with COVID-19 patients in intensive care units and with a suitable hygiene concepts.A hygiene concept is obligatory and must ensure - in addition to general measures - the training of employees and the hygienic discharge of material. Ideally, a cohort isolation is implemented.Monitoring of patients with COVID-19 is not different from other intensive care patients and should be adapted to the clinical situation of the individual patient. In laboratory analysis the typical abnormality of COVID-19 patients should be taken into account. In case of increasing inflammatory parameters, fungal infections should be tested.Due to the formation of aerosols, disconnection of the respiratory system must be avoided in invasive ventilation. If a disconnection from the respirator is necessary, the tube should be disconnected. After extubation, an intermittent NIV treatment for atelectase prophylaxis can be performed.

The Copmparison of Accuracy of PtcCO2 and in PetCO2 in COPD Patients With NIV Treatment

The Copmparison of Accuracy of PtcCO2 and in PetCO2 in COPD Patients With NIV Treatment

Obesity Hypoventilation: Pathophysiology, Diagnosis, and Treatment

This is a review of the current understanding of the pathophysiology behind the development of daytime hypercapnia in a subset of obese patients. It provides an overview of the recent evidence to guide physicians in the diagnosis and treatment of patients with obesity hypoventilation syndrome (OHS). OHS results from a complex interplay between obesity-related changes in respiratory mechanics, sleep-disordered breathing, changes in central ventilatory drive, and neurohormonal changes. Diagnosis is important given the associated morbidity, but reliance on a single measurement of PaCO2 on the arterial blood gas has been questioned. Positive airway pressure (PAP) has been shown to improve gas exchange, sleep-disordered breathing, and symptoms in OHS, and is an effective therapy. More recent studies have not shown bilevel positive airway pressure or volume-targeted pressure support to be superior to CPAP in treating stable OHS, but NIV treatment studies are limited by variability in the settings used. The development of daytime hypercapnia in a subset of obese patients is multifactorial. Phenotyping OHS patients can allow for individualization of therapies. Further long-term longitudinal studies exploring varying severities and clinical phenotypes of OHS are needed. There is also a need for additional studies to guide providers on the optimal PAP settings in OHS.

NIV for acute respiratory failure in COPD: high in-hospital mortality is determined by patient selection

ABSTRACTIntroduction: Hospital mortality among chronic obstructive pulmonary disease (COPD) patients receiving NIV for acute respiratory failure has shown to be significantly higher in clinical settings than in the randomized trials (RCTs) which clinical guidelines are based on. This may be due to the quality of care of NIV or patient selection. In daily clinical practice, we include patients with terminal pulmonary disease with a do-not-intubate (DNI) or a do-not-resuscitate (DNR) order with a high mortality risk compared to highly selected patients in RCTs. The aim of this study was to determine the role of patient selection for in-hospital mortality among patients receiving NIV for acute respiratory failure of COPD.Methods: We conducted a retrospective study including all patients receiving acute NIV due to acute respiratory failure at the respiratory wards in 2012–2013 at two hospitals in Greater Copenhagen.Results: Overall in-hospital mortality rate was 30%. In patients with a DNI/DNR order, mortality was 59% and in patients with no limitations in treatment 2%. Patients who fulfilled the exclusion criteria of the RCT by Plant et al. had a mortality of 41% compared to 25% in the remaining population.Conclusions: High overall in-hospital mortality reflects that patient selection in clinical practice is very different from RCT. Quality of acute NIV treatment seems acceptable in clinical practice for patients with less severe COPD and no limitations in treatment. Higher mortality in patients with DNI/DNR order may be due to inefficient NIV treatment for these patients with more severe COPD.

Non-invasive ventilation and clinical outcomes in cystic fibrosis: Findings from the UK CF registry

BackgroundNon-invasive ventilation (NIV) for respiratory failure and airway clearance is an established intervention in cystic fibrosis (CF), but its therapeutic benefit on lung function and survival remains under-investigated. MethodsUsing data from the UK CF Registry between 2007 and 2015, we explored the patterns of NIV use, and assessed changes in mean percent predicted FEV1 (ppFEV1) prior to and after NIV use, and the survival of patients on NIV. ResultsAmong 11,079 patients, 1107 had at least one record of NIV treatment. Incidence and prevalence of NIV was lower in children and followed non-linear temporal patterns. Adjusting for other risk factors, ppFEV1 rose by 0.70 (95%CI: -0.83, 2.24) after first NIV use in children. In adults with a low ppFEV1 (<40%) at initiation of treatment, NIV increased mean ppFEV1 by 2.60 (95% CI: 0.93, 4.27). Our analysis showed that NIV initiation is associated with an increased risk of death/transplant in both children (HR = 2.47; 95%CI: 1.20–5.08) and adults (HR = 1.96; 95% CI: 1.63–2.36) but effect was attenuated in children with low ppFEV1 (<40%). ConclusionsNIV usage in CF improves spirometric values but does not benefit survival. Further studies are required to better understand survival outcomes and ultimately improve NIV outcomes in CF.

P146 The patients with acute exacerbation of COPD maybe benefit from autotitrating EPAP during noninvasive ventilation: a prospective study

Introduction To determine whether the patients with acute exacerbation of COPD benefit from noninvasive ventilation, which EPAP is required for a varying range rather than a fixed level. Methods A randomized,prospective and controlled study, 30 elderly patients in AECOPD were divided into three groups: S/T(spontaneous/time) mode group, AVAPS(average volume assured pressure support) mode group and AVAPS-AE(average volume assured pressure support auto-EPAP) mode group. Each group was accepted noninvasive ventilation therapy (NIV via total face mask), for a period of 48 hours. Parameters in three NIV modes: S/T group(IPAP=18 cmH2O, EPAP =5cmH2O,tidal volume depending on individual BMI); the same adopted in AVAPS mode; AVAPS-AE mode(maximum EPAP=8cmH2O,minimum EPAP=4cmH2O, tidal volume depending on individual BMI) .The arterial blood gas analysis was observed at different time(the 0.5th, 1 st, 2 nd, 24 th and 48 th hour).During the NIV, RR, HR and Borg score were monitored and recorded continuosly. Degree of patients' comfort was measured by the VAS (Visual Analog Scale,0～10). Results 1. The 0.5th, 1st, and 2nd hours after NIV treatment, there was a greater decrease in PCO2 and increase in PO2 and PH during AVAPS-AE mode than two other modes(p< 0.05). RR, HR and Borg score in AVAPS-AE mode had a greater changes than others(p< 0.05). Compared with the S/T and AVAPS group, the recovery duration of shortness in AVAPS-AE group was significantly shorter than two others (p< 0.05). 2. During the whole NIV period, the main result was a higher VAS score in AVAPS-AE mode than others (p< 0.05). 3 cases with patient-ventilator asynchrony occurred in S/T group, 3 cases and 1 case happened in AVAPS group and AVAPS-AE group respectively. Conclusions Autotitrating EPAP during noninvasive ventilation support could be adjust to changing levels of PEEP in AECOPD patients. AVAPS-AE mode maybe more likely to relieve shortness quickly,especially in synchronization and comfort,worthy of promotion, and it may play an important role in improving dynamic hyperinflation of patients with AECOPD.

Supervivencia en exacerbaciones de la enfermedad pulmonar obstructiva crónica que requirieron ventilación no invasiva en planta

IntroductionNoninvasive ventilation (NIV) during hospitalization for acute hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD) has been shown to be effective, but data on the prognosis of such patients is limited. The aim of this study was to investigate in-hospital and long-term outcome in patients with COPD exacerbations requiring NIV treatment during hospitalization. MethodsBetween 2011 and 2013, hospitalized subjects with hypercapnic COPD exacerbations were included in this retrospective single-center cohort study. Subjects’ clinical and laboratory data and survival status after a median of 27 months were recorded. The predictive factors of in-hospital and long-term mortality were analyzed. ResultsA total of 574 patients (357 men, mean age 68±11 years) were recorded. During hospitalization, 24 (4.1%) patients died. In-hospital mortality was negatively affected by lower baseline values of hematocrit, albumin, and pH, and by higher baseline leucocytes and higher 24h PaCO2. Median survival of the cohort was 27 months. Mortality at 3 and 6 months, and 1 year were 14.5%, 19.5%, and 30%, respectively. In the univariate analysis, reduction in long-term survival was found to be related to older age, higher Charlson score, lower baseline levels of hematocrit and albumin, and lower pH level after 24h. In the multivariate analysis, older age and lower albumin were identified as the strongest predictors of mortality. ConclusionLife expectancy after a COPD exacerbation requiring NIV treatment is short. Baseline blood counts and day 2 arterial blood gases levels may predict in-hospital mortality. The strongest indicators of poorer long-term outcome were advanced age and lower albumin. Such patients may need closer follow-up.

Patient Outcome After COPD Exacerbations Requiring Non-invasive Ventilation During Hospitalization

IntroductionNoninvasive ventilation (NIV) during hospitalization for acute hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD) has been shown to be effective, but data on the prognosis of such patients is limited. The aim of this study was to investigate in-hospital and long-term outcome in patients with COPD exacerbations requiring NIV treatment during hospitalization. MethodsBetween 2011 and 2013, hospitalized subjects with hypercapnic COPD exacerbations were included in this retrospective single-center cohort study. Subjects’ clinical and laboratory data and survival status after a median of 27 months were recorded. The predictive factors of in-hospital and long-term mortality were analyzed. ResultsA total of 574 patients (357 men, mean age 68±11 years) were recorded. During hospitalization, 24 (4.1%) patients died. In-hospital mortality was negatively affected by lower baseline values of hematocrit, albumin, and pH, and by higher baseline leucocytes and higher 24h PaCO2. Median survival of the cohort was 27 months. Mortality at 3 and 6 months, and 1 year were 14.5%, 19.5%, and 30%, respectively. In the univariate analysis, reduction in long-term survival was found to be related to older age, higher Charlson score, lower baseline levels of hematocrit and albumin, and lower pH level after 24h. In the multivariate analysis, older age and lower albumin were identified as the strongest predictors of mortality. ConclusionLife expectancy after a COPD exacerbation requiring NIV treatment is short. Baseline blood counts and day 2 arterial blood gases levels may predict in-hospital mortality. The strongest indicators of poorer long-term outcome were advanced age and lower albumin. Such patients may need closer follow-up.

Long-term non-invasive ventilation therapies in children: a scoping review protocol

IntroductionNon-invasive ventilation (NIV) in children has become an increasingly common modality of breathing support where pressure support is delivered through a mask interface or less commonly through other non-invasive interfaces....

Are patients with COPD treated with NIV in accordance with national guidelines? An internal audit

IntroductionNon-invasive ventilation (NIV) as an add-on modality to medical treatment has been recommended in national guidelines for patients acutely admitted with chronic obstructive pulmonary disorder (COPD) exacerbation and hypercapnic respiratory failure. To address concerns regarding whether NIV is used appropriately, we conducted an audit of COPD patients admitted to a university hospital in Denmark.Material and methodsData from medical records were retrieved for two cohorts in 2010: 1) all patients admitted to the Medical Emergency Ward with the diagnosis of COPD, and 2) all patients receiving NIV regardless of their diagnosis at the Respiratory Ward. Demographic data and outcome of treatment were registered.ResultsCohort 1 comprised 804 admissions fulfilling criteria for COPD at evaluation, and of the 804 admissions, NIV was initiated in 151 (18.7%) admissions. In 42 additional cases (5.2%), initial mild respiratory acidosis was registered at admission, fulfilling criteria for NIV treatment; and, in 36 cases, the clinical status was reported as improved or not reported at all; no deaths were observed. In cohort 2, 124 admissions were registered that comprised 110 admissions with COPD and 14 without a diagnosis of COPD (of which half had a ‘not-to-intubate’ order). The indication for NIV treatment was met in 92.7% of the COPD admissions.ConclusionNIV was initiated in 18.8% of the COPD admissions, and in an additional 5.2%, NIV criteria were met without initiation. In 82.3% of the admissions receiving NIV, a COPD diagnosis and correct criteria for NIV treatment were met.

Epidemiology of noninvasive mechanical ventilation in acute respiratory failure - a retrospective population-based study

BackgroundNoninvasive mechanical ventilation (NIV) is a front-line therapy for the management of acute respiratory failure (ARF) in the intensive care units. However, the data on factors and outcomes associated with the use of NIV in ARF patients is lacking. Therefore, we aimed to determine the utilization of NIV for ARF in a population-based study.MethodsWe conducted a populated-based retrospective cohort study, where in all consecutively admitted adults (≥18 years) with ARF from Olmsted County, Rochester, MN, at the Mayo Clinic medical and surgical ICUs, during 2006 were included. Patients without research authorization or on chronic NIV use for sleep apnea were excluded.ResultsOut of 1461 Olmsted County adult residents admitted to the ICUs in 2006, 364 patients developed ARF, of which 146 patients were initiated on NIV. The median age in years was 75 (interquartile range, 60–84), 48% females and 88.7% Caucasians. Eighteen patients (12%) were on Continuous Positive Airway Pressure (CPAP) mode and 128 (88%) were on noninvasive intermittent positive-pressure ventilation (NIPPV) mode. Forty-six (10%) ARF patients were put on NIV for palliative strategy to alleviate dyspnea. Seventy-six ARF patients without treatment limitation were given a trial of NIV and 49 patients succeeded, while 27 had to be intubated. Mortality was similar between the patients initially supported with NIV versus invasive mechanical ventilation (33% vs 22%, P=0.289). In the multivariate analysis, the development of acute respiratory distress syndrome (ARDS) and higher APACHE III scores were associated with the failure of initial NIV treatment.ConclusionsOur results have important implications for a future planning of NIV in a suburban US community with high access to critical care services. The higher APACHE III scores and the development of ARDS are associated with the failure of initial NIV treatment.

Characterization of patients admitted to intensive care unit directly from emergency department

Results In the course of three months, 49 patients were admitted to the ICU via the ED. Average length of admission was 3.1 days. Main conditions were divided into seven subgroups; drug intoxication (n=13), respiratory insufficiency (n=11), GIhaemorrhage (n=6), high-pressure lung oedema (n=3), electrolyte disturbances (n=3), septic shock (n=3) and others (n=10). Treatments primarily used were, fluid/electrolyte therapy (n=29), broad-spectrum antibiotics (n=24), intubation (n=12), blood component therapy (n=11), NIV treatment (n=10), corticosteroids (n=10), beta-agonist inhalation treatment (n=7), vasopressor drugs (n=8), activated charcoal (n=9), diuretics (n=10), and others (n=52). In the subgroup of drug intoxication, 69% patients received activated charcoal. The remaining 31% were either unconscious and could not cooperate to place a gastric tube/drink the charcoal, or came to the ED too late, with activated charcoal having no effect. 69% of the patients also expressed that the incident was an attempt at suicide.