Predictors Of Noninvasive Ventilation Failure Research Articles

HACOR score to predict NIV failure in patients with COVID-related hypoxemic respiratory failure managed in the ordinary ward and in the critical care setting.

We evaluated the prevalence of non-invasive ventilation (NIV) failure among patients with COVID-19-related pneumonia, managed in the ordinary ward and in the HDU/ICU and we tested the prognostic role of the HACOR score in those different settings. This is a retrospective study, conducted in the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring NIV between March 2020 and May 2021, respectively managed in the ordinary ward (G1) and in the critical care setting (G2). Clinical parameters, HACOR and SOFA score were evaluated at Day 0 and after 1, 2 and 5days of treatment. The primary outcome was NIV failure. 13% G1 patients and 40% G2 patients underwent endotracheal intubation (ETI). NIV was successful in 60% G1 AND 43% G2 patients (p < 0.001). In G1, compared to those with successful NIV, patients who underwent ETI, had a higher HACOR since the baseline evaluation (T0: 6 [5-6] vs 5 [3-6]; T1: 6 [5-6] vs 5 [3-6], all p < 0.05). An HACOR score > 5 was associated with an increased prevalence of ETI independent to an advanced age and a SOFA score > 5 both in G1 (T1: RR 4.87, 95% CI 1.462-16.275; T5: 3.630, 95% CI 0.979-13.462) and G2 (T0: 1.76, 95% CI 0.906-3.422; T1: 3.38, 95% CI 1.386-8.265). Among patients with COVID-related-ARF, NIV could be managed in the ordinary ward in a consistent proportion of patients and, among them, an HACOR score > 5 was independently associated with increased NIV failure from the earliest evaluations.

Evaluation of HACOR scale as a predictor of non-invasive ventilation failure in acute cardiogenic pulmonary oedema patients: A prospective observational study

Background and importanceAcute cardiogenic pulmonary oedema (ACPO) is a common indication for non-invasive ventilation (NIV) in the emergency department (ED). HACOR score of >5 is used to predict NIV failure. The predictive ability of HACOR may be affected by altered physiological parameters in ACPO patients due to medications or comorbidities. ObjectivesTo validate the HACOR scale in predicting NIV failure among acute cardiogenic pulmonary oedema (ACPO) patients. Design, settings and participantsThis is a prospective, observational study of consecutive ACPO patients requiring NIV admitted to the ED. Outcome measure and analysisPrimary outcome was the ability of the HACOR score to predict NIV failure. Clinical, physiological, and HACOR score at baseline and at 1 h, 12 h and 24 h were analysed. Other potential predictors were assessed as secondary outcomes. Main resultsA total of 221 patients were included in the analysis. Fifty-four (24.4%) had NIV failure. Optimal HACOR score was >5 at 1 h after NIV initiation in predicting NIV failure (AUC 0.73, sensitivity 53.7%, specificity 83.2%). As part of the HACOR score, respiratory rate and heart rate were not found to be significant predictors. Other significant predictors of NIV failure in ACPO patients were acute coronary syndrome, acute kidney injury, presence of congestive heart failure as a comorbid, and the ROX index. ConclusionsThe HACOR scale measured at 1 h after NIV initiation predicts NIV failure among ACPO patients with acceptable accuracy. The cut-off level > 5 could be a useful clinical decision support tool in ACPO patient. However, clinicians should consider other factors such as the acute coronary and acute kidney diagnosis at presentation, presence of underlying congestive heart failure and the ROX index when clinically deciding on timely invasive mechanical ventilation.

Risk Factors of Non-Invasive Ventilation Failure in COPD Patients Presenting with Acute Exacerbation

Background: Non-invasive ventilation (NIV) is the first-line management for acute exacerbation of COPD (AECOPD), but some patients don’t improve and need invasive ventilation, leading to high mortality. We conducted a study to determine risk factors associated with NIV outcomes in these patients. Identifying predictive parameters of NIV failure could help timely intervention and prevent mortality. Methods: A Quasi Single Arm study was conducted at a tertiary care Hospital, in Karachi, from July to December 2022. We studied 170 COPD patients admitted to Medicine Department and Medical ICU with acute respiratory failure, among those 170 patients 80 were male and 90 were female, aged above 40 and below 80 years. Results: Among 170 AECOPD patients studied, 38% experienced NIV failure, while 61% had NIV success. In the NIV failure group, 38.46% of patients died in hospital. Most factors like quadrant infiltrate, weak cough reflex, low consciousness level, more requirements of oxygen, low pH, more respiratory rate, and positive blood cultures (p-value &lt;0.001) were significantly associated with NIV failure and mortality, while others with no significant association still contributed towards NIV failure, like co-morbidities. Out of the 66 patients with NIV failure, 56% experienced immediate failure, 33% had early NIV failure, and 11% had late NIV failure. Conclusion: Most identified risk factors significantly predicted NIV failure, suggesting they may serve as useful early indicators to guide intervention. Even non-significant factors still exhibited some association with NIV failure. Further research exploring additional predictors could optimize NIV outcomes and reduce mortality from AECOPD.

Predictors of Non-invasive Ventilation Failure and Associated Factors Among the COVID-19 Patients Admitted to Intensive Care Unit.

Non-invasive ventilation (NIV) is a method of oxygenation supply that eliminates the need for an endotracheal airway. Non-invasive ventilation failure is defined as the necessity for endotracheal intubation or death during the NIV trial. This study aimed to identify the predictors and associated factors of NIV failure in coronavirus disease 2019 (COVID-19) patients admitted to an intensive care unit (ICU). This retrospective, longitudinal cohort study utilized electronic medical records of COVID-19 patients admitted to the ICU. A total of 150 patients were included in the study. Patient demographics, medical history, laboratory tests, partial pressure of carbon dioxide (PCO2), oxygen saturation (SpO2), heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR score), and the ratio of oxygen saturation (ROX) index (the SpO2/fraction of inspired oxygen [FIO2] to respiratory rate [SF] ratio) were recorded. Non-invasive ventilation failure was determined based on the need for endotracheal intubation or cardiac-respiratory arrest while on NIV. Of 150 patients, 55.3% were male (mean age: 55.9 years), with an NIV failure rate of 67.3%, a mortality rate of 66.7%, and 3.3% of patients requiring tracheostomy after NIV failure. The ROX index consistently decreased over time, and an increase in the HACOR score and PCO2 after 6 hours of commencing NIV were the predictors of NIV failure. Additionally, higher levels of lactate dehydrogenase, lower SF ratios, and higher APACHE scores upon ICU admission were significantly associated with NIV failure. Notably, the erythrocyte sedimentation rate (ESR) as an inflammatory index, SF ratio upon ICU admission, HACOR score, ROX index, and PCO2 after 12 hours were significant predictors of in-hospital mortality in patients receiving NIV. The ROX index, HACOR scale, and PCO2 are significant predictors of both NIV failure and in-hospital mortality.

The role of ultrasound in predicting non-invasive ventilation outcomes: a systematic review.

To systematically review and compare ultrasonographic methods and their utility in predicting non-invasive ventilation (NIV) outcomes. A systematic review was performed using the PubMed, Medline, Embase, and Cochrane databases from January 2015 to March 2023. The search terms included the following: ultrasound, diaphragm, lung, prediction, non-invasive, ventilation, and outcomes. The inclusion criteria were prospective cohort studies on adult patients requiring non-invasive ventilation in the emergency department or inpatient setting. Fifteen studies were analyzed, which comprised of 1,307 patients (n = 942 for lung ultrasound score studies; n = 365 patients for diaphragm dysfunction studies). Lung ultrasound scores (LUS) greater than 18 were associated with NIV failure with a sensitivity 62-90.5% and specificity 60-91.9%. Similarly, a diaphragm thickening fraction (DTF) of less than 20% was also associated with NIV failure with a sensitivity 80-84.6% and specificity 76.3-91.5%. Predicting NIV failure can be difficult by routine initial clinical impression and diagnostic work up. This systematic review emphasizes the importance of using lung and diaphragm ultrasound, in particular the lung ultrasound score and diaphragm thickening fraction respectively, to accurately predict NIV failure, including the need for ICU-level of care, requiring invasive mechanical ventilation, and resulting in higher rates of mortality.

Trajectories of Host-Response Subphenotypes in Patients With COVID-19 Across the Spectrum of Respiratory Support

Hospitalized patients with severe COVID-19 follow heterogeneous clinical trajectories, requiring different levels of respiratory support and experiencing diverse clinical outcomes. Differences in host immune responses to SARS-CoV-2 infection may account for the heterogeneous clinical course, but we have limited data on the dynamic evolution of systemic biomarkers and related subphenotypes. Improved understanding of the dynamic transitions of host subphenotypes in COVID-19 may allow for improved patient selection for targeted therapies. We examined the trajectories of host-response profiles in severe COVID-19 and evaluated their prognostic impact on clinical outcomes. In this prospective observational study, we enrolled 323 inpatients with COVID-19 receiving different levels of baseline respiratory support: (1) low-flow oxygen (37%), (2) noninvasive ventilation (NIV) or high-flow oxygen (HFO; 29%), (3) invasive mechanical ventilation (27%), and (4) extracorporeal membrane oxygenation (7%). We collected plasma samples on enrollment and at days 5 and 10 to measure host-response biomarkers. We classified patients by inflammatory subphenotypes using two validated predictive models. We examined clinical, biomarker, and subphenotype trajectories and outcomes during hospitalization. IL-6, procalcitonin, and angiopoietin 2 persistently were elevated in patients receiving higher levels of respiratory support, whereas soluble receptor of advanced glycation end products (sRAGE) levels displayed the inverse pattern. Patients receiving NIV or HFO at baseline showed the most dynamic clinical trajectory, with 24% eventually requiring intubation and exhibiting worse 60-day mortality than patients receiving invasive mechanical ventilation at baseline (67% vs 35%; P < .0001). sRAGE levels predicted NIV failure and worse 60-day mortality for patients receiving NIV or HFO, whereas IL-6 levels were predictive in all patients regardless of level of support (P < .01). Patients classified to a hyperinflammatory subphenotype at baseline (< 10%) showed worse 60-day survival (P < .0001) and 50% of them remained classified as hyperinflammatory at 5 days after enrollment. Longitudinal study of the systemic host response in COVID-19 revealed substantial and predictive interindividual variability influenced by baseline levels of respiratory support.

Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India.

Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported. In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively. The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Mid-regional proadrenomedullin as a potential prognostic factor of NIV outcome in AECOPD

BackgroundEarly prediction of non-invasive ventilation failure by using clinical parameters and scoring systems is a promising strategy for reducing mortality in acute exacerbation of chronic obstructive pulmonary disease patients. Our aim was to assess predictors of non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease and the prognostic role of mid-regional proadrenomedullin.ResultsForty-five patients were enrolled, comprising thirty-six males and nine females with mean age 63.4 ± 9.22 years. Mid-regional proadrenomedullin could not predict non-invasive ventilation outcome, while acute physiology and chronic health evaluation score, blood pH, arterial carbon dioxide and platelet count had predictive value.ConclusionPrediction of non-invasive ventilation outcome in acute exacerbation of chronic obstructive pulmonary disease patients is multifactorial and mid-regional proadrenomedullin alone could not predict this outcome.

Lung and diaphragm ultrasound in noninvasive respiratory support: A real tool or fashion?

Over the past few years, there has been an increase in lung and diaphragm ultrasound applications as a tool to evaluate the outcomes and settings of noninvasive respiratory supports. However, actual clinical practices in this field are yet to be known. The aim of this study was to investigate the current clinical utilization of ultrasound for noninvasive respiratory supports on an international level. The study employed an online survey consisting of 32 items, which was sent via email to intensivists, pulmonologists, emergency medicine physicians, and other specialists with expertise in using ultrasound and/or noninvasive respiratory supports. We collected 52 questionnaires. The ultrasound study of diaphragm dysfunction was well-known by the majority of respondents (57.7%). Diaphragm performance was used as a weaning failure predictor (48.5%), as a predictor of noninvasive ventilation failure (38.5%) and as a tool for the ventilator settings adjustment (30.8%). In patients with acute respiratory failure, 48.1% used ultrasound to assess the damaged lung area to set up ventilatory parameters, 34.6% to monitor it after noninvasive ventilation application, and 32.7% to match it with the ventilatory settings for adjustment purposes. When administering high flow nasal cannula - oxygen therapy, 42.3% of participants used ultrasound to evaluate lung involvement and assess flow parameters. Lung and diaphragm ultrasound is an established clinical practice to evaluate noninvasive respiratory supports outcomes and settings. Further studies are needed to evaluate the educational aspects to increase confidence and indications for its use.

Failure of early non-invasive ventilation in preterm infants with respiratory distress syndrome in current care practice in Spanish level-III neonatal intensive care units - a prospective observational study.

Despite advances in respiratory distress syndrome (RDS) management over the past decade, non-invasive ventilation (NIV) failure is frequent and associated with adverse outcomes. There are insufficient data on the failure of different NIV strategies currently used in clinical practice in preterm infants. This was a prospective, multicenter, observational study of very preterm infants [gestational age (GA) <32 weeks] admitted to the neonatal intensive care unit for RDS that required NIV from the first 30 min after birth. The primary outcome was the incidence of NIV failure, defined as the need for mechanical ventilation for <72 h of life. Secondary outcomes were risk factors associated with NIV failure and complication rates. The study included 173 preterm infants with a median GA of 28 (IQR 27-30) weeks and a median birth weight of 1,100 (IQR 800-1,333) g. The incidence of NIV failure was 15.6%. In the multivariate analysis, lower GA (OR, 0.728; 95% CI, 0.576-0.920) independently increased the risk of NIV failure. Compared to NIV success, NIV failure was associated with higher rates of unfavorable outcomes, including pneumothorax, intraventricular hemorrhage, periventricular leukomalacia, pulmonary hemorrhage, and a combined outcome of moderate-to-severe bronchopulmonary dysplasia or death. NIV failure occurred in 15.6% of the preterm neonates and was associated with adverse outcomes. The use of LISA and newer NIV modalities most likely accounts for the reduced failure rate. Gestational age remains the best predictor of NIV failure and is more reliable than the fraction of inspired oxygen during the first hour of life.

Noninvasive Respiratory Support for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To develop evidence-based recommendations for the Second Pediatric Acute Lung Injury Consensus Conference (PALICC) regarding the effectiveness of noninvasive respiratory support for pediatric acute respiratory distress syndrome (PARDS). These include consideration of the timing and duration of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC), whether effectiveness varies by disease severity or by characteristics of treatment delivery, and best practices for the use of NIV. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Searches included all studies involving the use of NIV or HFNC in children with PARDS or hypoxemic respiratory failure. Title/abstract review, full-text review, and data extraction using a standardized data extraction form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Out of 6,336 studies, we identified 187 for full-text review. Four clinical recommendations were generated, related to indications, timing and duration of NIV in patients with PARDS, predictors of NIV failure and need for intubation (signs and symptoms of worsening disease including pulse oximetry saturation/Fio2 ratio), and use of NIV in resource-limited settings. Six good practice statements were generated related to how and where to deliver NIV, the importance of trained experienced staff and monitoring, types of NIV interfaces, the use of sedation, and the potential complications of this therapy. One research statement was generated related to indications of HFNC in patients with PARDS. NIV is a widely used modality for the treatment of respiratory failure in children and may be beneficial in a subset of patients with PARDS. However, there needs to be close monitoring for worsening disease and NIV failure.

Diaphragmatic impairment as a predictor of invasive ventilation in acute exacerbation of chronic obstructive pulmonary disease patients

ABSTRACT Objective Study the impact of ultrasound-assessed diaphragmatic impairment (DI) on predicting need for invasive mechanical ventilation (IMV) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients treated by non-invasive ventilation (NIV). Design A prospective observational study. Setting Critical Care Units of Alexandria Main University Hospital. Patients 75 adult AECOPD patients of both sexes according to sample size calculation. Methods Ultrasound was used to measure diaphragmatic thickness (DT), diaphragmatic thickness fraction (DTF) was calculated, and DI was diagnosed when fraction was less than 20%. Patients were treated by NIV. Switching to IMV was done after NIV failure. Primary outcome was value of DI to predict need for IMV after NIV failure. Secondary outcome was impact of DI on fate of patients. Results According to fate of NIV, patients were categorized into successful and failed NIV groups. DTF in both groups were ≥33–38% and ≤16–18%. DTF with a cut-off value of <26–29% on both sides was able to predict NIV failure with 96.67% sensitivity and 80–82.22% specificity. Days of MV and ICU stay were significantly lower in the successful NIV group, p < 0.001. 28-day mortality was significantly less encountered in successful NIV group, p = 0.018. Conclusion DTF was a good indicator of DI that could predict need for IMV after NIV failure in AECOPD patients with good sensitivity and moderate specificity. MV Days, ICU stay, and 28-day mortality were significantly higher in patients with DI who needed IMV.

Prediction of noninvasive ventilation failure using the ROX index in patients with de novo acute respiratory failure

BackgroundThe ratio of SpO2/FiO2 to respiratory rate (ROX) index is commonly used to predict the failure of high-flow nasal cannula. However, its predictive power for noninvasive ventilation (NIV) failure is unclear.MethodsThis was a secondary analysis of a multicenter prospective observational study, intended to update risk scoring. Patients with de novo acute respiratory failure were enrolled, but hypercapnic patients were excluded. The ROX index was calculated before treatment and after 1–2, 12, and 24 h NIV. Differences in predictive power for NIV failure using the ROX index, PaO2/FiO2, and PaO2/FiO2/respiratory rate were tested.ResultsA total of 1286 patients with de novo acute respiratory failure were enrolled. Of these, 568 (44%) experienced NIV failure. Patients with NIV failure had a lower ROX index than those with NIV success. The rates of NIV failure were 92.3%, 70.5%, 55.3%, 41.1%, 35.1%, and 29.5% in patients with ROX index values calculated before NIV of ≤ 2, 2–4, 4–6, 6–8, 8–10, and > 10, respectively. Similar results were found when the ROX index was assessed after 1–2, 12, and 24 h NIV. The area under the receiver operating characteristics curve was 0.64 (95% CI 0.61–0.67) when the ROX index was used to predict NIV failure before NIV. It increased to 0.71 (95% CI 0.68–0.74), 0.74 (0.71–0.77), and 0.77 (0.74–0.80) after 1–2, 12, and 24 h NIV, respectively. The predictive power for NIV failure was similar for the ROX index and for the PaO2/FiO2. Likewise, no difference was found between the ROX index and the PaO2/FiO2/respiratory rate, except at the time point of 1–2 h NIV.ConclusionsThe ROX index has moderate predictive power for NIV failure in patients with de novo acute respiratory failure.

An updated HACOR score for predicting the failure of noninvasive ventilation: a multicenter prospective observational study

BackgroundHeart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) have been used to predict noninvasive ventilation (NIV) failure. However, the HACOR score fails to consider baseline data. Here, we aimed to update the HACOR score to take into account baseline data and test its predictive power for NIV failure primarily after 1–2 h of NIV.MethodsA multicenter prospective observational study was performed in 18 hospitals in China and Turkey. Patients who received NIV because of hypoxemic respiratory failure were enrolled. In Chongqing, China, 1451 patients were enrolled in the training cohort. Outside of Chongqing, another 728 patients were enrolled in the external validation cohort.ResultsBefore NIV, the presence of pneumonia, cardiogenic pulmonary edema, pulmonary ARDS, immunosuppression, or septic shock and the SOFA score were strongly associated with NIV failure. These six variables as baseline data were added to the original HACOR score. The AUCs for predicting NIV failure were 0.85 (95% CI 0.84–0.87) and 0.78 (0.75–0.81) tested with the updated HACOR score assessed after 1–2 h of NIV in the training and validation cohorts, respectively. A higher AUC was observed when it was tested with the updated HACOR score compared to the original HACOR score in the training cohort (0.85 vs. 0.80, 0.86 vs. 0.81, and 0.85 vs. 0.82 after 1–2, 12, and 24 h of NIV, respectively; all p values < 0.01). Similar results were found in the validation cohort (0.78 vs. 0.71, 0.79 vs. 0.74, and 0.81 vs. 0.76, respectively; all p values < 0.01). When 7, 10.5, and 14 points of the updated HACOR score were used as cutoff values, the probability of NIV failure was 25%, 50%, and 75%, respectively. Among patients with updated HACOR scores of ≤ 7, 7.5–10.5, 11–14, and > 14 after 1–2 h of NIV, the rate of NIV failure was 12.4%, 38.2%, 67.1%, and 83.7%, respectively.ConclusionsThe updated HACOR score has high predictive power for NIV failure in patients with hypoxemic respiratory failure. It can be used to help in decision-making when NIV is used.

Predictors of Noninvasive Respiratory Support Failure in COVID-19 Patients: A Prospective Observational Study.

Background and Objective: Respiratory assistance tactic that is best for COVID-19-associated acute hypoxemic respiratory failure (AHRF) individuals has yet to be determined. Patients with AHRF may benefit from the use of a high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV). The goals of this prospective observational research were to estimate predictive factors for HFNC and NIV failure in COVID-19-related AHRF subjects. Materials and Methods: The research enlisted the participation of 124 patients. A stepwise treatment approach was used. HFNC and NIV were used on 124 (100%) and 64 (51.6%) patients, respectively. Thirty (24.2%) of 124 patients were intubated and received invasive mechanical ventilation. Results: 85 (68.5%) patients were managed successfully. Patients who required NIV exhibited a higher prevalence of treatment failure (70.3% vs. 51.6%, p = 0.019) and had higher mortality (59.4% vs. 31.5%, p = 0.001) than patients who received HFNC. Using logistic regression, the respiratory rate oxygenation (ROX) index at 24 h (odds ratio (OR) = 0.74, p = 0.018) and the Charlson Comorbidity Index (CCI) (OR = 1.60, p = 0.003) were found to be predictors of HFNC efficacy. It was the ROX index at 24 h and the CCI optimum cut-off values for HFNC outcome that were 6.1 (area under the curve (AUC) = 0.73) and 2.5 (AUC = 0.68), respectively. Serum ferritin level (OR = 0.23, p = 0.041) and lymphocyte count (OR = 1.03, p = 0.01) were confirmed as predictors of NIV failure. Serum ferritin level at a cut-off value of 456.2 ng/mL (AUC = 0.67) and lymphocyte count lower than 0.70 per mm3, (AUC = 0.70) were associated with NIV failure with 70.5% sensitivity, 68.7% specificity and sensitivity of 84.1%, specificity of 56.2%, respectively. Conclusion: The ROX index at 24 h, CCI, as well as serum ferritin level, and lymphocyte count can be used as markers for HFNC and NIV failure, respectively, in SARS-CoV-2-induced AHRF patients.

Predictors of non-invasive ventilation failure in adult patients with cardiac dysfunction presenting with community acquired pneumonia; an Egyptian multicenter prospective study

Abstract Funding Acknowledgements Type of funding sources: None. Background Non-invasive ventilation (NIV) might be successful if properly selected in adult patients with cardiac dysfunction presenting with community acquired pneumonia. The main objective was to identify contributing factors to NIV failure. Methods All adult patients with LV EF less than 50% admitted to the ICU with community acquired pneumonia and acute respiratory failure were enrolled in our multicenter prospective study after getting informed consents . The study was registered and given a number (ID ISRCTN14641518). Non-invasive ventilation failure was defined as requirement of intubation after institution of NIV intervention. Results We prospectively enrolled 177 patients between February 2019 to July 2020. Fifty-three patients (29.9%) were considered failed NIV. The mean age of studied patients was 64.1±12.6 years with a male predominance (73.4%) and a mean left ventricle EF of 36.4±7.8%. There were insignificant differences between the NIV success and NIV failure groups regarding the underlying morbidities nor the inflammatory markers. The patients who failed NIV were significantly older with higher mean SOFA and APACHE II scores compared to the patients with succeeded NIV. Non-invasive Ventilation failure was associated with longer ICU stay (p&amp;lt;0.001), higher SOFA at 48 hours (p&amp;lt;0.001) and higher mortality (p&amp;lt;0.001) compared to the NIV success group. NIV failure was independently predicted with APACHE II (OR:1.420, p 0.01, 95% CI:1.224 – 1.647), SOFA (OR:17.6 , p &amp;lt;0.001, 95% CI: 4.148-74.68), baseline HACOR (OR:2.041, P 0.026, 95% CI:1.225 –3.401), lung ultrasound score (OR:1.209,P 0.017,95% CI:1.014–1.441) and blood lactate (OR:9.702,P &amp;lt;0.001,95%CI:1.357–69.37).Conclusion: High initial APACHE II and SOFA scores , hindered lactate clearance as well as non-decrementing patterns of HACOR and LUS scores were associated with early NIV failure in patients with heart failure presenting with community acquired pneumonia.

Cardiac disorders worsen the final outcome in myasthenic crisis undergoing non-invasive mechanical ventilation: a retrospective 20-year study from a single center.

The study was performed to evaluate the impact of cardiological disorders on the outcome of myasthenic crisis (MC) requiring ventilation. The study includes 90 cases admitted to the Neurology Unit of Modena, Italy (January 2000 - September 2020). All patients were eligible for a non-invasive ventilation (NIV) trial. We analyzed the effect of cardiac comorbidities on the outcomes, which were the need of invasive ventilation, the risk tracheostomy for weaning failure and the duration of intensive care unit (ICU) stay Females were 58.9% and males 41.1%. Median age at diagnosis was 59 and at MC was 65. Patients were classified as early (EOMG) or late (LOMG), 34.4 and 65.6% respectively, according to age above or below 50; 85% of patients were anti- AChR antibody positive. Hypertension and cardiac diseases occurred at the diagnosis in 61 and 44.4%, respectively. Invasive mechanical ventilation (MV) was needed in 34% of cases. Nine subjects (10%) underwent tracheostomy because of weaning failure. Independent predictors of NIV failure were atrial fibrillation (AF), either parossistic or persistent (OR 3.05, p < 0.01), hypertensive cardiopathy (HHD) (OR 2.52, p < 0.01) and ischaemic heart disease (IHD) (OR 3.08, p < 0.01). Hypertension (HT) had no statistical effect on the outcomes. HHD was a predictor of weaning failure (OR 4.01, p = 0.017). Our study shows that HHD, AF and IHD increase the risk of NIV failure in MC receiving ventilation.

Predictors of non-invasive ventilation failure in adult patients with cardiac dysfunction presenting with community-acquired pneumonia: an Egyptian multicenter prospective study

Non-invasive ventilation (NIV) might be successful if carefully selected in adult patients with cardiac dysfunction presenting with community-acquired pneumonia. The main objective of this study was to identify the early predictors of NIV failure. Adult patients with left ventricle ejection fraction (LV EF) &lt;50% admitted to the intensive care unit (ICU) with community-acquired pneumonia and acute respiratory failure were enrolled in this multicenter prospective study after obtaining informed consents (study registrationID: ISRCTN14641518). Non-invasive ventilation failure was defined as the requirement of intubation after initiation of NIV. All patients were assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores at admission, while their Heart rate Acidosis Consciousness Oxygenation and Respiratory rate (HACOR) and lung ultrasound (LUS) scores in addition to blood lactate were assessed at NIV initiation and 12 and 24 hours later. A total of 177 patients were prospectively enrolled from February 2019 to July 2020. Of them, 53 (29.9%) had failed NIV. The mean age of the study cohort was 64.1± 12.6 years, with a male predominance (73.4%) and a mean LV EF of 36.4 ± 7.8%. Almost 55.9% of the studied patients had diabetes mellitus, 45.8% had chronic systemic hypertension, 73.4% had ischemic heart disease, 20.3% had chronic kidney disease, and 9.6% had liver cirrhosis. No significant differences were observed between the NIV success and NIV failure groups regarding underlying morbidities or inflammatory markers. Patients who failed NIV were significantly older and had higher mean SOFA and APACHE II scores than those with successful NIV. We also found that NIV failure was associated with longer ICU stay (p &lt; 0.001), higher SOFA scores at 48 hours (p &lt; 0.001) and higher mortality (p &lt; 0.001) compared with the NIV success group. In addition, SOFA (Odds Ratio (OR): 4.52, 95% Confidence Interval (CI): 2.59–7.88, p &lt; 0.001), HACOR (OR: 2.01, 95% CI: 0.97–4.18, p = 0.036) and LUS (OR: 1.33, 95% CI: 1.014–1.106, p = 0.027) scores and blood lactate levels (OR: 9.35, 95% CI: 5.32–43.26, p &lt; 0.001) were independent factors for NIV failure. High initial HACOR and SOFA scores, persistent hyperlactatemia and non-decrementing LUS score were associated with early NIV failure in patients with cardiac dysfunction presenting with community-acquired pneumonia, and could be used as clinical and paraclinical variables for early decision making regarding invasive ventilation.

Clinical Profile and Outcome of Children Requiring Noninvasive Ventilation (NIV).

To determine the clinical profile and outcome of children requiring noninvasive ventilation (NIV) in a PICU. This prospective observational study was conducted in the PICU at Dayanand Medical College and Hospital, Punjab. Children (1 mo-18 y) with moderate-to-severe respiratory distress who received NIV during one-year period were included. Failure was defined as the need for endotracheal intubation. The patients received bilevel positive airway pressure (BiPAP) with inspiratory and expiratory positive airway pressure (8-18cm H2O and 4-8cm), respectively and indigenous continuous positive airway pressure (CPAP) were included. Vital signs (heart rate, respiratory rate) and gasometric parameters (pH, HCO3, pCO2, pO2) were recorded. Out of total 115 patients, 81.7% were successfully treated by NIV whereas 18.3% constituted NIV failure group. Two types of NIV were used, 65.2% were started on BiPAP and 34.8% on indigenous bubble CPAP. Most common diagnosis was tropical fever (24.3%), bronchopneumonia (20%), and sepsis with multiple organ dysfunction syndrome (MODS) (7.8%). Commonest indication of NIV was respiratory distress (70.4%) and prevention of postextubation respiratory failure (20.8%). Seven patients (6.9%) died during the study. NIV failure is higher in children with sepsis with MODS, abnormal blood gas (acidosis), and moderate-to-severe acute respiratory distress syndrome (ARDS). This study demonstrates that NIV is an effective form of respiratory support for children with acute respiratory distress/failure. Sepsis with MODS, acidosis and ARDS (moderate to severe) were predictors of NIV failure. Careful patient selection may help in judicious use of NIV in PICU.

Noninvasive Ventilation in the Management of Respiratory Failure Due to COVID-19 Infection: Experience From a Resource-Limited Setting

ObjectiveTo study the role of noninvasive ventilation (NIV) in Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2) related acute respiratory failure (C-ARF). Patients and MethodsPatients with C-ARF managed on NIV were categorized as NIV success or failure (death or intubation). Factors associated with failure were explored using regression analysis and expressed as odds ratio (OR) with 95% CI. ResultsBetween April 1, 2020, and September 15, 2020, a total of 286 patients with a mean ± SD age of 53.1±11.6 years and Acute Physiology and Chronic Health Evaluation II score of 11.1±5.5 were initiated on NIV. Of the 182 patients (63.6%) successfully managed on NIV alone, 118 had moderate or severe acute respiratory distress syndrome. When compared with NIV success, NIV failure was associated with lower admission PaO2 to fraction of inspired oxygen ratio (P<.001) and higher respiratory rate (P<.001). On penalized logistic regression analysis, NIV failure was associated with higher Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.01 to 1.24), severe acute respiratory distress syndrome (OR, 3.99; 95% CI, 1.24 to 12.9), D-dimer level of 1000 ng/mL DDU (to convert to mg/L, divide by 1000) or greater (OR, 2.60; 95% CI, 1.16 to 5.87), need for inotropes or dialysis (OR, 12.7; 95% CI, 4.3 to 37.7), and nosocomial infections (OR, 13.6; 95% CI, 4.06 to 45.9). Overall mortality was 30.1% (86/286). In patients requiring intubation, time to intubation was longer in nonsurvivors than survivors (median, 5; interquartile range, 3-8 vs 3; interquartile range, 2-3 days; P<.001). ConclusionNoninvasive ventilation can be used successfully in C-ARF. Illness severity and need for non–respiratory organ support predict NIV failure.