Chest
Volume 145, Issue 5, May 2014, Pages 964-971
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Original Research
Use and Outcomes of Noninvasive Positive Pressure Ventilation in Acute Care Hospitals in Massachusetts

https://doi.org/10.1378/chest.13-1707Get rights and content

Background

This study determined actual utilization rates and outcomes of noninvasive positive pressure ventilation (NIV) at selected hospitals that had participated in a prior survey on NIV use.

Methods

This observational cohort study, based at eight acute care hospitals in Massachusetts, focused on all adult patients requiring ventilatory support for acute respiratory failure during predetermined time intervals.

Results

Of 548 ventilator starts, 337 (61.5%) were for invasive mechanical ventilation and 211 (38.5%) were for NIV, with an overall NIV success rate of 73.9% (ie, avoidance of intubation or death while on NIV or within 48 h of discontinuation). Causal diagnoses for respiratory failure were classified as (I) acute-on-chronic lung disease (23.5%), (II) acute de novo respiratory failure (17.9%), (III) neurologic disorders (19%), (IV) cardiogenic pulmonary edema (16.8%), (V) cardiopulmonary arrest (12.2%), and (VI) others (10.6%). NIV use and success rates for each of the causal diagnoses were, respectively, (I) 76.7% and 75.8%, (II) 37.8% and 62.2%, (III) 1.9% and 100%, (IV) 68.5% and 79.4%, (V) none, and (VI) 17.2% and 60%. Hospital mortality rate was higher in patients with invasive mechanical ventilation than in patients with NIV (30.3% vs 16.6%, P < .001).

Conclusions

NIV occupies an important role in the management of acute respiratory failure in acute care hospitals in selected US hospitals and is being used for a large majority of patients with acute-on-chronic respiratory failure and acute cardiogenic pulmonary edema. NIV use appears to have increased substantially in selected US hospitals over the past decade.

Trial registry

ClinicalTrials.gov; No.: NCT00458926; URL: www.clinicaltrials.gov

Section snippets

Study Centers

Eight of 76 medical centers from our prior survey11 were selected based on their willingness to participate, distance < 90 miles from Boston, and ability to provide a mix of teaching and nonteaching hospitals. The institutional review boards of participating institutions approved the study (Tufts ID #7642) and waived the need for patient consent because it was observational only. Characteristics of the eight acute care hospitals are presented in Table 1. Participating hospitals were estimated

Overall NIV Utilization

Figure 1 shows that of 1,153 episodes of mechanical ventilation screened, 605 were excluded and 548 episodes in 540 patients met entry criteria. The utilization rate of NIV as a first-line ventilator modality was 38.5% among all ventilator starts. NIV was discontinued early (prior to meeting weaning criteria) in 75 NIV starts (35.5%). Twenty, discontinued after a median of 3.6 hours of NIV (interquartile range, 0.4-20.3), required no further ventilatory assistance, survived, and were considered

Discussion

Our study demonstrates that use of NIV is quite common in selected acute care hospitals in the United States, even among low utilizers in a previous survey.11 As anticipated, use of NIV depends heavily on etiology of ARF and is most commonly applied in patients with COPD exacerbations and CPE, diagnoses for which it is recommended as a first-line therapy by current guidelines.1, 7, 8

In an early survey of NIV application in 15 acute care teaching hospitals in Ontario, Canada, 63% of respondents

Acknowledgments

Author contributions: Drs Ozsancak Ugurlu, Sidhom, and Hill are guarantors of the entire manuscript.

Dr Ozsancak Ugurlu: contributed to study design, data acquisition, and analysis and preparation of the manuscript.

Dr Sidhom: contributed to study design, data acquisition, and analysis and preparation of the manuscript.

Dr Khodabandeh: contributed to study design, data acquisition, and analysis and preparation of the manuscript.

Dr Ieong: contributed to data acquisition and preparation of the

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      On the other hand, immediate failure after secondary NIV application, which occurred in one episode, may have been the result of premature extubation. ICU mortality was 1.7%, while hospital mortality was 5%, which appears to be at the lower end of the range (5–22%) noted in recent observational studies.12,19,20 Recent literature has raised concerns about increased mortality among patients who fail NIV and need invasive mechanical ventilation compared with those who are managed with invasive ventilation from time zero.2,22,23

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    Funding/Support: Dr Hill received support from the Eli Lilly Distinguished Scholar Award of The CHEST Foundation of the American College of Chest Physicians. The study also received support from a generous gift from Respironics, Inc/Koninklijke Philips N.V. Dr Ozsancak Ugurlu received a research grant from The Scientific and Technological Research Council of Turkey (TUBITAK).

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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