Association Between Noninvasive Ventilation and Mortality Among Older Patients With Pneumonia

Relationship between the Pre-ECMO and ECMO Time and Survival of Severe COVID-19 Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) is the etiology of acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used to support gas exchange in patients who have failed conventional mechanical ventilation. However, there is no clear consensus on the timing of ECMO use in severe COVID-19 patients.

OBJECTIVE

The aim of this study is to compare the differences in pre-ECMO time and ECMO duration between COVID-19 survivors and non-survivors and to explore the association between them.

METHODS

PubMed, the Cochrane Library, Embase, and other sources were searched until 21 October 2022. Studies reporting the relationship between ECMO-related time and COVID-19 survival were included. All available data were pooled using random-effects methods. Linear regression analysis was used to determine the correlation between pre-ECMO time and ECMO duration. The meta-analysis was registered with PROSPERO under registration number CRD42023403236.

RESULTS

Out of the initial 2473 citations, we analyzed 318 full-text articles, and 54 studies were included, involving 13,691 patients. There were significant differences between survivors and non-survivors in the time from COVID-19 diagnosis (standardized mean difference (SMD) = -0.41, 95% confidence interval (CI): [-0.53, -0.29], p < 0.00001), hospital (SMD = -0.53, 95% CI: [-0.97, -0.09], p = 0.02) and intensive care unit (ICU) admission (SMD = -0.28, 95% CI: [-0.49, -0.08], p = 0.007), intubation or mechanical ventilation to ECMO (SMD = -0.21, 95% CI: [-0.32, -0.09], p = 0.0003) and ECMO duration (SMD = -0.18, 95% CI: [-0.30, -0.06], p = 0.003). There was no statistical association between a longer time from symptom onset to ECMO (hazard ratio (HR) = 1.05, 95% CI: [0.99, 1.12], p = 0.11) or time from intubation or mechanical ventilation (MV) and the risk of mortality (highest vs. lowest time groups odds ratio (OR) = 1.18, 95% CI: [0.78, 1.78], p = 0.42; per one-day increase OR = 1.14, 95% CI: [0.86, 1.52], p = 0.36; HR = 0.99, 95% CI: [0.95, 1.02], p = 0.39). There was no linear relationship between pre-ECMO time and ECMO duration.

CONCLUSION

There are differences in pre-ECMO time between COVID-19 survivors and non-survivors, and there is insufficient evidence to conclude that longer pre-ECMO time is responsible for reduced survival in COVID-19 patients. ECMO duration differed between survivors and non-survivors, and the timing of pre-ECMO does not have an impact on ECMO duration. Further studies are needed to explore the association between pre-ECMO and ECMO time in the survival of COVID-19 patients.

The Association of Frailty With Long-Term Outcomes in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation

The objective of this study was to investigate the prevalence and impact of frailty on mortality in patients with acute respiratory failure (ARF) treated with noninvasive ventilation (NIV). This was a single-center, prospective study of patients who developed ARF (irrespective of etiology) and were treated with NIV support. Frailty was assessed using the Clinical Frailty Scale (CFS). We modeled the relationship of CFS with one-year mortality using Cox proportional hazards regression, adjusting for other clinical and demographic characteristics. Of the 166 patients enrolled, 48% had moderate to severe frailty. These patients were more likely to be female (67% versus 33%) and on oxygen therapy at home (46% versus 28%). The median CFS score was 5 (interquartile range (IQR): 5-6). Moderate to severe frailty was associated with a 60% higher risk of one-year mortality (hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.15-2.31). Frailty assessment may identify patients in need of ventilatory support who are at increased risk of mortality and may be an important factor to consider when discussing goals of care in this vulnerable population.

Trends in survival during the pandemic in patients with critical COVID-19 receiving mechanical ventilation with or without ECMO: analysis of the Japanese national registry data

Background

The survival rate of patients with critical coronavirus disease-19 (COVID-19) over time is inconsistent in different settings. In Japan, a national database was organized to monitor and share the patient generation across the country in an immediate response to the COVID-19 pandemic. This study aimed to evaluate changes in survival over time and the prognostic factors in critical COVID-19 patients receiving mechanical ventilation with/without extracorporeal membrane oxygenation (ECMO) using the largest database in Japan.

Methods

This is a prospective observational cohort study of patients admitted to intensive care units in Japan with fatal COVID-19 pneumonia receiving mechanical ventilation and/or ECMO. We developed a prospective nationwide registry covering > 80% of intensive care units in Japan, and analyzed the association between patients’ backgrounds, institutional ECMO experience, and timing of treatment initiation and prognosis between February 2020 and November 2021. Prognostic factors were evaluated by Kaplan–Meier analysis and Cox proportional hazards analysis.

Results

A total of 9418 patients were ventilated, of whom 1214 (13%) received ECMO. The overall survival rate for ventilated patients was 79%, 65% for those receiving ECMO. There have been five outbreaks in Japan to date. The survival rate of ventilated patients increased from 76% in the first outbreak to 84% in the fifth outbreak (p < 0.001). The survival rate of ECMO patients remained unchanged at 60–68% from the first to fifth outbreaks (p = 0.084). Age of ≥ 59 (hazard ratio [HR] 2.17; 95% confidence interval [CI] 1.76–2.68), ventilator days of ≥ 3 before starting ECMO (HR 1.91; 95% CI 1.57–2.32), and institutional ECMO experiences of ≥ 11 (HR 0.70; 95% CI 0.58–0.85) were independent prognostic factors for ECMO.

Conclusions

During five COVID-19 outbreaks in Japan, the survival rate of ventilated patients tended to have gradually improved, and that of ECMO patients did not deteriorate. Older age, longer ventilator days before starting ECMO, and fewer institutional ECMO experiences may be independent prognostic factors for critical COVID-19 patients receiving ECMO.

Mechanical Ventilation and Survival in Patients With Advanced Dementia in Medicare Advantage

CONTEXT

Medicare Advantage (MA) cares for an increasing proportion of traditional Medicare (TM) patients although, the association of MA on low-value care among hospitalized patients is uncertain.

OBJECTIVES

We sought to determine whether invasive mechanical ventilation (IMV) use or mortality differs among hospitalized patients with advanced dementia (AD) enrolled in MA vs. TM and the influence of hospital MA concentration.

METHODS

Retrospective cohort of hospitalized Medicare patients from 2016 to 2017 who were ≥66 years old with AD (n=147,153) and had a hospitalization with an assessment completed during a nursing home stay ≤120 days prior to that hospitalization indicating AD and severe cognitive/functional impairment. MA enrollment was ascertained at hospitalization; IMV use and 30- and 365-day mortality were determined via Medicare data. Multivariable logistic regression models clustered by hospital were used.

RESULTS

Among hospitalized Medicare patients with AD, 27,253 (19%) were enrolled in MA, mean age was 84 (95% CI: 83.9-84.0) and 92,736 (63%) were female. Enrollment in MA was associated with increased IMV use (Adjusted Odds Ratio(AOR)=1.11, 95% CI: 1.04-1.18), 30- (Adjusted Hazard Ratio(AHR)=1.09, 95% CI: 1.05-1.12) and 365-day mortality (AHR=1.12, 95% CI: 1.08-1.16) compared to TM. Use of IMV was not different based on concentration of MA at the hospital level.

CONCLUSION

MA may reduce hospitalizations, however, once hospitalized, patients with AD enrolled in MA experience higher rates of IMV use and worse 30- and 365-day mortality compared to TM patients. Higher hospital concentration of MA did not reduce use of IMV. MA may not offer significant benefits in reducing low-value care among patients hospitalized with serious illness, questioning the benefits of this care model.

Clinical profile, outcomes and predictors of mortality in elderly patients admitted to the emergency medicine intensive care unit of a teaching hospital - A single-center registry

Aim:

Emergency intensive care of the elderly is often complicated and multifaceted. Understanding the clinical profile of elderly patients admitted in an emergency department-intensive care unit (ED-ICU) is crucial in planning health policies in geriatric emergency medicine. Thus, the aim of the study was to create a local registry of elderly people utilizing the ED-ICU services and to understand the rate and predictors of mortality.

Methods:

A retrospective chart analysis was performed including all patients aged ≥60 years who had an ED-ICU admission during a 6-month period (August 2018–January 2019). A structured case record form was used to capture information such as basic demography, clinical profile, and outcomes.

Results:

Total number of records considered for final analysis were 503. Mortality was seen in 21.07% (n = 106/503). The most common presenting complaint and cause of death was breathing difficulty (n = 48/503; 29.42%) and pneumonia (n = 41/106; 38.67%), repectively. The significant predictors of mortality [adjusted odds ratio; 95% confidence intervals; P value] were hypertension (2.195; 1.255, 3.840; 0.006), chronic liver disease (CLD) (4.324; 1.170, 15.979; 0.028), malignancy (2.854; 1.045, 7.796; 0.041), requiring noninvasive ventilation (NIV) (2.618; 1.449, 4.730; 0.001), requiring intubation (6.638; 3.705, 11.894; <0.001), and requiring vasopressors (3.583; 1.985, 6.465; <0.001).

Conlusion:

Approximately one in every five elderly patients getting admitted in ED-ICU died, and respiratory illness was the common diagnosis leading to death. Those with comorbidities such as hypertension, CLD, or malignancy and those requiring NIV, intubation, or vasopressors had higher mortality.

Burden of primary influenza and respiratory syncytial virus pneumonia in hospitalized adults: insights from a two-year multi-centre cohort study (2017-2018)

This two-year (2017-2018) multi-centre study on 356 adults hospitalized for influenza A/B and RSV pneumonia analysed factors associated with non-invasive ventilation (NIV) failure and in-hospital death (IHD.) Patients with both obstructive sleep apnoea or obesity hypoventilation syndrome and influenza-A virus pneumonia showed a higher risk for NIV failure (OR 4.66; 95% CI 1.42-15.30). Patients submitted to NIV showed a higher risk for IHD, regardless of comorbidities (influenza-A OR 3.00; 95% CI 1.35-6.65, influenza-B OR 4.52; 95% CI 1.13-18.01, RSV OR 5.61; 95% CI 1.26-24.93). The increased knowledge of influenza-A/B and RSV pneumonia burden may contribute to a better management of patients with viral pneumonia. This article is protected by copyright. All rights reserved.

Evolving outcomes of extracorporeal membrane oxygenation support for severe COVID-19 ARDS in Sorbonne hospitals, Paris

Background

Extracorporeal membrane oxygenation (ECMO) was frequently used to treat patients with severe coronavirus disease-2019 (COVID-19)-associated acute respiratory distress (ARDS) during the initial outbreak. Care of COVID-19 patients evolved markedly during the second part of 2020. Our objective was to compare the characteristics and outcomes of patients who received ECMO for severe COVID-19 ARDS before or after July 1, 2020.

Methods

We included consecutive adults diagnosed with COVID-19 in Paris–Sorbonne University Hospital Network ICUs, who received ECMO for severe ARDS until January 28, 2021. Characteristics and survival probabilities over time were estimated during the first and second waves. Pre-ECMO risk factors predicting 90-day mortality were assessed using multivariate Cox regression.

Results

Characteristics of the 88 and 71 patients admitted, respectively, before and after July 1, 2020, were comparable except for older age, more frequent use of dexamethasone (18% vs. 82%), high-flow nasal oxygenation (19% vs. 82%) and/or non-invasive ventilation (7% vs. 37%) after July 1. Respective estimated probabilities (95% confidence intervals) of 90-day mortality were 36% (27–47%) and 48% (37–60%) during the first and the second periods. After adjusting for confounders, probability of 90-day mortality was significantly higher for patients treated after July 1 (HR 2.27, 95% CI 1.02–5.07). ECMO-related complications did not differ between study periods.

Conclusions

90-day mortality of ECMO-supported COVID-19–ARDS patients increased significantly after July 1, 2020, and was no longer comparable to that of non-COVID ECMO-treated patients. Failure of prolonged non-invasive oxygenation strategies before intubation and increased lung damage may partly explain this outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03780-6.

Utilization Trends and Predictors of Non-invasive and Invasive Ventilation During Hospitalization Due to Community-Acquired Pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality. Non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV) are most important interventions for patients with severe CAP associated with respiratory failure. We analysed utilization trends and predictors of non-invasive and invasive ventilation in patients hospitalized with CAP.

METHODS

 Nationwide Inpatient Sample and Healthcare Cost and Utilization Project data for years 2008-2017 were analysed. Adult hospitalizations due to CAP were identified by previously validated International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. We then utilized the Cochran-Armitage trend test and multivariate survey logistic regression models to analyse temporal incidence trends, predictors, and outcomes. We used SAS 9.4 software (SAS Institute Inc., Cary, NC, USA) for analysing data.

RESULTS

Out of a total of 8,385,861 hospitalizations due to CAP, ventilation assistance was required in 552,395 (6.6%). The overall ventilation use increased slightly; however, IMV utilization decreased, while NIV utilization increased. In multivariable regression analysis, males, Asian/others and weekend admissions were associated with higher odds of any ventilation utilization. Concurrent diagnoses of septicemia, congestive heart failure, alcoholism, chronic lung diseases, pulmonary circulatory diseases, diabetes mellitus, obesity and cancer were associated with increased odds of requiring ventilation assistance. Ventilation requirement was associated with high odds of in-hospital mortality and discharge to facility.

CONCLUSION

The use of NIV among CAP patients has increased while IMV use has decreased over the years. We observed numerous factors linked with a higher use of ventilation support. The requirement of ventilation support is also associated with very high chances of mortality and morbidity.

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare

BACKGROUND/OBJECTIVE

Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment.

MEASUREMENTS

Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing.

RESULTS

Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM.

CONCLUSIONS

Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.

Analysis of pathogens and risk factors of secondary pulmonary infection in patients with COVID-19

To investigate the distribution and risk factors of pathogens in secondary pulmonary infection in patients with COVID-19.142 patients with confirmed COVID-19 from Shanghai Public Health Clinical Center were collected, and 32 patients with pulmonary infection were taken as the infection group. The distribution of pathogens in the sputum specimens was applied for retrospective analysis. Meanwhile, 110 patients diagnosed with COVID-19, but without pulmonary infection were regarded as the asymptomatic group. The risk factors of pulmonary infection were analyzed with generalized linear models and logistic regression. The pathogens in the lung infection group were mainly gram-negative bacteria (22, 68.8%), especially Klebsiella pneumoniae. Gram-positive bacteria and fungi accounted for 13 (40.6%), mainly Staphylococcus aureus, and 11 (34.4%), mainly Candida albicans. There were 14 cases (43.8%) infected with two or more pathogens. The comparison between the two groups found that, patients with elder age, underlying diseases, more lung lesions and low protein contents, were more likely to develop lung infections. At last, univariate analysis showed that 6 factors, including indwelling gastric catheter, the number of deep vein catheters, tracheal intubation tracheotomy, invasive mechanical ventilation, hormonal application, and the use of more than three antibacterial drugs, are risk factors for COVID-19 secondary pulmonary infection. Generalized linear models and logistic regression analysis showed antimicrobial use as an independent risk factor for COVID-19 secondary lung infection. There are many risk factors for secondary lung infection in severe COVID-19 patients, and it is recommended to use antibiotics reasonably.

Non-invasive positive pressure ventilation versus endotracheal intubation in treatment of COVID-19 patients requiring ventilatory support

Importance

Initial guidelines recommended prompt endotracheal intubation rather than non-invasive ventilation (NIV) for COVID-19 patients requiring ventilator support. There is insufficient data comparing the impact of intubation versus NIV on patient-centered outcomes of these patients.

Objective

To compare all-cause 30-day mortality for hospitalized COVID-19 patients with respiratory failure who underwent intubation first, intubation after NIV, or NIV only.

Design

Retrospective study of patients admitted in March and April of 2020.

Setting

A teaching hospital in Brooklyn, New York City.

Participants

Adult COVID-19 confirmed patients who required ventilator support (non-invasive ventilation and/or endotracheal intubation) at discretion of treating physician, were included.

Exposures

Patients were categorized into three exposure groups: intubation-first, intubation after NIV, or NIV-only.

Primary outcome

30-day all-cause mortality, a predetermined outcome measured by multivariable logistic regression. Data are presented with medians and interquartile ranges, or percentages with 95% confidence intervals, for continuous and categorical variables, respectively. Covariates for the model were age, sex, qSOFA score ≥ 2, presenting oxygen saturation, vasopressor use, and greater than three comorbidities. A secondary multivariable model compared mortality of all patients that received NIV (intubation after NIV and NIV-only) with the intubation-first group.

Results

A total of 222 were enrolled. Overall mortality was 77.5% (95%CI, 72–83%). Mortality for intubation-first group was 82% (95%CI, 73–89%; 75/91), for Intubation after NIV was 84% (95%CI, 70–92%; 37/44), and for NIV-only was 69% (95%CI, 59–78%; 60/87). In multivariable analysis, NIV-only was associated with decreased all-cause mortality (odds ratio [OR]: 0.30, 95%CI, 0.13–0.69). No difference in mortality was observed between intubation-first and intubation after NIV. Secondary analysis found all patients who received NIV to have lower mortality than patients who were intubated only (OR: 0.44, 95%CI, 0.21–0.95).

Conclusions & Relevance

Utilization of NIV as the initial intervention in COVID-19 patients requiring ventilatory support is associated with significant survival benefit. For patients intubated after NIV, the mortality rate is not worse than those who undergo intubation as their initial intervention.

Noninvasive ventilation in critically ill very old patients with pneumonia: A multicenter retrospective cohort study

Background

Very old patients (≥ 80 years-old, VOP) are increasingly admitted to intensive care units (ICUs). Community-acquired pneumonia (CAP) is a common reason for admission and the best strategy of support for respiratory failure in this scenario is not fully known. We evaluated whether noninvasive ventilation (NIV) would be beneficial compared to invasive mechanical ventilation (IMV) regarding hospital mortality.

Methods

Multicenter cohort study of VOPs admitted with CAP in need of IMV or NIV to 11 Brazilian ICUs from 2009 through 2012. We used logistic regression models to evaluate the association between the initial ventilatory strategy (NIV vs. IMV) and hospital mortality adjusting for confounding factors. We evaluated effect modification with interaction terms in pre-specified sub-groups.

Results

Of 369 VOPs admitted for CAP with respiratory failure, 232 (63%) received NIV and 137 (37%) received IMV as initial ventilatory strategy. IMV patients were sicker at baseline (median SOFA 8 vs. 4). Hospital mortality was 114/232 (49%) for NIV and 90/137 (66%) for IMV. For the comparison NIV vs. IMV (reference), the crude odds ratio (OR) was 0.50 (95% CI, 0.33–0.78, p = 0.002). This association was largely confounded by antecedent characteristics and non-respiratory SOFA (_adjOR = 0.70, 95% CI, 0.41–1.20, p = 0.196). The fully adjusted model, additionally including P_ao₂/F_io₂ ratio, pH and P_aco₂, yielded an _adjOR of 0.81 (95% CI, 0.46–1.41, p = 0.452). There was no strong evidence of effect modification among relevant subgroups, such as P_ao₂/F_io₂ ratio ≤ 150 (p = 0.30), acute respiratory acidosis (p = 0.42) and non-respiratory SOFA ≥ 4 (p = 0.53).

Conclusions

NIV was not associated with lower hospital mortality when compared to IMV in critically ill VOP admitted with CAP, but there was no strong signal of harm from its use. The main confounders of this association were both the severity of respiratory dysfunction and of extra-respiratory organ failures.

Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life

Importance

End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life.

Objective

To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life.

Design, Setting, and Participants

This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020.

Exposures

Use of NIV or IMV.

Main Outcomes and Measures

Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities.

Results

A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]).

Conclusions and Relevance

This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.

A physiological approach to understand the role of respiratory effort in the progression of lung injury in SARS-CoV-2 infection

Deterioration of lung function during the first week of COVID-19 has been observed when patients remain with insufficient respiratory support. Patient self-inflicted lung injury (P-SILI) is theorized as the responsible, but there is not robust experimental and clinical data to support it. Given the limited understanding of P-SILI, we describe the physiological basis of P-SILI and we show experimental data to comprehend the role of regional strain and heterogeneity in lung injury due to increased work of breathing.

In addition, we discuss the current approach to respiratory support for COVID-19 under this point of view.

Factors for Predicting Noninvasive Ventilation Failure in Elderly Patients with Respiratory Failure

Noninvasive ventilation (NIV) is useful when managing critically ill patients. However, it is not easy to apply to elderly patients, particularly those with pneumonia, due to the possibility of NIV failure and the increased mortality caused by delayed intubation. In this prospective observational study, we explored whether NIV was appropriate for elderly patients with pneumonia, defined factors that independently predicted NIV failure, and built an optimal model for prediction of such failure. We evaluated 78 patients with a median age of 77 years. A low PaCO2 level, a high heart rate, and the presence of pneumonia were statistically significant independent predictors of NIV failure. The predictive power for NIV failure of Model III (pneumonia, PaCO2 level, and heart rate) was better than that of Model I (pneumonia alone). Considering the improvement in parameters, patients with successful NIV exhibited significantly improved heart rates, arterial pH and PaCO2 levels, and patients with NIV failure exhibited a significantly improved PaCO2 level only. In conclusion, NIV is reasonable to apply to elderly patients with pneumonia, but should be done with caution. For the early identification of NIV failure, the heart rate and arterial blood gas parameters should be monitored within 2 h after NIV commencement.

Association Between Peripheral Blood Oxygen Saturation (SpO2)/Fraction of Inspired Oxygen (FiO2) Ratio Time at Risk and Hospital Mortality in Mechanically Ventilated Patients

INTRODUCTION

Acute respiratory failure requiring mechanical ventilation is a leading cause of mortality in the intensive care unit. Although single peripheral blood oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) ratios of hypoxemia have been evaluated to risk-stratify patients with acute respiratory distress syndrome, the utility of longitudinal SpO2/FiO2 ratios is unknown.

OBJECTIVE

To assess time-based SpO2/FiO2 ratios ≤ 150-SpO2/FiO2 time at risk (SF-TAR)-for predicting mortality in mechanically ventilated patients.

METHODS

Retrospective, observational cohort study of mechanically ventilated patients at 21 community and 2 academic hospitals. Association between the SF-TAR in the first 24 hours of ventilation and mortality was examined using multivariable logistic regression and compared with the worst recorded isolated partial pressure of arterial oxygen/fraction of inspired oxygen (P/F) ratio.

RESULTS

In 28,758 derivation cohort admissions, every 10% increase in SF-TAR was associated with a 24% increase in adjusted odds of hospital mortality (adjusted odds ratio = 1.24; 95% confidence interval [CI] = 1.23-1.26); a similar association was observed in validation cohorts. Discrimination for mortality modestly improved with SF-TAR (area under the receiver operating characteristic curve [AUROC] = 0.81; 95% CI = 0.81-0.82) vs the worst P/F ratio (AUROC = 0.78; 95% CI = 0.78-0.79) and worst SpO2/FiO2 ratio (AUROC = 0.79; 95% CI = 0.79-0.80). The SF-TAR in the first 6 hours offered comparable discrimination for hospital mortality (AUROC = 0.80; 95% CI = 0.79-0.80) to the 24-hour SF-TAR.

CONCLUSION

The SF-TAR can identify ventilated patients at increased risk of death, offering modest improvements compared with single SpO2/FiO2 and P/F ratios. This longitudinal, noninvasive, and broadly generalizable tool may have particular utility for early phenotyping and risk stratification using electronic health record data in ventilated patients.

Benefits of non-invasive ventilation in acute hypercapnic respiratory failure

Non-invasive ventilation (NIV) with bilevel positive airway pressure is a non-invasive technique, which refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This technique is successful in correcting hypoventilation. It has become widely accepted as the standard treatment for patients with hypercapnic respiratory failure (HRF). Since the 1980s, NIV has been used in intensive care units and, after initial anecdotal reports and larger series, a number of randomized trials have been conducted. Data from these trials have shown that NIV is a valuable treatment for HRF. This review aims to explore the principal areas in which NIV can be useful, focusing particularly on patients with acute HRF (AHRF). We will update the evidence base with the goal of supporting clinical practice. We provide a practical description of the main indications for NIV in AHRF and identify the group of patients with hypercapnic failure who will benefit most from the application of NIV.

Hospital Variation in Renal Replacement Therapy for Sepsis in the United States

OBJECTIVES

Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals-and whether greater use is associated with better outcomes-is unknown.

DESIGN

Retrospective cohort study.

SETTING

Nationwide Inpatient Sample in 2011.

PATIENTS

Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011.

INTERVENTIONS

We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics.

MEASUREMENTS AND MAIN RESULTS

We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9-4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99-1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157-$2,475; p = 0.03).

CONCLUSIONS

Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality.

Accounting for Patient Preferences Regarding Life-Sustaining Treatment in Evaluations of Medical Effectiveness and Quality

The importance of understanding patient preferences for life-sustaining treatment is well described for individual clinical decisions; however, its role in evaluations of healthcare outcomes and quality has received little attention. Decisions to limit life-sustaining therapies are strongly associated with high risks for death in ways that are unaccounted for by routine measures of illness severity. However, this essential information is generally unavailable to researchers, with the potential for spurious inferences. This may lead to "confounding by unmeasured patient preferences" (a type of confounding by indication) and has implications for assessments of treatment effectiveness and healthcare quality, especially in acute and critical care settings in which risk for death and adverse events are high. Through a collection of case studies, we explore the effect of unmeasured patient resuscitation preferences on issues critical for researchers and research consumers to understand. We then propose strategies to more consistently elicit, record, and harmonize documentation of patient preferences that can be used to attenuate confounding by unmeasured patient preferences and provide novel opportunities to improve the patient centeredness of medical care for serious illness.

Impact of COPD on outcomes in hospitalized patients with community-acquired pneumonia: Analysis of the Spanish national hospital discharge database (2004-2013)

AIM

To examine trends in incidence and outcomes of community-acquired pneumonia (CAP) hospitalizations among patients with or without COPD in Spain (2004-2013).

METHODS

We used national hospital discharge data to select all hospital admissions for CAP. Incidence was calculated overall and according to the presence or absence of COPD.

RESULTS

We identified 901,136 hospital admissions for CAP (32.25% with COPD). Incidence of hospitalizations of CAP increased significantly over time among patients with and without COPD, but it was higher among people with COPD for all years analyzed. S. pneumoniae decreased over time for both groups. Time trend analyses showed significant decreases in mortality during admission for CAP for patients with and without COPD. Factor independently associated with higher mortality in both groups included: male sex, older age, higher comorbidity, isolation of S. aureus or P. aeruginosa, use of mechanical ventilation, and readmission. The presence of COPD was associated with a lower in-hospital mortality (IHM) (OR: 0.58, 95%CI 0.57-0.59).

CONCLUSIONS

The incidence of hospitalizations for CAP increased over time in patients with and without COPD, being higher in the COPD population for all years analyzed. IHM decreased over time in both groups. There were no differences in mortality between COPD and non-COPD patients.

How Antibiotics Should be Prescribed to Hospitalized Elderly Patients with Community-Acquired Pneumonia

Elderly patients hospitalized with community-acquired pneumonia (CAP) should be administered antimicrobials in the emergency department prior to transfer to the ward or intensive care unit (ICU). For ward patients, a β-lactam with a macrolide or a respiratory fluoroquinolone alone should be given to cover typical and atypical pathogens. For ICU patients, a β-lactam with either a macrolide or a fluoroquinolone should be given. Other regimens are indicated if methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa is a concern. Patients who are hemodynamically stable and can tolerate oral intake can be considered for switch therapy as well as discharge if other co-morbidities are stable and a safe disposition plan exists. A number of special concerns for the elderly include noting adverse effects from antimicrobials, being watchful of comorbidity exacerbations, and vaccinating for pneumococcus and influenza.

The comparative effectiveness of noninvasive and invasive ventilation in patients with pneumonia

PURPOSE

To compare the outcomes of patients hospitalized with pneumonia treated with noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV).

MATERIALS AND METHODS

Using the HealthFacts multihospital electronic medical record database, we included patients hospitalized with a diagnosis of pneumonia and treated with NIV or IMV. We developed a propensity model for receipt of initial NIV and assessed the outcomes in a propensity-matched cohort, and in a covariate adjusted and propensity score weighted models.

RESULTS

Among 3971 ventilated patients, 1109 (27.9%) were initially treated with NIV. Patients treated with NIV were older, had lower acuity of illness score, and were more likely to have congestive heart failure and chronic pulmonary disease. Mortality was 15.8%, 29.8% and 25.9.0% among patients treated with initial NIV, initial IMV and among those with NIV failure. In the propensity matched analysis, the risk of death was lower in patients treated with NIV (relative risk: 0.71, 95% CI: 0.59-0.85). Subgroup analysis showed that NIV was beneficial among patients with cardiopulmonary comorbidities (relative risk 0.59, 95% CI: 0.47-0.75) but not in those without (relative risk 0.96, 95% CI: 0.74-0.1.25)NIV failure was significantly (p=0.002) more common in patients without cardiopulmonary conditions (21.3%) compared to those with these conditions (13.8%).

CONCLUSIONS

Initial NIV was associated with better survival among the subgroup of patients hospitalized with pneumonia who had COPD or heart failure. Patients who failed NIV had high in-hospital mortality, emphasizing the importance of careful patient selection monitoring when managing severe pneumonia with NIV.

Confounding in observational studies based on large health care databases: problems and potential solutions - a primer for the clinician

Population-based health care databases are a valuable tool for observational studies as they reflect daily medical practice for large and representative populations. A constant challenge in observational designs is, however, to rule out confounding, and the value of these databases for a given study question accordingly depends on completeness and validity of the information on confounding factors. In this article, we describe the types of potential confounding factors typically lacking in large health care databases and suggest strategies for confounding control when data on important confounders are unavailable. Using Danish health care databases as examples, we present the use of proxy measures for important confounders and the use of external adjustment. We also briefly discuss the potential value of active comparators, high-dimensional propensity scores, self-controlled designs, pseudorandomization, and the use of positive or negative controls.