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Lee KG, Roca O, Casey JD, Semler MW, Roman-Sarita G, Yarnell CJ, Goligher EC. When to intubate in acute hypoxaemic respiratory failure? Options and opportunities for evidence-informed decision making in the intensive care unit. THE LANCET. RESPIRATORY MEDICINE 2024; 12:642-654. [PMID: 38801827 DOI: 10.1016/s2213-2600(24)00118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/08/2024] [Accepted: 04/05/2024] [Indexed: 05/29/2024]
Abstract
The optimal timing of intubation in acute hypoxaemic respiratory failure is uncertain and became a point of controversy during the COVID-19 pandemic. Invasive mechanical ventilation is a potentially life-saving intervention but carries substantial risks, including injury to the lungs and diaphragm, pneumonia, intensive care unit-acquired muscle weakness, and haemodynamic impairment. In deciding when to intubate, clinicians must balance premature exposure to the risks of ventilation with the potential harms of unassisted breathing, including disease progression and worsening multiorgan failure. Currently, the optimal timing of intubation is unclear. In this Personal View, we examine a range of parameters that could serve as triggers to initiate invasive mechanical ventilation. The utility of a parameter (eg, the ratio of arterial oxygen tension to fraction of inspired oxygen) to predict the likelihood of a patient undergoing intubation does not necessarily mean that basing the timing of intubation on that parameter will improve therapeutic outcomes. We examine options for clinical investigation to make progress on establishing the optimal timing of intubation.
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Affiliation(s)
- Kevin G Lee
- Department of Physiology, Toronto, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Parc Taulí-I3PT, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation at the University of Toronto, Toronto, ON, Canada; Scarborough Health Network, Department of Critical Care Medicine, Toronto, ON, Canada; Scarborough Health Network Research Institute, Toronto, ON, Canada.
| | - Ewan C Goligher
- Department of Physiology, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
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Arias-Sanchez PP, Wendel-Garcia PD, Tirapé-Castro HA, Cobos J, Jaramillo-Aguilar SX, Peñaloza-Tinoco AM, Jaramillo-Aguilar DS, Martinez A, Holguín-Carvajal JP, Cabrera E, Roche-Campo F, Aguirre-Bermeo H. Use of a gas-operated ventilator as a noninvasive bridging respiratory therapy in critically Ill COVID-19 patients in a middle-income country. Intern Emerg Med 2024:10.1007/s11739-024-03681-w. [PMID: 38940989 DOI: 10.1007/s11739-024-03681-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
During the COVID-19 pandemic, there was a notable undersupply of respiratory support devices, especially in low- and middle-income countries. As a result, many hospitals turned to alternative respiratory therapies, including the use of gas-operated ventilators (GOV). The aim of this study was to describe the use of GOV as a noninvasive bridging respiratory therapy in critically ill COVID-19 patients and to compare clinical outcomes achieved with this device to conventional respiratory therapies. Retrospective cohort analysis of critically ill COVID-19 patients during the first local wave of the pandemic. The final analysis included 204 patients grouped according to the type of respiratory therapy received in the first 24 h, as follows: conventional oxygen therapy (COT), n = 28 (14%); GOV, n = 72 (35%); noninvasive ventilation (NIV), n = 49 (24%); invasive mechanical ventilation (IMV), n = 55 (27%). In 72, GOV served as noninvasive bridging respiratory therapy in 42 (58%) of these patients. In the other 30 patients (42%), 20 (28%) presented clinical improvement and were discharged; 10 (14%) died. In the COT and GOV groups, 68% and 39%, respectively, progressed to intubation (P ≤ 0.001). Clinical outcomes in the GOV and NIV groups were similar (no statistically significant differences). GOV was successfully used as a noninvasive bridging respiratory therapy in more than half of patients. Clinical outcomes in the GOV group were comparable to those of the NIV group. These findings support the use of GOV as an emergency, noninvasive bridging respiratory therapy in medical crises when alternative approaches to the standard of care may be justifiable.
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Affiliation(s)
- Pedro P Arias-Sanchez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | | | - Johanna Cobos
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | | | | | | | - Alberto Martinez
- Emergency Department, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | | | - Enrique Cabrera
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Ferran Roche-Campo
- Intensive Care Unit, Hospital Verge de la Cinta de Tortosa, Tarragona, Spain
- The Pere Virgili Institute for Health Research (IISPV), Tarragona, Spain
| | - Hernan Aguirre-Bermeo
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.
- Faculty of Medicine, Universidad de Cuenca, Cuenca, Ecuador.
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Chalkias A, Huang Y, Ismail A, Pantazopoulos I, Papagiannakis N, Bitterman B, Anderson E, Catalan T, Erne GK, Tilley CR, Alaka A, Amadi KM, Presswalla F, Blakely P, Bernal-Morell E, Cebreiros López I, Eugen-Olsen J, García de Guadiana Romualdo L, Giamarellos-Bourboulis EJ, Loosen SH, Reiser J, Tacke F, Skoulakis A, Laou E, Banerjee M, Pop-Busui R, Hayek SS. Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study. Crit Care Med 2024; 52:930-941. [PMID: 38391282 DOI: 10.1097/ccm.0000000000006229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
OBJECTIVES To evaluate the impact of intubation timing, guided by severity criteria, on mortality in critically ill COVID-19 patients, amidst existing uncertainties regarding optimal intubation practices. DESIGN Prospective, multicenter, observational study conducted from February 1, 2020, to November 1, 2022. SETTING Ten academic institutions in the United States and Europe. PATIENTS Adults (≥ 18 yr old) confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalized specifically for COVID-19, requiring intubation postadmission. Exclusion criteria included patients hospitalized for non-COVID-19 reasons despite a positive SARS-CoV-2 test. INTERVENTIONS Early invasive mechanical ventilation (EIMV) was defined as intubation in patients with less severe organ dysfunction (Sequential Organ Failure Assessment [SOFA] < 7 or Pa o2 /F io2 ratio > 250), whereas late invasive mechanical ventilation (LIMV) was defined as intubation in patients with SOFA greater than or equal to 7 and Pa o2 /F io2 ratio less than or equal to 250. MEASUREMENTS AND MAIN RESULTS The primary outcome was mortality within 30 days of hospital admission. Among 4464 patients, 854 (19.1%) required mechanical ventilation (mean age 60 yr, 61.7% male, 19.3% Black). Of those, 621 (72.7%) were categorized in the EIMV group and 233 (27.3%) in the LIMV group. Death within 30 days after admission occurred in 278 patients (42.2%) in the EIMV and 88 patients (46.6%) in the LIMV group ( p = 0.28). An inverse probability-of-treatment weighting analysis revealed a statistically significant association with mortality, with patients in the EIMV group being 32% less likely to die either within 30 days of admission (adjusted hazard ratio [HR] 0.68; 95% CI, 0.52-0.90; p = 0.008) or within 30 days after intubation irrespective of its timing from admission (adjusted HR 0.70; 95% CI, 0.51-0.90; p = 0.006). CONCLUSIONS In severe COVID-19 cases, an early intubation strategy, guided by specific severity criteria, is associated with a reduced risk of death. These findings underscore the importance of timely intervention based on objective severity assessments.
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Affiliation(s)
- Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Outcomes Research Consortium, Cleveland, OH
| | - Yiyuan Huang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anis Ismail
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | | | - Brayden Bitterman
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Elizabeth Anderson
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Tonimarie Catalan
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Grace K Erne
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Caroline R Tilley
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Abiola Alaka
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kingsley M Amadi
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Feriel Presswalla
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Enrique Bernal-Morell
- Infectious Diseases Unit, Department of Internal Medicine, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Iria Cebreiros López
- Department of Laboratory Medicine, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | | | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Eleni Laou
- Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Salim S Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Munroe ES, Prevalska I, Hyer M, Meurer WJ, Mosier JM, Tidswell MA, Prescott HC, Wei L, Wang H, Fung CM. High-Flow Nasal Cannula Versus Noninvasive Ventilation as Initial Treatment in Acute Hypoxia: A Propensity Score-Matched Study. Crit Care Explor 2024; 6:e1092. [PMID: 38725442 PMCID: PMC11081605 DOI: 10.1097/cce.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
IMPORTANCE Patients presenting to the emergency department (ED) with hypoxemia often have mixed or uncertain causes of respiratory failure. The optimal treatment for such patients is unclear. Both high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) are used. OBJECTIVES We sought to compare the effectiveness of initial treatment with HFNC versus NIV for acute hypoxemic respiratory failure. DESIGN SETTING AND PARTICIPANTS We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with HFNC or NIV within 24 hours of arrival to the University of Michigan adult ED from January 2018 to December 2022. We matched patients 1:1 using a propensity score for odds of receiving NIV. MAIN OUTCOMES AND MEASURES The primary outcome was major adverse pulmonary events (28-d mortality, ventilator-free days, noninvasive respiratory support hours) calculated using a win ratio. RESULTS A total of 1154 patients were included. Seven hundred twenty-six (62.9%) received HFNC and 428 (37.1%) received NIV. We propensity score matched 668 of 1154 (57.9%) patients. Patients on NIV versus HFNC had lower 28-day mortality (16.5% vs. 23.4%, p = 0.033) and required noninvasive treatment for fewer hours (median 7.5 vs. 13.5, p < 0.001), but had no difference in ventilator-free days (median [interquartile range]: 28 [26, 28] vs. 28 [10.5, 28], p = 0.199). Win ratio for composite major adverse pulmonary events favored NIV (1.38; 95% CI, 1.15-1.65; p < 0.001). CONCLUSIONS AND RELEVANCE In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with NIV compared with HFNC was associated with lower mortality and fewer composite major pulmonary adverse events calculated using a win ratio. These findings underscore the need for randomized controlled trials to further understand the impact of noninvasive respiratory support strategies.
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Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Ina Prevalska
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Madison Hyer
- Center for Biostatistics, Ohio State University, Columbus, OH
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ
- Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Mark A Tidswell
- Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Lai Wei
- Center for Biostatistics, Ohio State University, Columbus, OH
| | - Henry Wang
- Department of Emergency Medicine, Ohio State University, Columbus, OH
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Munroe ES, Prevalska I, Hyer M, Meurer WJ, Mosier JM, Tidswell MA, Prescott HC, Wei L, Wang H, Fung CM. High-flow nasal cannula vs non-invasive ventilation in acute hypoxia: Propensity score matched study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.26.23296167. [PMID: 37808723 PMCID: PMC10557810 DOI: 10.1101/2023.09.26.23296167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
RATIONALE The optimal treatment for early hypoxemic respiratory failure is unclear, and both high-flow nasal cannula and non-invasive ventilation are used. Determining clinically relevant outcomes for evaluating non-invasive respiratory support modalities remains a challenge. OBJECTIVES To compare the effectiveness of initial treatment with high-flow nasal cannula versus non-invasive ventilation for acute hypoxemic respiratory failure. METHODS We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with high-flow nasal cannula or non-invasive ventilation within 24 hours of Emergency Department arrival (1/2018-12/2022). We matched patients 1:1 using a propensity score for odds of receiving non-invasive ventilation. The primary outcome was major adverse pulmonary events (28-day mortality, ventilator-free days, non-invasive respiratory support hours) calculated using a Win Ratio. MEASUREMENTS AND MAIN RESULTS 1,265 patients met inclusion criteria. 795 (62.8%) received high-flow oxygen and 470 (37.2%) received non-invasive ventilation. We propensity score matched 736/1,265 (58.2%) patients. There was no difference between non-invasive ventilation vs high-flow nasal cannula in 28-day mortality (17.7% vs 23.1%, p=0.08) or ventilator-free days (median [Interquartile Range]: 28 [25, 28] vs 28 [13, 28], p=0.50), but patients on non-invasive ventilation required treatment for fewer hours (median 7 vs 13, p< 0.001). Win Ratio for composite major adverse pulmonary events favored non-invasive ventilation (1.26, 95%CI 1.06-1.49, p< 0.001). CONCLUSIONS In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with non-invasive ventilation was superior to high-flow nasal cannula for major pulmonary adverse events. Evaluation of composite outcomes is important in the assessment of respiratory support modalities.
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Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ina Prevalska
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Madison Hyer
- Center for Biostatistics, The Ohio State University, Columbus, OH
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona
- Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Mark A. Tidswell
- Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Chan Medical School – Baystate Medical Center, Springfield, MA
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Lai Wei
- Center for Biostatistics, The Ohio State University, Columbus, OH
| | - Henry Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Christopher M Fung
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
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