Noninvasive ventilation on mortality of acute respiratory distress syndrome

The Impact of Preintubation Noninvasive Ventilation on Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

There is evidence that noninvasive ventilation decreases the need for invasive mechanical ventilation. However, children with pediatric acute respiratory distress syndrome who fail noninvasive ventilation may have worse outcomes than those who are intubated without exposure to noninvasive ventilation. Our objective was to evaluate the impact of preintubation noninvasive ventilation on children with pediatric acute respiratory distress syndrome.

DESIGN

Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial.

SETTING

Thirty-one PICUs in the United States.

PATIENTS

Children 2 weeks to 17 years old with pediatric acute respiratory distress syndrome receiving invasive mechanical ventilation, excluding those admitted with tracheostomies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 2,427 subjects receiving invasive mechanical ventilation, preintubation noninvasive ventilation was used in 995 (41%). Compared with subjects without preintubation noninvasive ventilation use, subjects with preintubation noninvasive ventilation use were more likely to have a history of seizures (10% vs 8%; p = 0.04) or cancer (11% vs 6%; p < 0.001) and have moderate or severe pediatric acute respiratory distress syndrome by the end of their first full day of invasive mechanical ventilation (68% vs 60%; p < 0.001). Adjusting for age, severity of illness on PICU admission, and baseline functional status, preintubation noninvasive ventilation use resulted in longer invasive mechanical ventilation duration (median 7.0 vs 6.0 d), longer PICU (10.8 vs 8.9 d), and hospital (17 vs 14 d) lengths of stay, and higher 28-day (5% vs 4%) and 90-day (8% vs 5%) inhospital mortalities (all comparisons p < 0.001). Longer duration of noninvasive ventilation before intubation was associated with worse outcomes.

CONCLUSIONS

In children with pediatric acute respiratory distress syndrome, preintubation noninvasive ventilation use is associated with worse outcomes when compared with no preintubation noninvasive ventilation use. These data can be used to inform the design of clinical studies to evaluate best noninvasive ventilation practices in children with pediatric acute respiratory distress syndrome.

Outcomes of Noninvasive Positive Pressure Ventilation in Acute Respiratory Distress Syndrome and Their Predictors: A National Cohort

Rationale

Although noninvasive positive pressure ventilation (NIPPV) is increasingly used in acute respiratory distress syndrome (ARDS) to avoid invasive mechanical ventilation (IMV), the data supporting its benefit for this indication are lacking.

Objectives

To analyze the all-cause in-hospital mortality rate and length of stay (LOS) for ARDS patients who received NIPPV in the United States (US) compared to those who were initially intubated. Our secondary outcome of interest was to determine the predicting factors for NIPPV failure.

Methods

We used the 2016 National Inpatient Sample database to identify 4,277 adult records with ARDS who required positive pressure ventilation. We divided the cohort into initial treatment with IMV or NIPPV. Then, the NIPPV group was further subdivided into NIPPV failure or success. We defined NIPPV failure as same-patient use of NIPPV and IMV either on the same day or using IMV at a later date. We analyzed the in-hospital mortality, LOS, and NIPPV failure rate. Linear regression of log-transformed LOS and logistic regression of binary outcomes were used to test for associations.

Results

The NIPPV success group had the lowest mortality rate (4.9% [3.8, 6.4]) and the shortest LOS (7 days [6.6, 7.5]). The NIPPV failure rate was 21%. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure (adjusted OR: 4.47, 2.65, and 2.23, respectively). There was no significant difference between NIPPV failure and IMV groups in-hospital mortality (26.9% [21.8, 32.8] vs. 25.1% [23.5, 26.9], p=0.885) or LOS (16 [14, 18] vs. 15.6 [15, 16.3], p=0.926).

Conclusions

NIPPV success in ARDS exhibits significantly lower hospital mortality rates and shorter LOS compared with IMV, and NIPPV failure exhibits no significant difference in hospital mortality or LOS compared with patients who were initially intubated. Therefore, an initial trial of NIPPV may be considered in ARDS. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure; these factors should be used to stratify patients to the most suitable ventilation modality.