Noninvasive Mechanical Ventilation in Acute Respiratory Failure Patients: A Respiratory Therapist Perspective

Underrepresentation of Respiratory Therapists as Experts in Delphi Studies on Respiratory Practices and Research Priorities

Delphi survey techniques are a common consensus method used to collect feedback from an expert panel to inform practices, establish guidelines, and identify research priorities. Collecting respiratory therapists' (RT) expertise and experiences as part of consensus-building methodologies is one way to ensure that they align with RT practices and to better influence respiratory care practice. This narrative review aimed to report the RT representation in expert panels of Delphi studies focused on respiratory therapy practices and research priorities. The research question that guided this review is: to what extent are RTs included as expert participants among published Delphi studies relate to respiratory therapy and research topics? We conducted a structured search of the literature and identified 23 papers that reported Delphi studies related to respiratory care practices and 15 that reported on respiratory-related research priorities. Delphi studies that focused on reporting consensus on respiratory care practices included the following: (1) mechanical ventilation, (2) high-flow nasal cannula therapy, (3) COVID-19 respiratory management, (4) home oxygen therapy, (5) cardiopulmonary monitoring, and (6) disease-specific guidelines. Delphi studies that focused on establishing respiratory research priorities included the following: (1) theory and practice-orientated knowledge gaps, and (2) priority research topics for empirical investigation. The results of this review suggest that RTs were rarely included as expert participants and, when involved, were minimally represented (5% to 33%). Given RTs' diverse and relevant experience in respiratory care, incorporating their perspectives to inform future education, respiratory care practices, and research priorities would allow evidence to better align with knowledge gaps deemed important for the respiratory therapy profession.

Hospital Noninvasive Ventilation Case Volume and Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

RATIONALE

Higher hospital case volume may produce local expertise ("practice makes perfect"), resulting in better patient outcomes. Associations between hospital noninvasive ventilation (NIV) case volume and outcomes for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) are unclear.

OBJECTIVES

To determine associations between total hospital NIV case volume for all indications and NIV failure and hospital mortality among patients with acute exacerbations of COPD.

METHODS

Using the 2011 California State Inpatient Database and multivariable hierarchical logistic regression, we calculated hospital-level risk-adjusted rates for NIV failure (progression from NIV to invasive mechanical ventilation) and hospital mortality among patients with acute exacerbations of COPD.

MEASUREMENTS AND MAIN RESULTS

We identified 37,516 hospitalizations for acute exacerbations of COPD in 252 California hospitals in 2011. Total hospital NIV use for all indications ranged from 2 to 565 cases (median, 64; interquartile range, 96). Hospital NIV failure rates for acute exacerbations of COPD ranged from 3.7 to 31.3% (median, 8.5%; interquartile range, 4.2). At the hospital level, higher total hospital NIV case volume was weakly associated with higher hospital NIV failure rates for acute exacerbations of COPD (r = 0.13; P = 0.03). Higher hospital NIV failure rates were weakly associated with higher hospital mortality rates for acute exacerbations of COPD (r = 0.15; P = 0.02), but higher total hospital NIV case volume was not associated with hospital mortality for exacerbations of COPD (r = -0.11; P = 0.08). At the patient level, patients admitted to high-NIV versus low-NIV case-volume hospitals had greater odds of NIV failure (quartile 4 vs. quartile 1 adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.12-3.40). Compared with initial treatment with invasive mechanical ventilation, NIV failure was associated with higher odds of death (aOR, 1.81; 95% CI, 1.35-2.44). However, admission to high-NIV versus low-NIV case-volume hospitals was not significantly associated with patient in-hospital mortality (quartile 4 vs. quartile 1 aOR, 0.76; 95% CI, 0.57-1.02).

CONCLUSIONS

Despite strong evidence for use of NIV in the management of acute exacerbations of COPD, we observed no significant mortality benefit and higher rates of NIV failure in high-NIV case-volume hospitals. Further investigation of patient selection and hospital factors associated with NIV failure is needed to maximize favorable patient outcomes associated with use of NIV for acute exacerbations of COPD.