Outcomes of Noninvasive and Invasive Ventilation in Patients Hospitalized with Asthma Exacerbation.
Ann Am Thorac Soc. 2016 Apr 12;
Authors: Stefan MS, Nathanson BH, Lagu T, Priya A, Pekow PS, Steingrub JS, Hill NS, Goldberg RJ, Kent DM, Lindenauer PK
RATIONALE: Little is known about the effectiveness of noninvasive ventilation for patients hospitalized with asthma exacerbation.
OBJECTIVES: To assess clinical outcomes of noninvasive (NIV) and invasive mechanical ventilation (IMV) and examine predictors for NIV use in patients hospitalized with asthma.
METHODS: This was a retrospective cohort study at 97 US hospitals using an electronic medical record database. We developed a hierarchical regression model to identify factors associated with the choice of initial ventilation and used the Laboratory Acute Physiological Score (LAPS) to adjust for differences in the severity of illness. We assessed the outcomes of patients treated with initial NIV or IMV in a propensity matched cohort.
MEASUREMENTS AND MAIN RESULTS: Among 13,930 subjects, 73% were female, 54% white. The median age was 53 years. Overall, 1254 patients (9%) required ventilatory support (NIV or IMV). NIV was the initial ventilation method for 556 patients (4.0%) and IMV for 668 (5.0%). 26 patients (4.7% of patients treated with NIV) had to be intubated (NIV failure). The in-hospital mortality was 0.2%, 2.3%, 14.5% and 15.4%, and the median length of stay was 2.9 , 4.1, 6.7, and 10.9 days among those not ventilated, ventilated with NIV, IMV, and NIV failure respectively. Older patients were more likely to receive NIV (OR: 1.06 per 5 years; 95% CI (1.01, 1.11) while those with higher acuity (LAPS score per 5 units OR: 0.85; 95% CI (0.82, 0.88). Those with concomitant pneumonia were less likely to receive NIV. In a propensity matched sample, NIV was associated with a lower in-patient risk of dying (RR = 0.12; 95% CI (0.03, 0.51) and shorter lengths of stay (4.3 days less; 95% CI (2.9, 5.8) than IMV.
CONCLUSIONS: Among patients hospitalized with asthma exacerbation and requiring ventilatory support (NIV or IMV), over 40% received NIV. Although patients successfully treated with NIV appear to have better outcomes than those treated with IMV, the low rate of NIV failure suggests that NIV was being used selectively in a lower risk group. The increased risk of mortality for patients who fail NIV highlights the need for careful monitoring to avoid possible delay in intubation.
PMID: 27070493 [PubMed - as supplied by publisher]