Validity of a clinical scale in predicting the failure of non-invasive ventilation in hypoxemic patients

IntroductionThe HACOR scale is a clinical score that can predict early failure of NIV in hypoxemic acute respiratory failure (ARF) The aim of this study is to analyze the validity of the HACOR scale.MethodsA retrospective study of a cohort of over 2749 episodes on 2711 consecutive patients requiring NIV for hypoxemic ARF in a polyvalent intensive care unit. The scale was measured before starting NIV and at 1, 6, 12, 24 and 48 h after the initiation of NIV.ResultsNIV failure occurred in 963 patients (35%). The value of the HACOR scale before NIV did not differ between success and failure. However, at 1, 6, 12, 24 and 48 h of NIV, the scale values clearly differed between the two groups. The HACOR scale at NIV initiation accurately predicts NIV failure in the first hour, with an optimal cut-off value of 8 points. The AUC for predicting NIV failure with HACOR at 1 h is greater than 0.9 in patients with pneumonia and adult respiratory distress syndrome (ARDS).ConclusionsThe HACOR scale measured at 1 h after NIV initiation accurately predicts NIV failure, especially in pneumonia and ARDS.     

Acute respiratory failure in immunosuppressed patients admitted to ICU

IntroductionThe number of hospitalized immunosuppressed adults is a growing and often develop severe complications that require admission to an Intensive Care Unit (ICU). The main cause of admission is acute respiratory failure (ARF). The goal of the study was to determine if ARF represents an independent risk factor for hospital mortality and in particular, we sought to ascertain if any risk factors were independently and identifiably associated with a bad outcome.MethodsWe perform a retrospective study of a prospectively collected data from patients admitted to an ICU. Adult patients with known immunosuppressive condition admitted to ICU were included.ResultsA total of 248 patients were included. Of 248 patients, 117 (47.2%) had a diagnosis of ARF at the time of ICU admission. Patients with ARF had a significantly higher in-hospital mortality (53.4% vs. 28.2% p = 0.001). Factors independently associated with hospital mortality were diagnosis of ARF at ICU admission, the presence of septic shock, use of continuous renal replacement therapy and failure of high-flow nasal canula(HFNC)/non-invasive (NIV) respiratory therapies.ConclusionWe identified ARF on admission and failure of HFNC/NIV to be independently associated with increased hospital mortality in immunosuppressed patients.     

Decreased serial scores of severe organ failure assessments are associated with survival in mechanically ventilated patients; the prospective Maastricht Intensive Care COVID cohort

BackgroundThe majority of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are admitted to the Intensive Care Unit (ICU) for mechanical ventilation. The role of multi-organ failure during ICU admission as driver for outcome remains to be investigated yet.Design and settingProspective cohort of mechanically ventilated critically ill with SARS-CoV-2 infection.Participants and methods94 participants of the MaastrICCht cohort (21% women) had a median length of stay of 16 days (maximum of 77). After division into survivors (n = 59) and non-survivors (n = 35), we analysed 1555 serial SOFA scores using linear mixed-effects models.ResultsSurvivors improved one SOFA score point more per 5 days (95% CI: 4–8) than non-survivors. Adjustment for age, sex, and chronic lung, renal and liver disease, body-mass index, diabetes mellitus, cardiovascular risk factors, and Acute Physiology and Chronic Health Evaluation II score did not change this result. This association was stronger for women than men (P-interaction = 0.043).ConclusionsThe decrease in SOFA score associated with survival suggests multi-organ failure involvement during mechanical ventilation in patients with SARS-CoV-2. Surviving women appeared to improve faster than surviving men. Serial SOFA scores may unravel an unfavourable trajectory and guide decisions in mechanically ventilated patients with SARS-CoV-2.     

Use of High-Flow Nasal Cannula for Immunocompromise and Acute Respiratory Failure: A Systematic Review and Meta-Analysis

BackgroundAcute respiratory failure (ARF) is a common cause of emergency department (ED) and intensive care unit (ICU) admissions. High-flow nasal cannula oxygen therapy (HFNC) is widely used for patients with ARF.ObjectiveOur aim was to evaluate the latest evidence regarding the application of HFNC in immunocompromised patients with ARF.MethodsWe searched PubMed, Embase, and Cochrane databases from inception to January 2019. The primary outcome was short-term mortality and the secondary outcomes were intubation rate and length of ICU stay.ResultsEight studies involving 2,179 immunocompromised subjects with ARF were included. No significant differences for short-term mortality were observed when comparing HFNC with conventional oxygen therapy (COT) (risk ratio [RR] 0.89; 95% confidence interval [CI] 0.73 to 1.09; p = 0.25, I² = 47%) and with noninvasive ventilation (NIV) (RR 0.66; 95% CI 0.37 to 1.18; p = 0.16, I² = 58%). Lower intubation rates were found when comparing HFNC with COT (RR 0.89; 95% CI 0.80 to 0.99; p = 0.03, I² = 0%) and no significant difference was found between HFNC and NIV (RR 0.74; 95% CI 0.46 to 1.19; p = 0.22, I² = 67%). The length of ICU stay was similar when comparing HFNC with COT (mean difference [MD] 0.59; 95% CI –1.68 to 2.85; p = 0.61, I² = 56%), but was significantly shorter when HFNC was compared with NIV (MD –2.13; 95% CI –3.98 to –0.29; p = 0.02, I² = 0%).ConclusionsThere was no significant difference in short-term mortality with use of HFNC when compared with COT or NIV for immunocompromised patients with ARF. A lower intubation rate than COT and a shorter length of ICU stay than NIV were observed in the HFNC group.     

Noninvasive ventilation for acute respiratory failure after lung resection: an observational study

Background  A single prospective randomized study found that, in selected patients with acute respiratory failure (ARF) following lung resection, noninvasive ventilation (NIV) decreases the need for endotracheal mechanical ventilation and improves clinical outcome. Method  We prospectively evaluated early NIV use for ARF after lung resection during a 4-year period in the setting of a medical and a surgical ICU of a university hospital. We documented demographics, initial clinical characteristics and clinical outcomes. NIV failure was defined as the need for tracheal intubation. Results  Among 690 patients at risk of severe complications following lung resection, 113 (16.3%) experienced ARF, which was initially supported by NIV in 89 (78.7%), including 59 with hypoxemic ARF (66.3%) and 30 with hypercapnic ARF (33.7%). The overall success rate of NIV was 85.3% (76/89). In-ICU mortality was 6.7% (6/89). The mortality rate following NIV failure was 46.1%. Predictive factors of NIV failure in univariate analysis were age (P = 0.046), previous cardiac comorbidities (P = 0.0075), postoperative pneumonia (P = 0.0016), admission in the surgical ICU (P = 0.034), no initial response to NIV (P < 0.0001) and occurrence of noninfectious complications (P = 0.037). Only two independent factors were significantly associated with NIV failure in multivariate analysis: cardiac comorbidities (odds ratio, 11.5; 95% confidence interval, 1.9–68.3; P = 0.007) and no initial response to NIV (odds ratio, 117.6; 95% confidence interval, 10.6–1305.8; P = 0.0001). Conclusion  This prospective survey confirms the feasibility and efficacy of NIV in ARF following lung resection. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. This work was presented during the September 2008 ESICM congress in Lisbon international meeting and published as an abstract.     

An observational study on the practice of noninvasive ventilation at a tertiary level Australian intensive care unit

BackgroundFailure of Non-Invasive Ventilation (NIV) is associated with increased morbidity and mortality among critically ill patients. Although there is evidence of association between disease related factors and NIV failure, it is unclear whether factors related to NIV application contribute to NIV failure.ObjectivesTo evaluate NIV failure rate and factors associated with NIV failure.Design, Settings and OutcomesProspective, observational, pilot study conducted in a 23-bed, tertiary care Intensive Care Unit (ICU). NIV failure was defined as application of NIV resulting in intubation or death in ICU.ResultsAmongst 238 patients admitted with respiratory failure, NIV was administered to 60 patients (34 males, 26 females) for a total of 70 application episodes. The etiology of respiratory failure included acute pulmonary edema (28.6%), acute lung injury (22.9%) and pneumonia (15.7%). The mean (SD) age was 62 (17.6) years, BMI 32.0 (8.5) kg/m² and median APACHE-II score 17.5 (14.0–23.8). NIV failure occurred in 22 out of 70 applications (31.4% [95%CI 20.0–43.0]). NIV failure assessed by simple logistic regression analysis, was associated with admission diagnosis (OR 6.0, 95%CI: 1.3–28.7, p = 0.03), use of bi-level NIV-PS (OR 5.00, 95%CI: 1.04–24.1, p = 0.04), presence of nasogastric tube (OR 6.20, 95%CI: 1.9–19.8, p < 0.01) and with short NIV breaks in the 2nd 24-hours (OR 0.96, 95%CI: 0.91–0.99, p = 0.04).ConclusionNIV failure was observed in 31.4%. Factors associated with NIV failure were etiology of respiratory illness, type of NIV support and short NIV breaks, presumably reflecting illness severity or progress of disease. The presence of a nasogastric tube during application of NIV may adversely impact NIV application.     

Extent of pleural effusion on chest radiograph is associated with failure of high-flow nasal cannula oxygen therapy

PurposeThe purpose of the study was to determine whether pleural effusion (PE) is associated with a failure of high-flow nasal cannula (HFNC) therapy.Materials and methodsWe conducted a single-center retrospective study. Seventy-three patients with acute respiratory failure given HFNC therapy between January 2012 and December 2014 were reviewed. HFNC failure was defined as intubation or noninvasive positive pressure ventilation following HFNC therapy. The numbers of quadrants with consolidation or ground glass opacity were counted on chest radiographs performed within 24 hours before starting HFNC therapy, and the PE score was calculated. PE score was the original score, verified by the computed tomographic images of some of the study patients.ResultsOverall, 29 of 73 experienced HFNC failure. PE score was significantly greater in the HFNC failure group, but the number of quadrants with opacity was not significantly different. Age and Sequential Organ Failure Assessment (SOFA) score were significantly greater in the HFNC failure group. The PE (odds ratio, 1.49; 95% confidence interval, 1.10-2.02; P = .01) and SOFA (odds ratio, 1.33; 95% confidence interval, 1.05-1.68; P = .02) scores were independently associated with HFNC failure in multivariate analysis.ConclusionsThe extent of PE on chest radiograph and SOFA score were associated with HFNC failure.     

Predictors of early mortality in critically ill patients with acute kidney injury necessitating renal replacement therapy: A cohort study

PurposeReliable prediction of early mortality after initiation of renal replacement therapy (RRT) in critically ill patients may inform decision-making regarding this treatment. Our primary objective was to identify predictors of mortality within 2 days of starting RRT.Materials and methodsPatients with acute kidney injury (AKI), receiving RRT, and admitted to intensive care units of one hospital were included. Associations between baseline risk factors and mortality at 2 days and at hospital discharge were analyzed using logistic regression. Discrimination of both models was assessed.ResultsWe included 626 patients, treated initially with intermittent RRT (n = 300, 47.9%), continuous RRT (n = 211, 33.7%), or sustained low-efficiency dialysis (n = 115, 18.4%). Two-day mortality after starting RRT was 12.9% (n = 81), and hospital mortality was 50.5% (n = 316). Independent predictors of 2-day mortality included primary diagnostic category (p = 0.004) and sepsis-related organ failure assessment (SOFA) score (odds ratio [OR] 1.36 per point, 95% confidence interval [CI] 1.24–1.50). Independent predictors of hospital mortality included SOFA (1.29, 95%CI 1.21–1.37), Charlson score (1.20, 95%CI 1.18–1.43), and interhospital transfer (OR 0.55, 0.38–0.81). C-statistics were 0.81 (2-day mortality) and 0.80 (hospital mortality).ConclusionsHigher SOFA was associated with 2-day mortality after RRT initiation and with hospital mortality. Discrimination in both models was modest.     

Non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure

Purpose  

The use of non-invasive ventilation (NIV) in severe acute respiratory failure (ARF) due to community-acquired pneumonia (CAP) is controversial, and the risk factors for NIV failure in these patients are not well known. We assessed the characteristics and predictors of outcome of patients with CAP and severe ARF treated with NIV.     

Predictive factors of non invasive ventilation failure in critically ill children: a prospective epidemiological study

Objective  Identification of predictive factors for non-invasive ventilation (NIV) failure and determination of NIV characteristics. Design  Prospective observational study. Setting  Paediatric Intensive Care Unit in a University Hospital. Patients and measurements  A total of 116 episodes were included. Clinical data collected were respiratory rate (RR), heart rate and FiO₂ before NIV began. Same data and expiratory and support pressures were collected at 1, 6, 12, 24 and 48 h. Conditions precipitating acute respiratory failure (ARF) were classified into two groups: type 1 (38 episodes) and type 2 (78 episodes). Ventilation–perfusion impairment was the main respiratory failure mechanism in type 1, and hypoventilation in type 2. Factors predicting NIV failure were determined by multivariate analysis. Results  Most common admission diagnoses were pneumonia (81.6%) in type 1 and bronchiolitis (39.7%) and asthma (42.3%) in type 2. Complications secondary to NIV were detected in 23 episodes (20.2%). NIV success rate was 84.5% (68.4% in type 1 and 92.3% in type 2). Type 1 patients showed a higher risk of NIV failure compared to type 2 (OR 11.108; CI 95%, 2.578–47.863). A higher PRISM score (OR 1.138; CI 95%, 1.022–1.267), and a lower RR decrease at 1 h and at 6 h (OR 0.926; CI 95%, 0.860–0.997 and OR 0.911; CI 95%, 0.837–0.991, respectively) were also independently associated with NIV failure. Conclusions  NIV is a useful respiratory support technique in paediatric patients. Type 1 group classification, higher PRISM score, and lower RR decrease during NIV were independent risk factors for NIV failure.     

Noninvasive and invasive ventilation in acute respiratory failure associated with bronchiectasis

Purpose  

To describe the outcomes of patients with bronchiectasis and acute respiratory failure (ARF) treated with noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) after a failure of conservative measures, and to identify the predictors of hospital mortality and NIV failure.     

Acute hypoxemic respiratory failure in immunocompromised patients: the Efraim multinational prospective cohort study

Background

In immunocompromised patients with acute hypoxemic respiratory failure (ARF), initial management aims primarily to avoid invasive mechanical ventilation (IMV).

Methods

To assess the impact of initial management on IMV and mortality rates, we performed a multinational observational prospective cohort study in 16 countries (68 centers).

Results

A total of 1611 patients were enrolled (hematological malignancies 51.9%, solid tumors 35.2%, systemic diseases 17.3%, and solid organ transplantation 8.8%). The main ARF etiologies were bacterial (29.5%), viral (15.4%), and fungal infections (14.7%), or undetermined (13.2%). On admission, 915 (56.8%) patients were not intubated. They received standard oxygen (N = 496, 53.9%), high-flow oxygen (HFNC, N = 187, 20.3%), noninvasive ventilation (NIV, N = 153, 17.2%), and NIV + HFNC (N = 79, 8.6%). Factors associated with IMV included age (hazard ratio = 0.92/year, 95% CI 0.86–0.99), day-1 SOFA (1.09/point, 1.06–1.13), day-1 PaO₂/FiO₂ (1.47, 1.05–2.07), ARF etiology (Pneumocystis jirovecii pneumonia (2.11, 1.42–3.14), invasive pulmonary aspergillosis (1.85, 1.21–2.85), and undetermined cause (1.46, 1.09–1.98). After propensity score matching, HFNC, but not NIV, had an effect on IMV rate (HR = 0.77, 95% CI 0.59–1.00, p = 0.05). ICU, hospital, and day-90 mortality rates were 32.4, 44.1, and 56.4%, respectively. Factors independently associated with hospital mortality included age (odds ratio = 1.18/year, 1.09–1.27), direct admission to the ICU (0.69, 0.54–0.87), day-1 SOFA excluding respiratory score (1.12/point, 1.08–1.16), PaO₂/FiO₂ < 100 (1.60, 1.03–2.48), and undetermined ARF etiology (1.43, 1.04–1.97). Initial oxygenation strategy did not affect mortality; however, IMV was associated with mortality, the odds ratio depending on IMV conditions: NIV + HFNC failure (2.31, 1.09–4.91), first-line IMV (2.55, 1.94–3.29), NIV failure (3.65, 2.05–6.53), standard oxygen failure (4.16, 2.91–5.93), and HFNC failure (5.54, 3.27–9.38).

Conclusion

HFNC has an effect on intubation but not on mortality rates. Failure to identify ARF etiology is associated with higher rates of both intubation and mortality. This suggests that in addition to selecting the appropriate oxygenation device, clinicians should strive to identify the etiology of ARF.

     

Critical care in the emergency department: acute respiratory failure

Acute respiratory failure (ARF) is a frequent emergency department (ED) presentation. The definition and common causes of ARF are discussed in this article and ED management of the condition is discussed, using an illustrative case report. The paper considers the role of B-type natriuretic peptide in diagnosis and non-invasive ventilation (NIV) in treatment. Intensive care unit admission denial is common in ARF, although the evidence base is lacking. Finally, the decision-making process is described when a patient with ARF fails to improve with NIV.     

The SOFA score could predict the severity and prognosis of infective endocarditis

IntroductionAlthough infectious endocarditis (IE) is a potentially severe infectious disease, there are no prognostic tools for in-hospital mortality for IE patients. This is the first report documenting that the Sequential Organ Failure Assessment (SOFA) score could evaluate the severity and outcome among IE patients.Patients and methodsFrom 2007 to 2018, we reviewed all patients who were diagnosed as having IE at our institue. Patients diagnosed as definite IE according to the modified Duke criteria or by surgical procedure were included in this study.ResultsA total of 66 IE patients were enrolled in this study. They were 45 males (68%) and the median age was 70 years. As for prognostic factors for in-hospital death among IE patients, SOFA score ≥6, CCI ≥3, surgical procedure, heart failure, immunological phenomena and detection of S. aureus as a causative pathogen were identified as prognostic factors by univariate analysis. Of these 6 factors, SOFA score ≥6 (OR 7.6, 95%CI 1.3–46.6, p = 0.029), heart failure (OR 9.7, 95%CI 1.1–86.1, p = 0.042), surgery (OR 0.1, 95%CI 0–0.8, p = 0.037) and immunological phenomena (OR 0.1, 95%CI 0–0.9, p = 0.042) were independent prognostic factors for in-hospital mortality among IE by logistic regression analysis.ConclusionThe SOFA score could be a good prognostic tool to use for IE patients. Also, SOFA score ≥6, surgery, immunological phenomena and heart failure were independent prognostic factors for in-hospital mortality among IE patients.     

Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study

PurposeEarly recognition and treatment in severe sepsis improve outcomes. However, out-of-hospital patient characteristics and emergency medical services (EMS) care in severe sepsis is understudied. Our goals were to describe out-of-hospital characteristics and EMS care in patients with severe sepsis and to evaluate associations between out-of-hospital characteristics and severity of organ dysfunction in the emergency department (ED).Materials and MethodsWe performed a secondary data analysis of existing data from patients with severe sepsis transported by EMS to an academic medical center. We constructed multivariable linear regression models to determine if out-of-hospital factors are associated with serum lactate and sequential organ failure assessment (SOFA) in the ED.ResultsTwo hundred sixteen patients with severe sepsis arrived by EMS. Median serum lactate in the ED was 3.0 mmol/L (interquartile range, 2.0-5.0) and median SOFA score was 4 (interquartile range, 2-6). Sixty-three percent (135) of patients were transported by advanced life support providers and 30% (62) received intravenous fluid. Lower out-of-hospital Glasgow Coma Scale score was independently associated with elevated serum lactate (P < .01). Out-of-hospital hypotension, greater respiratory rate, and lower Glasgow Coma Scale score were associated with greater SOFA (P < .01).ConclusionsOut-of-hospital fluid resuscitation occurred in less than one third of patients with severe sepsis, and routinely measured out-of-hospital variables were associated with greater serum lactate and SOFA in the ED.     

Noninvasive ventilation in the event of acute respiratory failure in patients with idiopathic pulmonary fibrosis

Background

Some patients with idiopathic pulmonary fibrosis (IPF) develop severe acute respiratory failure (ARF) requiring admission to an intensive care unit (ICU) and ventilatory support. A limited number of observational studies have reported that noninvasive ventilation (NIV) can be an effective treatment to support breathing and to prevent use of invasive mechanical ventilation in these patients. This study aimed to retrospectively investigate the clinical status and outcomes in IPF patients receiving NIV for ARF and to identify those clinical and laboratory characteristics, which could be considered risk factors for its failure.

Methods

This is a retrospective analysis of short-term outcomes in 18 IPF patients being administered NIV for ARF. This study was conducted in a 4-bed respiratory ICU (RICU) in a university hospital. Eighteen IPF patients who were administered NIV between January 1, 2005, and April 30, 2013, were included. The outcome measures are the need for endotracheal intubation despite NIV treatment and mortality rate during their RICU stay. The length of the patients' stay in the RICU and their survival rate following RICU admission were also evaluated.

Results

Noninvasive ventilation was successful in 8 patients and unsuccessful in 10 who required endotracheal intubation. All the patients in the NIV failure group died within 20.2 ± 15.3 days of intubation. The patients in the NIV success group spent fewer days in the RICU (11.6 ± 4.5 vs 24.6 ± 13.7; P = .0146). The median survival time was significantly shorter for the patients in the NIV failure with respect to the success group (18.0 [95% confidence interval {CI}, 9.0-25.0] vs 90.0 [95% CI, 65.0-305.0] days; P < .0001); the survival rate at 90 days was, likewise, lower in the NIV failure group (0% vs 34% ± 19.5%). At admission, the patients in the failure group had significantly higher respiratory rate values (36.9 ± 7.8 vs 30.5 ± 3.3 breaths/min; P = .036), plasma N-terminal fragment of the prohormone of B-type natriuretic peptide (NT-proBNP) levels (4528.8 ± 4012.8 vs 634.6 ± 808.0 pg/mL; P = .023) and serum C-reactive protein values (72.0 ± 50.0 vs 20.7 ± 24.0 μg/mL; P = .0289) with respect to those in the success group. Noninvasive ventilation failure was correlated to the plasma NT-proBNP levels at RICU admission (P = .0326) with an odds ratio of 12.2 (95% CI, 1.2 to infinity) in the patients with abnormally high values (>900 pg/mL).

Conclusions

The outcome of IPF patients who were administered NIV was quite poor. The use of NIV was, nevertheless, found to be associated with clinical benefits in selected IPF patients, preventing the need for intubation and reducing the rate of complications/death. Elevated plasma NT-proBNP levels at the time of ICU admission is a simple clinical marker for poor NIV outcome.     

Noninvasive Ventilation in the Management of Respiratory Failure Due to COVID-19 Infection: Experience From a Resource-Limited Setting

ObjectiveTo study the role of noninvasive ventilation (NIV) in Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2) related acute respiratory failure (C-ARF).Patients and MethodsPatients with C-ARF managed on NIV were categorized as NIV success or failure (death or intubation). Factors associated with failure were explored using regression analysis and expressed as odds ratio (OR) with 95% CI.ResultsBetween April 1, 2020, and September 15, 2020, a total of 286 patients with a mean ± SD age of 53.1±11.6 years and Acute Physiology and Chronic Health Evaluation II score of 11.1±5.5 were initiated on NIV. Of the 182 patients (63.6%) successfully managed on NIV alone, 118 had moderate or severe acute respiratory distress syndrome. When compared with NIV success, NIV failure was associated with lower admission PaO₂ to fraction of inspired oxygen ratio (P<.001) and higher respiratory rate (P<.001). On penalized logistic regression analysis, NIV failure was associated with higher Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.01 to 1.24), severe acute respiratory distress syndrome (OR, 3.99; 95% CI, 1.24 to 12.9), D-dimer level of 1000 ng/mL DDU (to convert to mg/L, divide by 1000) or greater (OR, 2.60; 95% CI, 1.16 to 5.87), need for inotropes or dialysis (OR, 12.7; 95% CI, 4.3 to 37.7), and nosocomial infections (OR, 13.6; 95% CI, 4.06 to 45.9). Overall mortality was 30.1% (86/286). In patients requiring intubation, time to intubation was longer in nonsurvivors than survivors (median, 5; interquartile range, 3-8 vs 3; interquartile range, 2-3 days; P<.001).ConclusionNoninvasive ventilation can be used successfully in C-ARF. Illness severity and need for non–respiratory organ support predict NIV failure.     

Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions: effectiveness and predictors of failure

Objective This study compared the effectiveness of noninvasive ventilation (NIV) and the risk factors for NIV failure in hypercapnic acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) vs. non-COPD conditions.Design and setting Prospective cohort study in the medical intensive care unit of a university hospital.Patients and participants 111 patients with hypercapnic ARF, 43 of whom had COPD exacerbations and 68 other conditions. Baseline characteristics of the two groups were similar.Measurements and results The risk of NIV failure, defined as the need for endotracheal intubation, was significantly lower in COPD than in other conditions (19% vs. 47%). High APACHE II score was an independent predictor of NIV failure in COPD (OR 5.38 per 5 points). The presence of pneumonia (OR 5.63), high APACHE II score (OR 2.59 per 5 points), rapid heart rate (OR 1.22 per 5 beats/min), and high PaCO₂ 1 h after NIV (OR 1.22 per 5 mmHg) were independent predictors of NIV failure in the non-COPD group. Failure of NIV independently predicted mortality (OR 10.53).Conclusions Noninvasive ventilation was more effective in preventing endotracheal intubation in hypercapnic ARF due to COPD than non-COPD conditions. High APACHE II score predicted NIV failure in both groups. Noninvasive ventilation was least effective in patients with hypercapnic ARF due to pneumonia.This revised version was published online in March 2005. In the abstract all occurrences of 95% CI were deleted, and in the main text some orthographical corrections were made.     

Predicting non-invasive ventilation failure in children from the SpO2/FiO2 (SF) ratio

Purpose

Our objective was to assess whether SpO₂/FiO₂ (SF) ratio could be a useful NIV outcome predictor in children with acute respiratory failure (ARF) and tried to develop a predictive model of NIV failure.

Methods

Prospective, observational, multicenter study. Episodes of ARF-fulfilling inclusion criteria from 15 January 2010 to 14 January 2011 were treated with NIV according to a pre-established protocol. Clinical variables were collected at baseline and at 1, 2, 6, 12 and 24 h. Failure criterion was the need for endotracheal intubation. Failures were considered as “early” if occurring ≤6 h after NIV initiation, “intermediate” if occurring between 6 and 24 h, and “late” if occurring after 24 h. Variables with a p < 0.1 in univariate analysis corrected by age were included in multivariate analysis. Models were calculated based on multivariate analysis.

Results

During the study period, 390 episodes were included. NIV success rate was 81.3 %. Among ARF causes, failure occurred most frequently in ARDS episodes. The failure predictive model for the whole sample included SF ratio at 1 h, age and PRISM III-24 (area under the curve AUC of 0.755). For early NIV failures, SF ratio at 1 h was the only variable within model (AUC 0.748). The analysis of intermediate NIV failures identified 3 variables independently linked to NIV outcome: PRISM III-24, RR decrease at 6 h, and SF ratio at 6 h (AUC 0.895). No model was identified for late NIV failure.

Conclusions

SF ratio is a reliable predictor of early NIV failure in children.     

Acute respiratory failure in kidney transplant recipients: a multicenter study

Introduction

Data on pulmonary complications in renal transplant recipients are scarce. The aim of this study was to evaluate acute respiratory failure (ARF) in renal transplant recipients.

Methods

We conducted a retrospective observational study in nine transplant centers of consecutive kidney transplant recipients admitted to the intensive care unit (ICU) for ARF from 2000 to 2008.

Results

Of 6,819 kidney transplant recipients, 452 (6.6%) required ICU admission, including 200 admitted for ARF. Fifteen (7.5%) of these patients had combined kidney-pancreas transplantations. The most common causes of ARF were bacterial pneumonia (35.5%), cardiogenic pulmonary edema (24.5%) and extrapulmonary acute respiratory distress syndrome (ARDS) (15.5%). Pneumocystis pneumonia occurred in 11.5% of patients. Mechanical ventilation was used in 93 patients (46.5%), vasopressors were used in 82 patients (41%) and dialysis was administered in 104 patients (52%). Both the in-hospital and 90-day mortality rates were 22.5%. Among the 155 day 90 survivors, 115 patients (74.2%) were dialysis-free, including 75 patients (65.2%) who recovered prior renal function. Factors independently associated with in-hospital mortality were shock at admission (odds ratio (OR) 8.70, 95% confidence interval (95% CI) 3.25 to 23.29), opportunistic fungal infection (OR 7.08, 95% CI 2.32 to 21.60) and bacterial infection (OR 2.53, 95% CI 1.07 to 5.96). Five factors were independently associated with day 90 dialysis-free survival: renal Sequential Organ Failure Assessment (SOFA) score on day 1 (OR 0.68/SOFA point, 95% CI 0.52 to 0.88), bacterial infection (OR 0.43, 95% CI 0.21 to 0.90), three or four quadrants involved on chest X-ray (OR 0.44, 95% CI 0.21 to 0.91), time from hospital to ICU admission (OR 0.98/day, 95% CI 0.95 to 0.99) and oxygen flow at admission (OR 0.93/liter, 95% CI 0.86 to 0.99).

Conclusions

In kidney transplant recipients, ARF is associated with high mortality and graft loss rates. Increased Pneumocystis and bacterial prophylaxis might improve these outcomes. Early ICU admission might prevent graft loss.