Level of consciousness as a predictor of complications following tricyclic overdose

In order to determine whether patients at low risk for complications following tricyclic antidepressant (TCA) overdose can be identified, we analyzed the records of all admissions for TCA overdose from 1975 to 1985. Of the 92 patients reviewed, 37 had serious complications including hypoventilation, loss of protective airway reflexes, seizures, hypotension, hemodynamically significant arrhythmias, or death. Patients with complications had increased heart rate, depressed level of consciousness, depressed Glasgow Coma Scale, and prolonged QRS interval, as compared to patients without complications. All 37 patients with serious complications required intubation in the emergency department. A Glasgow Coma Scale of less than 8 was the most sensitive predictor of serious complications (sensitivity = .86; specificity = .89). This was significantly better than the QRS interval (QRS greater than or equal to 100 msec; sensitivity = 59; specificity = .76). We conclude that level of consciousness is a better predictor of risk of complications and need for ICU admission than the QRS interval. Patients who are responsive to verbal stimuli on leaving the ED are at very low risk of developing complications.     

Factor VII levels as a guide to prognosis in fulminant hepatic failure.

Levels of clotting factors II, V, and VII were measured on admission and then daily in 12 patients with grade IV hepatic coma due to fulminant hepatic failure. Factor VII levels obtained within 36 hours of the development of grade IV coma were not of value in predicting which patients would subsequently recover consciousness. Four of the latter group had levels below 9% at this time while the levels in three of the seven fatal cases were higher. Serial determinations were of more value and levels rose rapidly in those patients who ultimately made a complete recovery.     

Mechanism and significance of widened QRS complexes during complete atrioventricular block in acute inferior myocardial infarction

Twelve of 35 consecutive patients admitted with complete, atrioventricular (A-V) block complicating acute inferior myocardial infarction manifested widened QRS complexes. The escape beats had the pattern of left bundle branch block in four patients, right bundle branch block in five patients and both left and right bundle branch block in three patients.

His bundle recordings in five patients with escape beats that had a left bundle branch block configuration revealed a His bundle potential preceding the widened QRS complex at His-V intervals of 45 to 60 msec. Bradycardia-dependent left bundle branch block was demonstrated in two patients by His bundle pacing. In three patients the conducted beats had a left bundle branch block configuration after critical lengthening of the R-R interval during second degree A-V block before or after the episode of complete A-V block. In six patients whose escape beats had a right bundle branch block configuration, His bundle recordings did not reveal a His bundle potential preceding these beats.

Our observations suggest that widened QRS complexes with a left bundle branch block configuration could be due to an A-V junctional escape rhythm with phase 4 left bundle branch block. Alternatively in association with a right bundle branch block configuration it is possible that the widened QRS complexes represent a ventricular or fascicular escape rhythm.

Two of 12 patients with widened QRS complexes died. There were no significant differences in immediate mortality, 6 month mortality or mean peak serum glutamic oxaloacetic transaminase (SGOT) values between patients with narrow and widened QRS complexes. This finding suggests that widened QRS complexes during complete A-V block in acute inferior myocardial infarction have no prognostic significance.     

Reversal of severe tricyclic antidepressant-induced cardiotoxicity with intravenous hypertonic saline solution

A 29-year-old woman ingested 8 g of nortriptyline and presented to the emergency department with coma, hypotension, and widened QRS interval. After intubation, gastric lavage, hyperventilation, and therapy with intravenous normal saline solution, sodium bicarbonate boluses (rapid intravenous push), and high doses of norepinephrine and dopamine, she transiently improved, only to deteriorate on arrival to the ICU. Because her arterial pH was alkalemic at 7.5 at this point, she was given additional sodium in the form of 200 mL of 7.5% NaCl by means of rapid intravenous infusion (intravenous push) to treat hypotension and widening QRS interval with ventricular ectopy. A continuous 12-lead ECG documented narrowing of her QRS interval with concomitant improvement of hypotension within 3 minutes of hypertonic saline solution infusion. Hypertonic saline solution should be considered for wide complex QRS and hypotension caused by tricyclic antidepressant-induced cardiotoxicity that is unresponsive to standard therapies.     

Relation of terminal QRS distortion to left ventricular functional recovery and remodeling in acute myocardial infarction treated with primary angioplasty

The association between admission electrocardiogram and 6-month change in left ventricular function and volume was assessed in 200 patients who had acute myocardial infarction that was treated with primary percutaneous coronary intervention. Logistic regression analysis indicated peak creatine phosphokinase-MB, number of Q-wave leads, QRS interval distortion, wall motion score index, and angiographic Thrombolysis In Myocardial Infarction flow grade as predictors of no functional recovery and QRS interval distortion and Thrombolysis In Myocardial Infarction flow grade as predictors of left ventricular remodeling.     

Late death in tricyclic antidepressant overdose revisited

We report a late death following the ingestion of amitriptyline. A 46-year-old woman presented to the emergency department with coma, hypotension, tachycardia, and a prolonged QRS interval after the ingestion of a large quantity of Elavil. She was managed with aggressive supportive care, multiple doses of oral charcoal, and charcoal hemoperfusion. The patient's ECG and hemodynamic status returned to normal within 24 hours. Despite an apparent total recovery, she suddenly sustained a cardiorespiratory arrest and died 33 hours after ECG normalization (at 57 hours after admission). This case brings into question the feasibility of ceasing ECG monitoring in tricyclic antidepressant overdoses once the ECG has stabilized, especially in patients with a history of chronic usage. A possible explanation for late sequelae is the myocardial cell binding and depressant effect of preexisting therapeutic TCA medication.     

Indications for cardiac resynchronization therapy: 2011 update from the Heart Failure Society of America Guideline Committee

Cardiac resynchronization therapy (CRT) improves survival, symptoms, quality of life, exercise capacity, and cardiac structure and function in patients with New York Heart Association (NYHA) functional class II or ambulatory class IV heart failure (HF) with wide QRS complex. The totality of evidence supports the use of CRT in patients with less severe HF symptoms. CRT is recommended for patients in sinus rhythm with a widened QRS interval (≥150 ms) not due to right bundle branch block (RBBB) who have severe left ventricular (LV) systolic dysfunction and persistent NYHA functional class II-III symptoms despite optimal medical therapy (strength of evidence A). CRT may be considered for several other patient groups for whom evidence of benefit is clinically significant but less substantial, including patients with a QRS interval of ≥120 to <150 ms and severe LV systolic dysfunction who have persistent mild to severe HF despite optimal medical therapy (strength of evidence B), some patients with atrial fibrillation, and some with ambulatory class IV HF. Several evidence gaps remain that need to be addressed, including the ideal threshold for QRS duration, QRS morphology, lead placement, degree of myocardial scarring, and the modality for evaluating dyssynchrony. Recommendations will evolve over time as additional data emerge from completed and ongoing clinical trials.     

The outcome of children requiring admission to an intensive care unit following bone marrow transplantation

We report the results of a retrospective study of the role of intensive care unit (ICU) admission in the management of 367 children who underwent bone marrow transplantation (BMT) at a tertiary referral institution. 39 patients (11%) required 44 ICU admissions for a median of 6 d. 70% received marrow from unrelated donors, half of which were mismatched; 80% had leukaemia and two-thirds were considered high-risk transplants. Respiratory failure was the major reason for admission to ICU. 75% of admissions required mechanical ventilation (for a median of 5 d) and 20 patients had lung injury as defined by the criteria of the Seattle group. None of 11 patients with proven viral pneumonitis survived ( P  = 0.06) and only one of 20 patients with lung injury survived ( P  < 0.01). Six of seven patients with a primary neurological problem survived ( P  < 0.001); these appear to represent a good outcome group. Age, the presence of graft-versus-host disease, the use of inotropes, isolated renal or hepatic impairment, and paediatric risk of mortality (PRISM) score were not predictive of outcome. In total, 12 patients (27% of admissions) survived and were discharged from hospital 30 d or more after admission and eight (18%) survived >6 months. ICU admission can be beneficial to selected children post-BMT but it may be less useful in proven viral pneumonitis. Where mechanical ventilation is required, the duration of this support should be limited unless there is rapid improvement.     

Coagulation factor V and VIII/V ratio as predictors of outcome in paracetamol induced fulminant hepatic failure: relation to other prognostic indicators.

The value of coagulation factor V and VIII/V levels as prognostic indicators was assessed in 27 patients with fulminant hepatic failure and compared with other predictive indices. Admission factor V levels were significantly reduced in 22 patients with paracetamol induced hepatic failure compared with a healthy control group (median 9.5% v 103%, respectively; p less than 0.001) and with lower values in non-A non-B hepatitis (median 2.7%). Values in the seven patients who died after paracetamol overdose, considered together with the four who underwent liver transplantation (group median 5.1%), were significantly lower than in the 11 who survived (median 11.8%; p less than 0.01). Median admission factor VIII was higher in those who died or received a transplant than in those who survived (298% v 162%; p less than 0.05), with both results higher than in healthy volunteers (median 104%; p less than 0.01) but lower than in non-A non-B hepatitis (median 340%). The ratio of factor VIII/V on admission was less than 30 in all patients who survived paracetamol overdose (median 17) with corresponding values greater than 30 in 10 of 11 of those who died (median 39). A factor V result less than or equal to 10% on admission predicted an adverse outcome in 10 of 11 fatal cases, a 91% sensitivity which was greater than for the previously defined indicator of an arterial blood pH less than 7.30 on admission (sensitivity 82%). Prothrombin time at admission or on day 4 did not usefully predict outcome in our series. Predictive accuracy was 73% and 82% for factor V and admission acidosis respectively and 95% for factor V in conjunction with admission coma grade III or IV and factor VIII (ratio > 30). These criteria may be useful in selecting patients with paracetamol induced fulminant hepatic failure for transplantation.     

Electrocardiographic criteria for tricyclic antidepressant cardiotoxicity

To determine if electrocardiographic findings characterize tricyclic antidepressant (TCA) overdose and cardiotoxicity, 25 patients suspected of taking an overdose of TCA were studied. Toxicologic assays for a TCA were positive in 11 patients (+TCA, n = 11). Toxicologic study results for a TCA were negative in 14 patients (-TCA, control subjects). Patients with positive TCA results (+TCA) had a significantly greater heart rate (117 +/- 23 vs 100 +/- 22 beats/min, p less than 0.05), QRS duration (103 +/- 15 vs 87 +/- 10 ms, p less than 0.005) and corrected QT interval (449 +/- 38 vs 418 +/- 36 ms, p less than 0.05) than control patients (-TCA) on admission. Patients with positive TCA results also had a more rightward terminal 40-ms frontal plane QRS vector (195 +/- 51 degrees vs 54 +/- 64 degrees, p less than 0.001) than control patients. This observation has not been previously reported. A terminal QRS vector of 130 degrees to 270 degrees accurately discriminated between -TCA and +TCA patients (positive and negative predictive value = 1.00). Counterclockwise rotation (normalization) of the terminal frontal plane QRS vector was noted in +TCA patients during hospitalization. All +TCA patients had a sinus tachycardia, a corrected QT interval 418 ms or longer, and a terminal QRS vector between 130 degrees and 270 degrees. Using these values as selection criteria, a computer-aided search of 15,064 electrocardiograms (ECGs) recorded in our emergency department was performed. The likelihood of encountering such an electrocardiographic pattern in this population was 1.0%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Antiarrhythmic effects of cibenzoline

Thirty-three patients with ventricular tachyarrhythmias were referred for evaluation of their arrhythmias using programmed electrical stimulation to guide antiarrhythmic therapy. Cibenzoline succinate, a new antiarrhythmic agent, was compared to procainamide in patients with ventricular tachycardia. Cibenzoline was given intravenously, initially 1.0 mg/kg, then in 1 mg/kg increments to a maximum of 3.0 mg/kg, during electrophysiologic testing. The results were compared to procainamide, which was also administered intravenously to 1000 and then to 1500 mg. Cibenzoline provided protection against ventricular tachycardia induction in 16 of 33 patients. The PR interval increased 13%, QRS duration widened 26%, and QTc interval was prolonged by 7%. There was a 9% fall in mean arterial blood pressure. Procainamide prevented ventricular tachycardia induction in 21 out of 31 patients tested. The PR interval increased 11%, QRS duration widened 27%, and QTc interval prolonged by 8%. Cibenzoline was given orally to 13 patients for chronic treatment. Chronic oral cibenzoline therapy after a mean follow-up of 8.8 months caused a reduction of ventricular ectopy from 666 to 190 beats/hr. Ventricular tachycardia events decreased per Holter monitor recording from 6 to 0.6. Cibenzoline therapy was discontinued in 5 of 13 patients due to break-through arrhythmias (nonsustained ventricular tachycardia on Holter monitor and recurrence of symptoms). Cibenzoline may be an effective antiarrhythmic agent in selected patients.     

Class 1 antiarrhythmic drugs--characteristic electrocardiographic differences when assessed by atrial and ventricular pacing

Class 1 antiarrhythmic drugs have been subdivided into 1a, 1b and 1c according to their effect on the action potential duration. The effects on the surface electrocardiogram of one drug from each subgroup were investigated in nine patients. Electrocardiographic recordings were taken during sinus rhythm and at identical atrial and ventricular paced rates. Disopyramide (1a) significantly prolonged the QT interval during sinus rhythm and at the identical paced rates, by increasing both the QRS duration and JT interval. Lignocaine (1b) significantly reduced the QT interval during sinus rhythm and at the identical paced rates, by reducing the JT interval. Lignocaine had no effect on the QRS duration. Flecainide (1c) significantly prolonged the QRS duration during sinus rhythm, but not the QTc. However the QT interval at the paced rates prolonged significantly, due entirely to an increase of the QRS duration. Flecainide had no effect on the JT interval. These characteristic electrocardiographic differences support the differentiation of class 1 drugs into three separate subgroups.     

Heart failure: what proportion of patients satisfy the electrocardiographic criteria for cardiac resynchronization therapy?

BACKGROUND: Cardiac resynchronization therapy has emerged as a new therapeutic modality for patients with congestive cardiac failure and associated intraventricular conduction delay. The purpose of this study was to find out what proportion of Indian patients with congestive heart failure may be candidates for cardiac resynchronization therapy based on electrocardiographic characteristics. METHODS AND RESULTS: One hundred twenty-one consecutive patients with congestive cardiac failure due to various etiologies whose left ventricular ejection fraction was less than 40% were included in the study. Standard 12-lead electrocardiogram was recorded in all the patients, and various parameters (rhythm, conduction, QRS axis, chamber enlargement, chamber hypertrophy, and the presence of Q waves) were analyzed. The study population comprised 82 male (67.8%) and 39 female (32.2%) patients with a mean age of 53 +/- 13 years. Thirty-nine patients (32.2%) had NYHA class I-II symptoms, and 82 (67.8%) had NYHA class III-IV symptoms. The mean QRS duration was 111 +/- 27 ms. Bundle branch block was seen in 43 patients (35.5%), of whom 30 (24.8%) had left bundle branch block, and 13 (10.7%) had right bundle branch block. Of the 30 patients who had left bundle branch block, 19 (15.7%) had a QRS duration of between 120 and 149 ms, and 11 (9%) had a QRS duration > or = 150 ms. In the latter group, 7 patients (5.8%) were in NYHA classes III and IV. As the clinical severity of heart failure increased, the mean QRS duration also increased, but this increment was not statistically significant. CONCLUSIONS: Based on our data, it can be estimated that of the patients with heart failure who attend a tertiary care center, 2 5% of patients present with left bundle branch block. If we use the criteria for NYHA class III and IV congestive cardiac failure with QRS duration of > or = 150 ms in patients with left bundle branch block, 6% of patients are likely to need cardiac resynchronization therapy.     

Relation of admission QRS duration with development of angiographic no-reflow in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous interventions

Background

Although QRS-complex changes during ischemia have been described previously, their relation with no-reflow is not clear.

Purpose

To evaluate relation of admission QRS duration with angiographic no-reflow, we studied 162 patients who underwent primary angioplasty.

Methods

Twelve-lead electrocardiogram with a paper speed of 50 mm/s was recorded on admission and repeated after angioplasty. Patients were divided into reflow and no-reflow groups based on postangioplasty coronary thrombolysis in myocardial infarction flow grade.

Results

Patients in the no-reflow group (26 patients) were older (P = .001) and had significantly longer pain-to-balloon interval (P = .007). The patients in the no-reflow group had significantly longer QRS duration on admission electrocardiogram compared with patients in the reflow group (interquartile range, 80-93 [median, 84] milliseconds vs 60-80 [median, 76] milliseconds, respectively; P < .001). After adjusting all variables, QRS duration on admission was found to be independently related to angiographic no-reflow (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P = .003).

Conclusion

QRS duration on admission may be valuable in predicting no-reflow.     

Massive Metoprolol Poisoning Treated with Prenalterol

ABSTRACT. A case of massive metoprolol poisoning (50 g) is described. Clinical signs included coma, seizures, hypoventilation, immeasurable blood pressure, nodal bradycardia, and metabolic acidosis. Treatment comprised intubation, assisted ventilation, gastric lavage, atropin, bicarbonate, glucagon and repeated doses of prenalterol (a total of 160 mg over 15 hours). Prenalterol dosage was simple and could be guided by blood pressure response. Pacemaker treatment was not required. Ethanol concentration was 50 mmol/l (2.4 %c) on admission. Plasma metoprolol was 68 nmol/l (18000 ng/ml) 2 hours after admission. The patient was awake after 15 hours.     

Incidence of Brugada electrocardiographic pattern and outcomes of these patients after intentional tricyclic antidepressant ingestion

Brugada syndrome is a genetic dysfunction of the myocardial sodium channel that leads to ventricular dysrhythmias. The electrocardiographic (ECG) pattern of Brugada syndrome is occasionally seen after tricyclic antidepressant (TCA) ingestion; however, the outcome and complication risk for these patients is not clear. The objective of our study was to describe the incidence of Brugada ECG pattern (BEP) and serious complications of these patients in a large case series of intentional TCA ingestions. We also compared the proportion of complications of patients with BEP versus those without BEP. We evaluated 402 TCA ingestions, of which 9 (2.3%) were associated with the development of BEP. We compared the adverse outcomes of all TCA ingestions versus TCA ingestions with BEP. A increase in the adverse outcomes in the BEP group was found: seizures (relative risk [RR] 4; 95% confidence interval [CI] 1.5 to 10.8), widened QRS (RR 4.8; 95% CI 1.8 to 12.9), and hypotension (RR 3.9; 95% CI 2.1 to 7.4). To reduce confounding ingestants, we also compared all patients with an isolated TCA ingestion versus those with BEP. A significant increase in adverse outcomes was again found with the BEP group: seizures (RR 3; 95% CI 1.1 to 8.6), widened QRS (RR 4.8; 95% CI 1.5 to 15.1), and hypotension (RR 3.4; 95% CI 1.9 to 22.3). No deaths or dysrhythmias were found in the BEP group. In conclusion, BEP after TCA ingestion is rare, and death or dysrhythmias did not occur. However, patients with BEP are likely at increased risk for TCA-induced complications.     

Prognosis and Clinical Follow-Up of Patients Resuscitated from Out-of-Hospital Cardiac Arrest

ABSTRACT A new organization has been formed in which ambulance personnel have been trained to recognize ventricular tachycardia and ventricular fibrillation (VF) and to defibrillate. Cardiac arrest (CA) occurred in 307 patients and 140 were defibrillated. Twenty-eight patients were resuscitated and admitted for further hospital care. A previous history of ischaemic heart disease was found in 24 patients. Twenty-two of the patients admitted were found to have VF, two asystole and four other rhythms. All 11 survivors regained circulation at the site of the CA. At the time of admission all but one of the patients were unconscious and one longtime survivor remained unconscious until the 5th day following admission. Seventeen patients died while still in hospital. In 16 cases a diagnosis of acute myocardial infarction was established, a further six had VF without evidence of acute myocardial infarction and six had other diagnoses. Ten out of the 11 survivors were still alive six months after discharge. Only one case of recurrent VF was seen during a median follow-up period of 16 months. Prolonged coma, especially in combination with convulsions, was associated with a poor prognosis, while early return of circulation was significantly more common among survivors. Ongoing medication with β-blockers, a high QRS rate on admission and VF without proof of any acute myocardial infarction were also found to be more common in survivors.     

Estimating the cost of illness in colorectal cancer patients who were hospitalized for severe chemotherapy-induced diarrhea.

BACKGROUND: Previous studies have suggested that grade III/IV diarrhea is a common complication in colorectal cancer, occurring in 20% to 30% of patients receiving chemotherapy. In some of these patients, hospitalization for supportive care is often required. However, the impact that these hospitalized patients have on overall use of health care resources has not been quantified. In the present study, a cost of illness analysis was conducted to estimate the overall cost of patients with colorectal cancer who were hospitalized for supportive care secondary to severe diarrhea. METHODS: This was a retrospective cohort study consisting of patients with colorectal cancer that had received fluoropyrimidines, irinotecan or oxaliplatin (or a combination thereof) and had developed grade III or IV diarrhea that resulted in hospital admission for supportive care. Data collection included patient demographics, disease-related information and use of health care resources to manage the grade III/IV diarrhea event. RESULTS: Patients had a mean age of 64.2 years, and 32 of 63 (50.8%) were receiving adjuvant chemotherapy with a curative intent. The severe diarrhea developed after the first cycle of chemotherapy in 58% of the patients and contributed to a dose reduction, change or discontinuation of chemotherapy in 9.5%, 15.9% and 34.2% of patients, respectively. Overall, the median length of hospital stay was eight days (range one to 49 days) translating to a mean cost of $8,230 per patient (95% CI $6,519 to $9,942). The diarrhea successfully resolved in 54 of 63 patients (85.7%). CONCLUSIONS: Severe diarrhea requiring hospital admission is a costly and potentially fatal complication of chemotherapy in colorectal cancer. The identification of predictive factors and the implementation of prophylactic measures could reduce the morbidity and mortality associated with diarrhea.     

Predictive factors and long-term outcome of respiratory failure after Guillain-Barré syndrome

OBJECTIVE: To analyze predictive factors and long-term recovery in patients with Guillain-Barré syndrome (GBS) who are in need of mechanical ventilation. METHODS: In this 15-year retrospective study, 77 adult patients were identified with GBS. A comparison was made between the clinical data from patients who required mechanical ventilation and those who did not. Furthermore, the therapeutic outcomes of those 25 patients in need of mechanical ventilation during hospitalization at 1 year were determined using a modified Barthel index. A score below 12 was defined as a poor outcome, whereas a score of 12 or more was good. RESULTS: The study revealed 32% of patients (25/77) in need of respiratory support during hospitalization. At a follow-up of 1 year among the 25 ventilated patients, 7 patients (28%) had normal or minor signs and symptoms, 6 had unassisted gait, 3 had assisted gait, 6 were wheelchair- or bed-bound, and 3 died. The cause of death was septicemia with septic shock in all 3 cases. Factors that predict respiratory failure in the study GBS patients were disability grade on admission and areflexia. Those ventilated patients who had low maximal inspiratory pressure (PImax) (<14.5 cmH2O) and maximal expiratory pressure (PEmax) (<13.5 cmH2O) values at the time of intubation and the presence of complications after mechanical ventilation inevitably had worse outcomes than those who had not. CONCLUSION: If low values of PImax and PEmax at intubation were detected, aggressive respiratory management, which might include tracheostomy to allow more efficient bronchial clearing, and prevention of complications caused by prolonged course of mechanical ventilation are essential to maximize the potential for survival.     

Noninvasive versus conventional mechanical ventilation. An epidemiologic survey

A prospective survey was performed over a period of 3 wk among 42 intensive care units to assess the incidence of use and effectiveness of noninvasive mechanical ventilation (NIV) in clinical practice. All patients requiring ventilatory support for acute respiratory failure (ARF), either with endotracheal intubation (ETI) or NIV, were included. Ventilatory support was required in 689 patients, 581 with ETI and 108 (16%) with NIV (35% of patients not intubated on admission). Reasons for mechanical ventilation were coma (30%), cardiogenic pulmonary edema (7%), and hypoxemic (48%) and hypercapnic ARF (15%). NIV was never used for patients in coma (who were excluded from further analysis), but was used in 14% of patients with hypoxemic ARF, in 27% of those with pulmonary edema, and in 50% of those with hypercapnic ARF. NIV was followed by ETI in 40% of cases. The incidence of both nosocomial pneumonia (10% versus 19%, p = 0.03), and mortality (22% versus 41%, p < 0.001) was lower in NIV patients than in those with ETI. After adjusting for differences at baseline, Simplified Acute Physiology Score (SAPS) II (odds ratio [OR] = 1.05 per point; confidence interval [CI]: 1.04 to 1.06), McCabe/Jackson score (OR = 2.18; CI: 1.57 to 3.03), and hypoxemic ARF (OR = 2.30; CI: 1.33 to 4.01) were identified as risk factors explaining mortality; success of NIV was associated with a lower risk of pneumonia (OR = 0.06; CI: 0.01 to 0.45) and of death (OR = 0.16; CI: 0.05 to 0.54). In NIV patients, SAPS II and a poor clinical tolerance predicted secondary ETI. Failure of NIV was associated with a longer length of stay. In conclusion, NIV can be successful in selected patients, and is associated with a lower risk of pneumonia and death than is ETI.