Elsevier

Journal of Critical Care

Volume 43, February 2018, Pages 190-196
Journal of Critical Care

Pulmonary
The comparative effectiveness of noninvasive and invasive ventilation in patients with pneumonia

https://doi.org/10.1016/j.jcrc.2017.05.023Get rights and content

Highlights

  • One in four patients hospitalized with pneumonia and ventilated received NIV

  • Patients treated with NIV were older and had lower severity of illness score

  • NIV was associated with lower risk of death only in pneumonia patients with COPD or heart failure.

  • NIV failure was more common among patients without COPD and/or heart failure comorbidity

Abstract

Purpose

To compare the outcomes of patients hospitalized with pneumonia treated with noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV).

Materials and methods

Using the HealthFacts multihospital electronic medical record database, we included patients hospitalized with a diagnosis of pneumonia and treated with NIV or IMV. We developed a propensity model for receipt of initial NIV and assessed the outcomes in a propensity-matched cohort, and in a covariate adjusted and propensity score weighted models.

Results

Among 3971 ventilated patients, 1109 (27.9%) were initially treated with NIV. Patients treated with NIV were older, had lower acuity of illness score, and were more likely to have congestive heart failure and chronic pulmonary disease. Mortality was 15.8%, 29.8% and 25.9.0% among patients treated with initial NIV, initial IMV and among those with NIV failure. In the propensity matched analysis, the risk of death was lower in patients treated with NIV (relative risk: 0.71, 95% CI: 0.59–0.85). Subgroup analysis showed that NIV was beneficial among patients with cardiopulmonary comorbidities (relative risk 0.59, 95% CI: 0.47–0.75) but not in those without (relative risk 0.96, 95% CI: 0.74–0.1.25)NIV failure was significantly (p = 0.002) more common in patients without cardiopulmonary conditions (21.3%) compared to those with these conditions (13.8%).

Conclusions

Initial NIV was associated with better survival among the subgroup of patients hospitalized with pneumonia who had COPD or heart failure. Patients who failed NIV had high in-hospital mortality, emphasizing the importance of careful patient selection monitoring when managing severe pneumonia with NIV.

Section snippets

Background

Each year in the United States, nearly one million patients with acute respiratory failure (ARF) are treated with invasive mechanical ventilation (IMV) [1]. Up to 40% of mechanically ventilated patients die in the hospital [2], [3], and some of these deaths are directly attributable to complications of the ventilator [4]. In selected groups of patients with ARF, noninvasive mechanical ventilation (NIV) reduces the need for endotracheal intubation leading to better outcomes. While most of the

Design and setting

We conducted a retrospective cohort study of patients hospitalized between January 1, 2009 and December 31, 2012 using Cerner HealthFacts (Cerner Corporation, Kansas City). Data in HealthFacts is extracted directly from the EMR from hospitals in which Cerner has a data use agreement. Encounters may include pharmacy, clinical and microbiology laboratory, admission and billing information. All admissions, medication orders and dispensing, laboratory orders and specimens are date and time stamped,

Results

A total of 3971 patients from 81 hospitals were included in the analysis. 1109 (27.9%) patients were initially managed with NIV and 2862 (72.1%) received IMV. (Fig. 1) Patients' mean (SD) age was 61.7 (13.6) years, 51.7% were male, 72.5% were white and mean (SD) comorbidity score was 3.6 (2.6). Mean (SD) LAPS was 70.7 (28.7), 39.2% were admitted to the ICU and 45.2% had community acquired pneumonia. In-hospital mortality was 25.9%, mean (SD) length of stay was 10.4 days (8.5) and 30-day

Discussion

In this retrospective study of nearly 4000 patients hospitalized with pneumonia who required ventilation, we found that more than one fourth of the patients received NIV as the initial ventilation method. Patients treated with NIV tended to have lower severity of illness at admission as evidenced by lower LAPS scores and were more likely to have comorbid COPD, and heart failure. In the propensity-matched cohort, NIV therapy was associated with a 29% relative reduction of in-hospital mortality

Author contributions

Drs. Stefan, Lindenauer, Pekow, Steingrub, Lagu and Hill conceived and designed the study. Dr. Stefan acquired the data used in the analysis. Drs. Stefan, Priya, Nathanson, Lindenauer, Lagu, Steingrub, and Hill were involved in the analysis and interpretation of the data. Dr. Stefan drafted the manuscript and Drs. Lindenauer, Priya, Pekow, Lagu, Steingrub, Nathanson, Pekow and Hill reviewed and contributed to revisions prior to submission.

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  • Cited by (0)

    This work was supported by grant 1K01HL114631-011 from the National Heart, Lung and Blood Institute of the National Institutes of Health. Dr Lindenauer was supported by grant K24HL132008 from the National Heart Lung and Blood Institute. Dr. Lagu was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K01HL114745. The funders had no role in data collection, management, analysis; study design, conduct, or interpretation of study findings; or the preparation, review, or approval of the manuscript for submitted for publication.

    Dr. Hill has served as a consultant for Phillips Respironics, Actelion, Gilead, Pfizer, and Bayer and has received grants/research support from Fisher Paykel, Actelion, Gilead, and United Therapeutics; the article submitted is not related in any way to these relationships. The other authors have indicated no financial conflicts of interest.

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