Elsevier

Journal of Critical Care

Volume 30, Issue 1, February 2015, Pages 49-54
Journal of Critical Care

Mechanical Ventilation
The role of noninvasive positive pressure ventilation in community-acquired pneumonia,☆☆,

https://doi.org/10.1016/j.jcrc.2014.09.021Get rights and content

Abstract

Background

Despite the increasing use of noninvasive positive pressure ventilation (NIV) in the treatment of critically ill patients with respiratory failure, its role in the treatment of severe community-acquired pneumonia (CAP) is controversial. The aim of this study was to assess the use of NIV in patients with CAP requiring ventilation who are admitted an intensive care unit.

Methods

A retrospective cohort study of all consecutive patients admitted to 3 tertiary care, university-affiliated, intensive care units from January 2007 to January 2012 with the principal diagnosis of CAP and requiring positive pressure ventilation was carried out. The primary outcome was acute hospital mortality. Univariable and multivariable analysis were performed to assess the association between mode of ventilation and death as well as factors associated with failure of NIV.

Results

A total of 229 patients were admitted, with 20 patients excluded from the analysis because of do-not-resuscitate orders. Fifty-six percent of patients were initially treated with NIV. Of those, 76% failed NIV and required intubation and invasive ventilation. After adjusting for confounders, no difference in mortality was seen between patients who received NIV as first-line therapy in comparison with patients who received invasive ventilation (odds ratio [OR], 1.63; 95% confidence interval [CI], 0.81-3.28; P = .17). Multivariable analysis demonstrated a trend toward increased NIV failure for the patients who had higher Acute Physiology and Chronic Health Evaluation II scores (P = .07) and vasopressor use at 2 hours after initiation of positive pressure ventilation (OR, 7.5; 95% CI, 1.8-31.3, P = .006). In an adjusted analysis, patients who failed NIV had an increased odds of death when compared with patients who were treated with invasive ventilation (OR, 2.2; 95% CI, 1.0-4.8; P = .03).

Conclusion

Noninvasive pressure ventilation is frequently used in CAP but is associated with high failure rates. Mortality was not improved in the group of patients who received NIV as first-line therapy despite clinical characteristics that might have suggested a more favorable prognosis. Given the high rates of NIV use, high failure rates, and the hypothesis generating nature of the data in this study, further randomized studies are needed to better delineate the role of NIV in CAP.

Introduction

The use of noninvasive positive pressure ventilation (NIV) in the treatment for critically ill patients with respiratory failure has dramatically increased over the past decade. However, its role in the treatment of severe community-acquired pneumonia (CAP) is controversial due to high rates of reported treatment failure [1]. Despite this, NIV is commonly used in emergency departments and intensive care units (ICU) for treatment of CAP [2], with the goal of preventing intubation and invasive mechanical ventilation.

The strongest evidence of benefit from NIV has been observed in patients with hypercapneic respiratory failure from acute exacerbation of chronic obstructive lung disease [3], cardiogenic pulmonary edema [4], and immuonocompromised patients with lung infiltrates [5]. Hospitalized patients with severe CAP frequently have high rates of these comorbidities [6], [7]. This confounds much of the published data on the use of NIV in CAP which is based on a few randomized and observational studies of small sample size [1], [5], [8], [9], [10], [11], [12], [13]. Given the limited data, recently published clinical practice guidelines on evidence-based application of NIV made no recommendations on the use of NIV in severe CAP [14].

The role of NIV in pneumonia is therefore still unclear and warrants further evaluation. The objective of this study was to assess in a retrospective cohort study the application of NIV in patients with CAP in a critical care setting and identify clinical and laboratory parameters that would predict NIV failure.

Section snippets

Setting and study population

A retrospective cohort study of all consecutive patients admitted to 3 tertiary care, university-affiliated, ICUs during the period January 2007 to January 2012 with the principal diagnosis of CAP and placed on positive pressure ventilation was carried out. Data were abstracted by a trained data collector using a standardized data collection tool. The study was approved by the McGill University Health Centre Research Ethics Board.

The patients were identified via each center's ICU database.

Results

A total of 229 patients were admitted to the 3 participating ICUs for CAP requiring ventilation. Twenty patients had do-not-resuscitate orders and were excluded from the analysis. Of the 20 patients, 19 were treated with NIV initially. Of the 209 patients included in the analysis, 117 patients (56%) were initially treated with NIV, whereas 92 patients (44%) were initially intubated and treated with IV on presentation to either the emergency department or critical care unit (Fig. 1).

When

Discussion

The aim of the current study was to assess the use of NIV in patients with CAP admitted to the ICU. The study demonstrated that most patients admitted to the ICU with CAP and respiratory failure received NIV as first-line therapy, with three quarters eventually failing and requiring IV. Patients who received NIV as first-line therapy tended to have lower severity of illness but with more frequent respiratory disorders. Acute hospital mortality was not improved in patients who received NIV as

Acknowledgments

The authors would like to thank Dr R. Menzies for his input on the study analysis.

References (19)

There are more references available in the full text version of this article.

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Source of funding: This research was supported by the Department of Medicine of Mc-Gill University.

☆☆

Conflict of interest: All authors declare no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted in the previous 3 years, and no other relationship or activities that could appear to have influenced the submitted work.

Data sharing: technical appendix and statistical code are available from corresponding author at [email protected].

Authors' contribution: J.S., A.M., and S.D. contributed to the study design, analysis, and drafting of the manuscript. P.Z.L. contributed to the study analysis. All authors approved the final manuscript. J.S. is the paper guarantor.

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