Mechanical VentilationThe role of noninvasive positive pressure ventilation in community-acquired pneumonia☆,☆☆,★
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.
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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.
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Cited by (49)
Noninvasive ventilation improves the outcome in patients with pneumonia-associated respiratory failure: Systematic review and meta-analysis
2022, Journal of Infection and Public HealthCitation Excerpt :In earlier studies, the benefit of NIV in pneumonia has not been clearly defined, but there is an increasing trend of using NIV in pneumonia in the United States [31]. Previous randomized and observational studies demonstrated that NIV treatment decreased the need for endotracheal intubation and the length of ICU stay in pneumonia [21, 23, 32–34], but the effectiveness of NIV on mortality has remained controversial, as NIV was shown to decrease death rate in some studies [23,34], but it had no or even adverse effect on the mortality in other studies [21, 22, 24, 32, 33]. Unfortunately, some of these studies did not have randomized design [32–34], thus could not be included in the present analysis.
Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review
2021, Clinical Microbiology and InfectionCitation Excerpt :Our study found that almost half the patients admitted to the ICU needed invasive MV (58%), and a lower percentage (25.5%) required non-invasive ventilation. Studies in CAP described a much higher proportion of patients (up to 56%) using NIV in acute respiratory failure [45,46]. Indeed, the role of NIV in COVID-19 remains unclear.
The Burden of Community-Acquired Pneumonia Requiring Admission to ICU in the United States
2020, ChestCitation Excerpt :The value of noninvasive ventilation for CAP is debatable. Observational cohort studies have reported a high rate of failure of noninvasive ventilation in patients with CAP.26,27 The failure of noninvasive ventilation in patients with CAP may represent a marker of the severity of their illness.
Hospital admissions for community-acquired, ventilator-associated and nonventilator hospital-acquired pneumonia in COPD patients in Spain (2016-2017).
2020, European Journal of Internal MedicineCitation Excerpt :Our investigation showed that mechanical ventilation was associated with higher IHM in COPD patients with CAP and NV-HAP. A recent study reported that noninvasive pressure ventilation is frequently used in CAP but is associated with high failure rates, indicating that patients who failed to undergo noninvasive mechanical ventilation had an increased odds of death compared with that of patients who were treated with invasive ventilation [43]. End-stage renal disease patients receiving dialysis are frequently elderly and usually have multiple comorbidities, and their clinical management is complex.
Non-invasive positive pressure ventilation in pneumonia outside Intensive Care Unit: An Italian multicenter observational study
2019, European Journal of Internal MedicineCitation Excerpt :Our population had a mean APACHE II of 18, compared to patients observed by Carrillo et al. where SAPS II was 42 [13] or Murad et al. where APACHE II was 23 [18]. Similarly, the impact of gas exchange reported in our paper showing a mean PaO2/FiO2 ratio of 176 was higher compared to previous studies by Carrillo and Murad who had a mean PaO2/FiO2 ratio in their population of 127 and 108, respectively [13,18]. We might speculate that NIV treatment in our population was started in an earlier stage of ARF, with patients enrolled before their admission to ICU.
Noninvasive ventilation failure in pneumonia patients ≥ 65 years old: The role of cough strength
2018, Journal of Critical Care
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Source of funding: This research was supported by the Department of Medicine of Mc-Gill University.
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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].
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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.