Risk factors for noninvasive ventilation failure in patients with acute cardiogenic pulmonary edema: A prospective, observational cohort study

Evaluation of factors affecting the success of non invasive mechanical ventilation in acute cardiogenic pulmonary edema in the emergency department

OBJECTIVES

The aim of this study was to evaluate the factors associated with non-invasive mechanical ventilation (NIMV) failure in acute cardiogenic pulmonary edema (ACPE) diagnosed in the emergency department.

METHODS

This study was prospectively conducted at the Ege University Faculty of Medicine ED between February 19, 2021 and December 01, 2021. Patients who received NIMV with ACPE were included. Patients' clinical and laboratory parameters, treatments, NIMV mode, and settings were recorded. The primary endpoint was NIMV failure (intubation within 24 h). Secondary endpoints were early NIMV failure, early mortality (within 24 h), and in-hospital mortality. Early NIMV failure was defined as follows: if the patient had a respiratory rate of more than 25 per minute, oxygen saturation below 90%, PaCO2 >50 mmHg in blood gas, and pH <7.35, 1 h after starting NIMV.

RESULTS

Out of 347 patients in this study, 34 (10.7%) of them intubated within 24 h. Female sex percentage was 48.7%. Median age was 73 years. Risk factors for NIMV failure were respiratory rate >40.5, systolic blood pressure <122.5 mmHg, Glasgow Coma Score <14, pH <7.21, lactate level >5.2 mmol/L, base excess <-4.5 mmol/L, B-type natriuretic peptide level >3007 pg/mL (respectively area under the curve values; 0.723, 0.693, 0.739, 0.721, 0.690, 0.698, and 0.616).

CONCLUSION

Signs of hypoperfusion such as low systolic blood pressure (<122.5 mmHg) and high lactate (lactate level >5.2 mmol/L) are risk factors for NIMV failure. Evaluation of initial vital signs and arterial blood gas parameters is significantly important for prediction of NIMV success in ED.

Effectiveness and safety of non-invasive ventilation in the management of cardiogenic shock

INTRODUCTION AND OBJECTIVES

Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV).

METHODS

Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis.

RESULTS

Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09-2.63) and 1 year mortality (OR 1.61, 95% CI 1.04-2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage.

CONCLUSIONS

NIV seems to be relatively effective and safe in the treatment of early-stage CS.

Outcome of patients with acute heart failure secondary to acute myocardial infarction treated with noninvasive mechanical ventilation

INTRODUCTION AND OBJECTIVES

Noninvasive ventilation (NIV) has been shown to reduce the rate of endotracheal intubation and mortality in patients with acute heart failure (AHF). However, patients with AHF secondary to acute coronary syndrome/acute myocardial infarction (ACS-AMI) have been excluded from many clinical trials. The purpose of this study was to compare the effectiveness of NIV between patients with AHF triggered by ACS-AMI and by other etiologies.

METHODS

Prospective cohort study of all patients with AHF treated with NIV admitted to the intensive care unit for a period of 20 years. Patients were divided according to whether they had ACS-AMI as the cause of the AHF episode. NIV failure was defined as the need for endotracheal intubation or death.

RESULTS

A total of 1009 patients were analyzed, 403 (40%) showed ACS-AMI and 606 (60%) other etiologies. NIV failure occurred in 61 (15.1%) in the ACS-AMI group and in 64 (10.6%) in the other group (P=.031), without differences in in-hospital mortality (16.6% and 14.9%, respectively; P=.478).

CONCLUSIONS

The presence of ACS-AMI as the triggering cause of AHF did not influence patients with acute respiratory failure requiring noninvasive respiratory support.

Risk factors of non-invasive ventilation failure in hematopoietic stem-cell transplantation patients with acute respiratory distress syndrome

Background:

Non-invasive ventilation (NIV) was one of the first-line ventilation supports for hematopoietic stem-cell transplantation (HSCT) patients with acute respiratory distress syndrome (ARDS). Successful NIV may avoid need for intubation. However, the influence NIV failure had on patients’ outcome and its risk factors were hardly known.

Methods:

In this retrospective observational study, we reported risk factors and incidence of NIV failure in HSCT patients who were admitted to the Intensive Care Unit (ICU) with a diagnosis of ARDS and supported with mechanical ventilation, in a 5-year period. Patient outcomes, such as ventilator-free days, ICU-free days, and ICU mortality were also reported.

Results:

Of all the 94 patients included, 70 patients were initially supported with NIV. NIV failure occurred in 44 (63%) patients. Male sex, elevated serum galactomannan (GM) test, (1-3)-β-D-glucan (BG) assay, or elevated serum creatinine level were risk factors for NIV failure. When compared with the NIV success group, failure of NIV was associated with much fewer ICU-free days (22 versus 0, p < 0.001, Cohen’s d = 0.62) and higher ICU mortality (9.5% versus 75.5%, p < 0.001, Pearson’s r = 0.75). There was no difference in ICU-free days, ventilator-free days and ICU mortality between NIV failure and initial invasive mechanical ventilation (IMV) groups. Patients who failed in NIV support had a higher ICU mortality (75.5%) than those who succeeded (9.5%).

Conclusion:

In a small cohort of HSCT patients with mainly moderate severity of ARDS, male patients with elevated serum GM/BG test or serum creatinine level had a higher risk of NIV failure. Both NIV failure and initial IMV groups were characterized by high mortality rate and extremely low ICU-free days and ventilator-free days; failure of NIV support may further aggravate patient prognosis.

The reviews of this paper are available via the supplemental material section.

Predictive Factors for Failure of Noninvasive Ventilation in Adult Intensive Care Unit: A Retrospective Clinical Study

Background

Noninvasive ventilation (NIV) has been reported to be beneficial for patients with acute respiratory failure in intensive care unit (ICU); however, factors that influence the clinical outcome of NIV were unclarified. We aim to determine the factors that predict the failure of NIV in critically ill patients with acute respiratory failure (ARF). Setting. Adult mixed ICU in a medical university affiliated hospital. Patients and Methods. A retrospective clinical study using data from critical adult patients with initial NIV admitted to ICU in the period August 2016 to November 2017. Failure of NIV was regarded as patients needing invasive ventilation. Logistic regression was employed to determine the risk factor(s) for NIV, and a predictive model for NIV outcome was set up using risk factors.

Results

Of 101 included patients, 50 were unsuccessful. Although more than 20 variables were associated with NIV failure, multivariate logistic regression demonstrated that only ideal body weight (IBW) (OR 1.110 (95%1.027-1.201), P=0.009), the maximal heart rate during NIV period (HR-MAX) (OR 1.024 (1.004-1.046), P=0.021), the minimal respiratory rate during NIV period (RR-MIN) (OR 1.198(1.051-1.365), P=0.007), and the highest body temperature during NIV period (T-MAX) (OR 1.838(1.038-3.252), P=0.037) were independent risk factors for NIV failure. We set up a predictive model based on these independent risk factors, whose area under the receiver operating characteristic curve (AUROC) was 0.783 (95% CI: 0.676-0.899, P < 0.001), and the sensitivity and specificity of model were 68.75% and 71.43%, respectively, with the optimal cut-off value of 0.4863.

Conclusion

IBW, HR-MAX, RR-MIN, and T-MAX were associated with NIV failure in patients with ARF. A predictive model based on the risk factors could help to discriminate patients who are vulnerable to NIV failure.

Risk factors for noninvasive ventilation failure in patients with post-extubation acute respiratory failure after cardiac surgery

Background

The effect of noninvasive ventilation (NIV) in patients with acute respiratory failure (ARF) after cardiac surgery is controversial. This study identified the feasibility of NIV and assessed the risk factors of NIV failure in patients with ARF after cardiac surgery.

Methods

We retrospectively reviewed data from 112 patients with ARF requiring NIV and categorized them into the NIV failure and success groups. Patient data were extracted for further analysis, the primary outcomes were the need for endotracheal intubation and NIV-related in-hospital mortality. The risk factors for NIV failure in patients with post-extubation ARF was analyzed.

Results

The median time from extubation to NIV was 11 hours. No difference in the EuroSCORE existed between the two groups. NIV failed in 38.4% of the patients. The NIV failure group had a higher in-hospital mortality and stay at the longer intensive care unit (ICU). Most cases of NIV failure occurred within 1-48 hours of the treatment. The main causes of early NIV failure were a weak cough reflex and/or excessive secretions and hemodynamic instability. A Sequential Organ Failure Assessment (SOFA) score ≥10.5, vasoactive-inotropic score ≥6, and pneumonia were predictors of NIV failure, whereas a body mass index (BMI) ≥25.0 kg/m² predicted NIV success.

Conclusions

NIV was effective in the study population. Multiple organ dysfunction, pneumonia, and significant inotropic drug support before NIV were associated with NIV failure, whereas a BMI ≥25 kg/m² was a predictor of NIV success.