Risk factors for mortality in patients admitted to intensive care units with pneumonia

Novel and Rapid Diagnostics for Common Infections in the Critically Ill Patient

There are several novel platforms that enhance detection of pathogens that cause common infections in the intensive care unit. These platforms have a sample to answer time of a few hours, are often higher yield than culture, and have the potential to improve antibiotic stewardship.

Improved performance of an intensive care unit after changing the admission triage model

The aim of this study is to analyze the effect of implementing a prioritization triage model for admission to an intensive care unit on the outcome of critically ill patients. Retrospective longitudinal study of adult patients admitted to the Intensive Care Unit (ICU) carried out from January 2013 to December 2017. The primary outcome considered was vital status at hospital discharge. Patients were divided into period 1 (chronological triage) during the years 2013 and 2014 and period 2 (prioritization triage) during the years 2015-2017. A total of 1227 patients in period 1 and 2056 in period 2 were analyzed. Patients admitted in period 2 were older (59.8 years) compared to period 1 (57.3 years; p < 0.001) with less chronic diseases (13.6% vs. 19.2%; p = 0.001), and higher median APACHE II score (21.0 vs. 18.0; p < 0.001)) and TISS 28 score (28.0 vs. 27.0; p < 0.001). In period 2, patients tended to stay in the ICU for a shorter time (8.5 ± 11.8 days) compared to period 1 (9.6 ± 16.0 days; p = 0.060) and had lower mortality at ICU (32.8% vs. 36.9%; p = 0.016) and hospital discharge (44.2% vs. 47.8%; p = 0.041). The change in the triage model from a chronological model to a prioritization model resulted in improvement in the performance of the ICU and reduction in the hospital mortality rate.

Frequency, Predictors, and Outcomes of the Potential Drug-Drug Interactions in the ICUs of Teaching Hospitals in Ardabil, Northwest of Iran During 2019-2020

Introduction: Drug-drug interactions (DDIs) can reduce therapeutic efficacy and increase the duration and cost of hospitalization so that patients are sometimes exposed to significant complications and even death. Patients in the intensive care unit (ICU) are at higher risk of DDIs for a variety of reasons, including impaired absorption, decreased metabolism, and renal failure. The main objective of this study was to evaluate frequency, clinical ranking and risk factors of potential DDIs in the ICUs of 3 teaching hospitals in Ardabil. Methods: In this descriptive-analytical cross-sectional study, drug prescriptions 355 patients admitted to the ICUs were studied. Patient information including age, sex, diagnosis, number of prescribers, number of drugs, length of stay, and status of patients' discharge (recovery or death) were recorded and checked using the online software up to date and the book Drug Interaction Facts. Finally, the data were statistically analyzed using the SPSS software. Results: The number of patients studied was 355. The mean age of the patients were 51.88 ± 23.22 years, and on average, 8.45 drugs had been prescribed for each patient. The total number of DDIs was 1597 among which class X was 1.4%, class D was 26.2%, and class C was 67.7%. Four hundred ninety-seven unique pairs of DDIs were identified. Age, number of prescribed drugs and length of stay in ICU were associated with prevalence of DDIs. Age and number of drugs were also identified as the risk factors of patients' discharge caused by death. Conclusion: DDIs can complicate health state of patients in ICUs and may increase the length of hospital stay. Setting up computerized systems to alert drug interactions in hospital wards and pharmacotherapeutic intervention by clinical pharmacist can minimize DDIs.

Development and validation of an in-hospital mortality risk prediction model for patients with severe community-acquired pneumonia in the intensive care unit

BACKGROUND

A high mortality rate has always been observed in patients with severe community-acquired pneumonia (SCAP) admitted to the intensive care unit (ICU); however, there are few reported predictive models regarding the prognosis of this group of patients. This study aimed to screen for risk factors and assign a useful nomogram to predict mortality in these patients.

METHODS

As a developmental cohort, we used 455 patients with SCAP admitted to ICU. Logistic regression analyses were used to identify independent risk factors for death. A mortality prediction model was built based on statistically significant risk factors. Furthermore, the model was visualized using a nomogram. As a validation cohort, we used 88 patients with SCAP admitted to ICU of another hospital. The performance of the nomogram was evaluated by analysis of the area under the receiver operating characteristic (ROC) curve (AUC), calibration curve analysis, and decision curve analysis (DCA).

RESULTS

Lymphocytes, PaO2/FiO2, shock, and APACHE II score were independent risk factors for in-hospital mortality in the development cohort. External validation results showed a C-index of 0.903 (95% CI 0.838-0.968). The AUC of model for the development cohort was 0.85, which was better than APACHE II score 0.795 and SOFA score 0.69. The AUC for the validation cohort was 0.893, which was better than APACHE II score 0.746 and SOFA score 0.742. Calibration curves for both cohorts showed agreement between predicted and actual probabilities. The results of the DCA curves for both cohorts indicated that the model had a high clinical application in comparison to APACHE II and SOFA scoring systems.

CONCLUSIONS

We developed a predictive model based on lymphocytes, PaO2/FiO2, shock, and APACHE II scores to predict in-hospital mortality in patients with SCAP admitted to the ICU. The model has the potential to help physicians assess the prognosis of this group of patients.

High-flow nasal cannula reduces intubation rate in patients with COVID-19 with acute respiratory failure: a meta-analysis and systematic review

OBJECTIVE

This study aimed to investigate the effect of high-flow nasal cannula therapy (HFNC) versus conventional oxygen therapy (COT) on intubation rate, 28-day intensive care unit (ICU) mortality, 28-day ventilator-free days (VFDs) and ICU length of stay (ICU LOS) in adult patients with acute respiratory failure (ARF) associated with COVID-19.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Web of Science, Cochrane Library and Embase up to June 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Only randomised controlled trials or cohort studies comparing HFNC with COT in patients with COVID-19 were included up to June 2022. Studies conducted on children or pregnant women, and those not published in English were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened the titles, abstracts and full texts. Relevant information was extracted and curated in the tables. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to assess the quality of randomised controlled trials or cohort studies. Meta-analysis was conducted using RevMan V.5.4 computer software using a random effects model with a 95% CI. Heterogeneity was assessed using Cochran's Q test (χ²) and Higgins I² statistics, with subgroup analyses to account for sources of heterogeneity.

RESULTS

Nine studies involving 3370 (1480 received HFNC) were included. HFNC reduced the intubation rate compared with COT (OR 0.44, 95% CI 0.28 to 0.71, p=0.0007), decreased 28-day ICU mortality (OR 0.54, 95% CI 0.30 to 0.97, p=0.04) and improved 28-day VFDs (mean difference (MD) 2.58, 95% CI 1.70 to 3.45, p<0.00001). However, HFNC had no effect on ICU LOS versus COT (MD 0.52, 95% CI -1.01 to 2.06, p=0.50).

CONCLUSIONS

Our study indicates that HFNC may reduce intubation rate and 28-day ICU mortality, and improve 28-day VFDs in patients with ARF due to COVID-19 compared with COT. Large-scale randomised controlled trials are necessary to validate our findings.

PROSPERO REGISTRATION NUMBER

CRD42022345713.

Metagenomics next-generation sequencing provides insights into the causative pathogens from critically ill patients with pneumonia and improves treatment strategies

Background

The metagenomics next-generation sequencing (mNGS) is a promising technique for pathogens diagnosis. However, whether the application of mNGS in critically ill patients with pneumonia could cause anti-infection treatment adjustment and thereby affect the prognosis of these patients has not been explored.

Methods

We retrospectively collected the clinical data of patients diagnosed with pulmonary infection in the ICU of the Affiliated Hospital of Qingdao University from January 2018 to January 2021. These patients with pneumonia were divided into mNGS group and no-mNGS group by whether being performed NGS or not. The clinical data, including demographics, illness history, APACHE II score, length of mechanical ventilation, length of stay in the hospital, length of stay in ICU and outcome, were collected. In addition, the data of pathogens and anti-infection treatment before and after NGS were also collected. Propensity score matching was performed to evaluate the mortality and deterioration rate between NGS group and non-NGS group.

Results

A total of 641 patients diagnosed with pneumonia were screened, and 94 patients were excluded based on exclusion criteria. Finally, 547 patients were enrolled, including 160 patients being performed NGS. Among these 160 patients, 142 cases had NGS-positive results. In addition, new pathogens were detected in 132 specimens by NGS, which included 82 cases with virus, 18 cases with fungus, 17 cases with bacteria, 14 cases with mycoplasma, and 1 case with mycobacterium tuberculosis. Anti-infection treatments were adjusted in some patients who performed NGS, including 48 anti-bacterial treatments, 20 antifungal treatments and 20 antiviral treatments. There were no significant differences in the mortality and deterioration rate between NGS and non-NGS group, but it exhibited a trend that the mortality and deterioration rate of NGS group was lower than non-NGS group after the propensity score matching analysis (15.8% vs 24.3%, P=0.173; 25.6% vs 37.8%, P=0.093).

Conclusion

NGS could affect the anti-infection treatments and had a trend of reducing the mortality and deterioration rate of critically ill patients with pneumonia.

The Impact of Nonalcoholic Fatty Liver Disease on Severe Community-Acquired Pneumonia Outcomes

Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality, while nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. NAFLD is associated with systemic changes in immune response, possibly linked to CAP severity. However, the impact of NAFLD on CAP outcomes has not been determined. The aim of this study was to evaluate clinical course, complications and outcomes of severe CAP requiring ICU treatment in patients with NAFLD in the pre-COVID-19 era. A retrospective cohort study included 138 consecutively hospitalized adult patients with severe CAP admitted to the ICU during a 4-year period: 80 patients with NAFLD and 58 controls. Patients with NAFLD more frequently presented with ARDS (68.7% vs. 43.1%), and required invasive mechanical ventilation (86.2% vs. 63.8%), respiratory ECMO (50% vs. 24.1%), and continuous renal replacement therapy (62.5% vs. 29.3%). Mortality was significantly higher in the NAFLD group (50% vs. 20.7%), and the time from hospital admission to death was significantly shorter. In survival analysis, NAFLD (HR 2.21, 95%CI 1.03-5.06) was associated with mortality independently of other components of metabolic syndrome. In conclusion, our study identified NAFLD as an independent predictor of mortality in patients with severe CAP.

Tissue Penetration of Antimicrobials in Intensive Care Unit Patients: A Systematic Review-Part II

In patients that are admitted to intensive care units (ICUs), the clinical outcome of severe infections depends on several factors, as well as the early administration of chemotherapies and comorbidities. Antimicrobials may be used in off-label regimens to maximize the probability of therapeutic concentrations within infected tissues and to prevent the selection of resistant clones. Interestingly, the literature clearly shows that the rate of tissue penetration is variable among antibacterial drugs, and the correlation between plasma and tissue concentrations may be inconstant. The present review harvests data about tissue penetration of antibacterial drugs in ICU patients, limiting the search to those drugs that mainly act as protein synthesis inhibitors and disrupting DNA structure and function. As expected, fluoroquinolones, macrolides, linezolid, and tigecycline have an excellent diffusion into epithelial lining fluid. That high penetration is fundamental for the therapy of ventilator and healthcare-associated pneumonia. Some drugs also display a high penetration rate within cerebrospinal fluid, while other agents diffuse into the skin and soft tissues. Further studies are needed to improve our knowledge about drug tissue penetration, especially in the presence of factors that may affect drug pharmacokinetics.

Novel and Rapid Diagnostics for Common Infections in the Critically Ill Patient

There are several novel platforms that enhance detection of pathogens that cause common infections in the intensive care unit. These platforms have a sample to answer time of a few hours, are often higher yield than culture, and have the potential to improve antibiotic stewardship.

Donor-recipient sex is associated with transfusion-related outcomes in critically ill patients

Transfusion of female RBCs to male recipients increases the risk of ICU mortality compared with female blood to female recipients.

Receiving RBCs from female donors is associated with a trend toward ARDS.

Transfusion of red blood cells (RBCs) from female donors has been associated with increased risk of mortality. This study aims to investigate the associations between donor-recipient sex and posttransfusion mortality and morbidity in critically ill patients who received RBC transfusions from either male-only donors or from female-only donors (unisex-transfusion cases). Survival analysis was used to compare 4 groups: female-to-female, female-to-male, male-to-female, and male-to-male transfusion. Multivariate logistic model was used to evaluate the association between donor sex and intensive care unit (ICU) mortality. Associations between transfusion and acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), and nosocomial infections were assessed. Of the 6992 patients included in the original cohort study, 403 patients received unisex-transfusion. Survival analysis and the logistic model showed that transfusion of female RBCs to male patients was associated with an increased ICU mortality compared with transfusion of female RBCs to female patients (odds ratio, 2.43; 95% confidence interval, 1.02-5.77; P < .05). There was a trend toward increased ARDS in patients receiving RBC from female donors compared with those receiving blood from males (P = .06), whereas AKI was higher in donor-recipient sex-matched transfusion groups compared with sex-mismatched groups (P = .05). This was an exploratory study with potential uncontrolled confounders that limits broad generalization of the findings. Results warrant further studies investigating biological mechanisms underlying the association between donor sex with adverse outcomes as well as studies on the benefit of matching of blood between donor and recipient.

Use of Azelastine and Sodium Chloride Spray for Prevention of Sinusitis in ICU Admitted Patients: A Randomized Clinical Trial

Background:

Nosocomial sinusitis is a common and less attended complication in patients admitted to intensive care units (ICU). It can cause several problems, such as prolongation of hospitalization, comorbidity, and mortality in patients. The present study aimed to evaluate the effect of azelastine (second-generation antihistamine) and sodium chloride spray on sinusitis prevention in ICU admitted patients.

Methods:

In this randomized, open-label, and parallel clinical trial a total of 126 patients were enrolled (63 patients per arm). Finally, 121 patients (61 patients in the control group and 60 patients in the treatment group) completed the study, and 120 patients entered the final analysis. In the treatment group, during 24 h after the insertion of nasogastric tube azelastine and sodium chloride sprays were administered (one puff from each spray every 12 h) while no intervention was conducted in the control group. Primary and secondary end-points were evaluated within 10 days of the study period.

Results:

The incidence of sinusitis and pneumonia (18.3% and 16.6% in the control group compared to 8.3% and 3.3% in the treatment group, respectively) in the treatment group showed a decreasing trend; however, only the difference of pneumonia was statistically significant between groups (P = 0.03). In addition to the clinical pulmonary infection score, nasal and tracheal secretions were significantly improved in the treatment group (P = 0.03, P < 0.001, and P = 0.01, respectively).

Conclusions:

The findings of the present study offer an inexpensive, low-risk, and efficacious intervention for the prevention of upper respiratory tract infections in ICU patients.

Extended Lung Ultrasound to Differentiate Between Pneumonia and Atelectasis in Critically Ill Patients: A Diagnostic Accuracy Study

OBJECTIVES

To determine the diagnostic accuracy of extended lung ultrasonographic assessment, including evaluation of dynamic air bronchograms and color Doppler imaging to differentiate pneumonia and atelectasis in patients with consolidation on chest radiograph. Compare this approach to the Simplified Clinical Pulmonary Infection Score, Lung Ultrasound Clinical Pulmonary Infection Score, and the Bedside Lung Ultrasound in Emergency protocol.

DESIGN

Prospective diagnostic accuracy study.

SETTING

Adult ICU applying selective digestive decontamination.

PATIENTS

Adult patients that underwent a chest radiograph for any indication at any time during admission. Patients with acute respiratory distress syndrome, coronavirus disease 2019, severe thoracic trauma, and infectious isolation measures were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Lung ultrasound was performed within 24 hours of chest radiograph. Consolidated tissue was assessed for presence of dynamic air bronchograms and with color Doppler imaging for presence of flow. Clinical data were recorded after ultrasonographic assessment. The primary outcome was diagnostic accuracy of dynamic air bronchogram and color Doppler imaging alone and within a decision tree to differentiate pneumonia from atelectasis. Of 120 patients included, 51 (42.5%) were diagnosed with pneumonia. The dynamic air bronchogram had a 45% (95% CI, 31-60%) sensitivity and 99% (95% CI, 92-100%) specificity. Color Doppler imaging had a 90% (95% CI, 79-97%) sensitivity and 68% (95% CI, 56-79%) specificity. The combined decision tree had an 86% (95% CI, 74-94%) sensitivity and an 86% (95% CI, 75-93%) specificity. The Bedside Lung Ultrasound in Emergency protocol had a 100% (95% CI, 93-100%) sensitivity and 0% (95% CI, 0-5%) specificity, while the Simplified Clinical Pulmonary Infection Score and Lung Ultrasound Clinical Pulmonary Infection Score had a 41% (95% CI, 28-56%) sensitivity, 84% (95% CI, 73-92%) specificity and 68% (95% CI, 54-81%) sensitivity, 81% (95% CI, 70-90%) specificity, respectively.

CONCLUSIONS

In critically ill patients with pulmonary consolidation on chest radiograph, an extended lung ultrasound protocol is an accurate and directly bedside available tool to differentiate pneumonia from atelectasis. It outperforms standard lung ultrasound and clinical scores.

Tigecycline in the Treatment of Ventilator-Associated Pneumonia Due to Stenotrophomonas maltophilia: A Multicenter Retrospective Cohort Study

Introduction

Tigecycline is a potential alternative to trimethoprim–sulfamethoxazole in treating Stenotrophomonas maltophilia infections due to its potent in vitro antimicrobial activity. Clinical evidence regarding the use of tigecycline in the treatment of S. maltophilia infections is scarce. In this study, we assessed the efficacy of tigecycline treating ventilator-associated pneumonia (VAP) due to S. maltophilia in comparison with fluoroquinolones.

Methods

This is a multicenter retrospective cohort study of patients admitted between January 2017 and December 2020 with the diagnosis of VAP caused by S. maltophilia receiving either tigecycline or fluoroquinolones as the definitive therapy ≥ 48 h. Clinical outcomes including 28-day mortality, clinical cure and microbiological cure were analyzed.

Results

Of 82 patients with S. maltophilia VAP included, 46 received tigecycline, and 36 received fluoroquinolones; 70.7% of patients had polymicrobial pneumonia, and the appropriate empiric therapy was applied to only 14.6% of patients. The overall 28-day mortality was 39%. Compared with patients receiving fluoroquinolones, tigecycline therapy resulted in worse clinical cure (32.6% vs. 63.9%, p = 0.009) and microbiological cure (28.6% vs. 59.1%, p = 0.045), while there was no statistical difference between 28-day mortality (47.8% vs. 27.8%, p = 0.105) in the two groups. Similar results were also shown in the inverse probability of treatment weighted univariable regression model and multivariable regression model.

Conclusions

The standard dose of tigecycline therapy was associated with a lower clinical and microbiological cure rate but not associated with an increased 28-day mortality in patients with S. maltophilia VAP compared with fluoroquinolones. Considering the unfavorable clinical outcomes, we therefore recommend against using the standard dose of tigecycline in treating S. maltophilia VAP unless new clinical evidence emerges.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00516-5.

The effect of high flow nasal oxygen therapy in intensive care units: a systematic review and meta-analysis

BACKGROUND

High flow nasal oxygen (HFNO) therapy has been widely used in intensive care units (ICU); however, its efficacy remains inconclusive. This systematic review and meta-analysis aimed to compare the efficacy of HFNO therapy with th at of alternative noninvasive oxygen therapies such as conventional oxygen therapy (COT) and noninvasive ventilation (NIV) in ICU.

METHODS

A Pubmed, Embase, Web of Science, Cochrane Library database search was performed in March 2020. Results: The meta-analysis ultimately included 17 clinical studies. Compared with the overall effect of COT and NIV, HFNO was associated with a low incidence of pneumonia (95% CI: 0.6-0.99, P = 0.04) and improvement in lowest pulse oxygen saturation (SpO₂) during oxygenation (95% CI: 0.02-1.61; P = 0.04). However, no differences were detected in the following outcomes: length of ICU stay, the rate of intubation or reintubation, mortality at day 28, hospital mortality, and SpO₂ at the end of oxygen therapy (all P > 0.05).

CONCLUSIONS

In adult patients in ICU, HFNO may improve oxygenation and decrease pneumonia rate without affecting the length of ICU stay, intubation or reintubation rate, mortality, and SpO₂ at the end of oxygen therapy.

Usefulness of β-lactam and macrolide combination therapy for treating community-acquired pneumonia patients hospitalized in the intensive care unit: Propensity score analysis of a prospective cohort study

INTRODUCTION

Whether β-lactam and macrolide combination therapy reduces mortality in severe community-acquired pneumonia (SCAP) patients hospitalized in the intensive care unit (ICU) is controversial. The aim of the present study was to evaluate the usefulness of β-lactam and macrolide combination therapy for SCAP patients hospitalized in the ICU.

METHODS

A prospective, observational, cohort study of hospitalized pneumonia patients was performed. Hospitalized SCAP patients admitted to the ICU within 24 h between October 2010 and October 2017 were included for analysis. The primary outcome was 30-day mortality, and secondary outcomes were 14-day mortality and ICU mortality. Inverse probability of treatment weighting (IPTW) analysis as a propensity score analysis was used to reduce biases, including six covariates: age, sex, C-reactive protein, albumin, Pneumonia Severity Index score, and APACHE II score.

RESULTS

A total of 78 patients were included, with 48 patients in the non-macrolide-containing β-lactam therapy group and 30 patients in the macrolide combination therapy group. β-lactam and macrolide combination therapy significantly decreased 30-day mortality (16.7% vs. 43.8%; P = 0.015) and 14-day mortality (6.7% vs. 31.3%; P = 0.020), but not ICU mortality (10% vs 27.1%, P = 0.08) compared with non-macrolide-containing β-lactam therapy. After adjusting by IPTW, macrolide combination therapy also decreased 30-day mortality (odds ratio, 0.29; 95%CI, 0.09-0.96; P = 0.04) and 14-day mortality (odds ratio, 0.19; 95%CI, 0.04-0.92; P = 0.04), but not ICU mortality (odds ratio, 0.34; 95%CI, 0.08-1.36; P = 0.13).

CONCLUSIONS

Combination therapy with β-lactam and macrolides significantly improved the prognosis of SCAP patients hospitalized in the ICU compared with a non-macrolide-containing β-lactam regimen.

Risk factors for 3-month mortality in bedridden patients with hospital-acquired pneumonia: A multicentre prospective study

BACKGROUND

Mortality among patients with hospital-acquired pneumonia (HAP) is quite high; however, information on risk factors for short-term mortality in this population remains limited. The aim of the current study was to identify the risk factors for mortality in bedridden patients with HAP during a 3-month observation period.

METHODS

A secondary data analysis was conducted. In total, 1141 HAP cases from 25 hospitals were included in the analysis. Univariate and multilevel regression analyses were performed to identify the risk factors for mortality.

RESULTS

During the 3-month observation period, there were 189 deaths among bedridden patients with HAP. The mortality rate in this study was 16.56%. Multilevel regression analysis showed that ventilator-associated pneumonia (OR = 2.034, 95%CI: 1.256, 3.296, p = 0.004), pressure injuries (OR = 2.202, 95%CI: 1.258, 3.852, p = 0.006), number of comorbidities (OR = 1.076, 95%CI: 1.016,1.140, p = 0.013) and adjusted Charlson Comorbidity Index score (OR = 1.210, 95%CI: 1.090, 1.343, p<0.001) were associated with an increased risk of mortality, while undergoing surgery with general anaesthesia (OR = 0.582, 95%CI: 0.368, 0.920, p = 0.021) was associated with a decreased risk of mortality.

CONCLUSIONS

The identification of risk factors associated with mortality is an important step towards individualizing care plans. Our findings may help healthcare workers select high-risk patients for specific interventions. Further study is needed to explore whether appropriate interventions against modifiable risk factors, such as reduced immobility complications or ventilator-associated pneumonia, could improve the prognoses.

A propensity score-matched analysis of mortality in solid organ transplant patients with COVID-19 compared to non-solid organ transplant patients

In the context of COVID-19 pandemic, we aimed to analyze the epidemiology, clinical characteristics, risk factors for mortality and impact of COVID-19 on outcomes of solid organ transplant (SOT) recipients compared to a cohort of non transplant patients, evaluating if transplantation could be considered a risk factor for mortality. From March to May 2020, 261 hospitalized patients with COVID-19 pneumonia were evaluated, including 41 SOT recipients. Of these, thirty-two were kidney recipients, 4 liver, 3 heart and 2 combined kidney-liver transplants. Median time from transplantation to COVID-19 diagnosis was 6 years. Thirteen SOT recipients (32%) required Intensive Care Unit (ICU) admission and 5 patients died (12%). Using a propensity score match analysis, we found no significant differences between SOT recipients and non-transplant patients. Older age (OR 1.142; 95% [CI 1.08–1.197]) higher levels of C-reactive protein (OR 3.068; 95% [CI 1.22–7.71]) and levels of serum creatinine on admission (OR 3.048 95% [CI 1.22–7.57]) were associated with higher mortality. The clinical outcomes of SARS-CoV-2 infection in our cohort of SOT recipients appear to be similar to that observed in the non-transplant population. Older age, higher levels of C-reactive protein and serum creatinine were associated with higher mortality, whereas SOT was not associated with worse outcomes.

High flow nasal cannula versus conventional oxygen therapy in postoperative patients at high risk for pulmonary complications: A systematic review and meta-analysis

BACKGROUND

The effects of high flow nasal cannula (HFNC) on postoperative patients at high risk for pulmonary complications(PC) are controversial. We aimed to further determine the effectiveness of HFNC in postoperative patients at high risk for PC by comparison to conventional oxygen therapy (COT).

METHODS

We performed a comprehensive search that compared HFNC with COT in postoperative patients at high risk for PC. The main outcomes were length of hospital stay (hospital LOS) and respiratory complications.

RESULTS

Six trials with a total of 733 patients were pooled in our final studies. Except for Hospital LOS (I²  = 53%, χ²  = 8.51, P = .07) and rate of intubation or non-invasive ventilation (NIV) for respiratory failure (RF) (I²  = 49%, χ²  = 1.97, P = .16) between HFNC and COT, no significant heterogeneity was found in outcome measures. Compared with COT, HFNC was associated with a lower rate of intubation or NIV for RF (RR 0.23, 95% CI 0.08-0.66, P = .006) and rate of hypercapnia (RR 0.37, 95% CI 0.20-0.68, P = .002). As for the Hospital LOS, ICU LOS, rate of requirement of O2 after discontinuous and hypoxemia, HFNC did not show any advantage over COT. Trial Sequential Analysis (TSA) for Hospital LOS showed that monitoring boundaries were finally not surpassed and required information size (RIS) was not met.

CONCLUSIONS

The available randomised controlled trials (RCTs) suggest that, among the postoperative patients at high risk for PC, HFNC therapy compared with the COT significantly reduces rate of incubation or NIV for RF and rate of hypercapnia, meanwhile is safely administered. Further large-scale, multicenter, randomised and controlled studies are needed to confirm our results.

Bilateral Nephrectomy in Patients with Autosomal Dominant Polycystic Kidney Disease and End-Stage Chronic Renal Failure

BACKGROUND

In patients with autosomal dominant polycystic kidney disease (ADPKD) and end-stage kidney disease, bilateral nephrectomy (BN) is currently performed predominantly via the laparoscopic approach. We analysed the results of BN depending on the approach and preoperative and perioperative factors.

PATIENTS AND METHODS

This was a single-centre retrospective study carried out from April 2010 to March 2020, including a total of 142 patients presenting with ADPKD who were treated by BN. Of these, 108 patients meeting the inclusion criteria were selected to analyse the results. We compared therapeutic outcomes depending on the surgical approach (laparotomy or laparoscopy) and the type of the operation (emergent or elective).

RESULTS

Of the 108 eligible patients, 36 (group I) underwent laparoscopic BN and the remaining 72 patients (group II) were subjected to midline laparotomy. Sixty-nine patients underwent elective surgery and 39 endured emergent operations. The most frequent indications (87 patients, 80.6%) for surgical treatment were urinary tract infection and infected cysts. The median length of hospital stay for group I and group II patients amounted to 8 days (IQR: 7.5-9) and 12.5 days (IQR: 9-16.5), respectively (p < 0.001). However, comparing the patients operated on electively, the actual difference in the length of hospital stay was inconsiderable: median 8 days (IQR: 7-9) in group I and 9 days (IQR: 9-11.5) in group II. The median duration of the operation was significantly (p < 0.001) longer in group I amounting to 217.5 min (IQR: 197.5-305) than in group II equalling 115 min (IQR: 107.5-145). The frequency of postoperative complications, lethal outcomes, and blood loss volume did not statistically significantly differ depending on the surgical approach. Only patients operated on emergency underwent releparotomy due to intraoperative large bowel injury. Lethal outcomes (n = 18, 16.7%) after surgery were observed only in emergent patients. Sepsis prior to surgery, systemic inflammation response syndrome (SIRS) with the CRP level above 173 mg/mL, prolonged preoperative antibacterial therapy, and undiagnosed large bowel injury were associated with a lethal outcome after BN.

CONCLUSION

The results of open and laparoscopic BN in elective surgery were comparable. Emergency operations for infected renal cysts and SIRS were associated with increased incidence of large bowel injury and lethal outcomes.

Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review

OBJECTIVES

Coronavirus disease 19 (COVID-19) is a major cause of hospital admission and represents a challenge for patient management during intensive care unit (ICU) stay. We aimed to describe the clinical course and outcomes of COVID-19 pneumonia in critically ill patients.

METHODS

We performed a systematic search of peer-reviewed publications in MEDLINE, EMBASE and the Cochrane Library up to 15th August 2020. Preprints and reports were also included if they met the inclusion criteria. Study eligibility criteria were full-text prospective, retrospective or registry-based publications describing outcomes in patients admitted to the ICU for COVID-19, using a validated test. Participants were critically ill patients admitted in the ICU with COVID-19 infection.

RESULTS

From 32 articles included, a total of 69 093 patients were admitted to the ICU and were evaluated. Most patients included in the studies were male (76 165/128 168, 59%, 26 studies) and the mean patient age was 56 (95%CI 48.5-59.8) years. Studies described high ICU mortality (21 145/65 383, 32.3%, 15 studies). The median length of ICU stay was 9.0 (95%CI 6.5-11.2) days, described in five studies. More than half the patients admitted to the ICU required mechanical ventilation (31 213/53 465, 58%, 23 studies) and among them mortality was very high (27 972/47 632, 59%, six studies). The duration of mechanical ventilation was 8.4 (95%CI 1.6-13.7) days. The main interventions described were the use of non-invasive ventilation, extracorporeal membrane oxygenation, renal replacement therapy and vasopressors.

CONCLUSIONS

This systematic review, including approximately 69 000 ICU patients, demonstrates that COVID-19 infection in critically ill patients is associated with great need for life-sustaining interventions, high mortality, and prolonged length of ICU stay.

The characteristics and outcomes of patients with idiopathic pulmonary fibrosis admitted to the ICU with acute respiratory failure

BACKGROUND

To date, studies have provided conflicting results regarding the outcomes of patients with Idiopathic Pulmonary Fibrosis (IPF) admitted to the ICU with acute respiratory failure (ARF).

OBJECTIVE

To understand the characteristics and outcomes of these patients.

METHODS

Retrospective study using a large single-center ICU database. We identified 48 unique patients with IPF admitted for ARF from 2001-2012.

RESULTS

The most common causes of ARF were IPF exacerbation and pneumonia. The overall hospital mortality rate was 43.8% and was 56.7% in those who required invasive mechanical ventilation (IMV). In patients requiring IMV for IPF exacerbation, the mortality rate was 81.3%. In multiple regression analysis, the presence of diabetes mellitus was associated with decreased mortality whereas the need for IMV was associated with increased mortality.

CONCLUSIONS

Although the overall mortality rate for IPF patients with ARF has improved, the need for IMV due to IPF exacerbations is associated with increased mortality.

The effect of performance feedback and educational video on endotracheal-suctioning practices of critical care nurses

INTRODUCTION

Majority of critical care nurses do not have desirable skills in performing endotracheal tube suctioning (ETS) despite related training taught in the curricula. This study aimed to investigate and compare the effect of education through video and performance feedback (PF) on nurses' skills in performing ETS.

METHODS

This was a quasi-experimental study. The sample size comprised of all nurses (n = 49) working in the intensive care unit of one of the educational hospital located in one of the western cities of Iran. Nurses were assigned to either one of educational video (EV) and PF groups. Data were collected using a 25-item structured best practices information sheet. Data were analyzed using SPSS software version 20 (SPSS Inc., Chicago, IL, USA).

RESULTS

After the interventions, no significant difference was found in the total mean score of nurses' practice in ETS between those who received education through EV and those who received through PF (16.3 vs. 15.1) (P > 0.05). Before and after the intervention, a significant improvement was observed in the total mean score and other dimensions of nurses' practice in endotracheal suctioning (P < 0.0001).

CONCLUSIONS

The results showed that both of methods through feedback and EV are useful in improving nurses' ETS practice. However, further studies are required to examine the effects of such interventions in the long term.

The aetiology of severe community-acquired pneumonia requiring intensive care unit admission in the Western Cape Province, South Africa

Background

Community-acquired pneumonia (CAP) is a common condition, with mortality increasing in patients who require intensive care unit (ICU) admission. A better understanding of the current aetiology of severe CAP will aid clinicians in requesting appropriate diagnostic tests and initiating appropriate empiric antimicrobials.

Objectives

To assess the comorbidities, aetiology and mortality associated with severe CAP in a tertiary ICU in Cape Town, South Africa.

Methods

We retrospectively analysed a prospective registry of all adults admitted to the medical intensive care unit at Tygerberg Hospital with severe CAP over a 1-year period.

Results

We identified 74 patients (mean (SD) age 40.0 (15.5) years; 44 females). The patients had a mean (SD) APACHE II score of 21.4 (7.9), and the mean ICU stay was 6.6 days. Of the 74 patients, 16 (21.6%) died in ICU. Non-survivors had a higher mean (SD) APACHE II score than survivors (28.3 (6.8) v. 19.4 (7.1); p<0.001). Mycobacterium tuberculosis (n=16; 21.6%) was the single most common agent identified, followed by Pseudomonas aeruginosa (n=9; 12.2%). All P. aeruginosa isolates were sensitive to first-line treatment. No organism was identified in 32 patients (43.2%).

Conclusion

M. tuberculosis was the single most common agent identified in patients presenting with CAP. The mortality of CAP requiring invasive ventilation was relatively low, with a strong association between mortality and a higher APACHE II score.

Intubation rate, duration of noninvasive ventilation and mortality after noninvasive neurally adjusted ventilatory assist (NIV-NAVA)

BACKGROUND

Asynchrony is a common problem in patients treated with noninvasive ventilation (NIV). Neurally adjusted ventilatory assist (NAVA) has shown to improve patient-ventilator interaction. However, it is unknown whether NIV-NAVA improves outcomes compared to noninvasive pressure support (NIV-PS).

METHODS

This observational cohort study included patients 18 years or older receiving noninvasive ventilation using an oro-nasal face mask for more than 2 hours in a Danish ICU. The study included a NIV-NAVA cohort (year 2013-2015) and two comparison cohorts: (a) a historical NIV-PS cohort (year 2011-2012) before the implementation of NIV-NAVA at the ICU in 2013, and (b) a concurrent NIV-PS cohort (year 2013-2015). Outcomes of NIV-NAVA (intubation rate, duration of NIV and 90-day mortality) were assessed and compared using multivariable linear and logistic regression adjusted for relevant confounders.

RESULTS

The study included 427 patients (91 in the NIV-NAVA, 134 in the historic NIV-PS and 202 in the concurrent NIV-PS cohort). Patients treated with NIV-NAVA did not have improved outcome after adjustment for measured confounders. Actually, there were statistically imprecise higher odds for intubation in NIV-NAVA patients compared with both the historical [OR 1.48, CI (0.74-2.97)] and the concurrent NIV-PS cohort [OR 1.67, CI (0.87-3.19)]. NIV-NAVA might also have a longer length of NIV [63%, CI (19%-125%)] and [139%, CI (80%-213%)], and might have a higher 90-day mortality [OR 1.24, CI (0.69-2.25)] and [OR 1.39, CI (0.81-2.39)]. Residual confounding cannot be excluded.

CONCLUSION

This present study found no improved clinical outcomes in patients treated with NIV-NAVA compared to NIV-PS.

Gender differences in mortality and quality of life after septic shock: A post-hoc analysis of the ARISE study

PURPOSE

To assess the impact of gender and pre-menopausal state on short- and long-term outcomes in patients with septic shock.

MATERIAL AND METHODS

Cohort study of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial, an international randomized controlled trial comparing early goal-directed therapy (EGDT) to usual care in patients with early septic shock, conducted between October 2008 and April 2014. The primary exposure in this analysis was legal gender and the secondary exposure was pre-menopausal state defined by chronological age (≤ 50 years).

RESULTS

641 (40.3%) of all 1591 ARISE trial participants in the intention-to-treat population were females and overall, 337 (21.2%) (146 females) patients were 50  years of age or younger. After risk-adjustment, we could not identify any survival benefit for female patients at day 90 in the younger (≤50 years) (adjusted Odds Ratio (aOR): 0.91 (0.46-1.89), p = .85) nor in the older (>50 years) age-group (aOR: 1.10 (0.81-1.49), p = .56). Similarly, there was no gender-difference in ICU, hospital, 1-year mortality nor quality of life measures.

CONCLUSIONS

This post-hoc analysis of a large multi-center trial in early septic shock has shown no short- or long-term survival effect for women overall as well as in the pre-menopausal age-group.

Sepsis in Pregnancy: Recognition and Resuscitation

The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant patients. This narrative review evaluates the presentation, scoring systems for risk stratification, diagnosis, and management of sepsis in pregnancy. Sepsis is potentially fatal, but literature for the evaluation and treatment of this condition in pregnancy is scarce. While the definition and considerations of sepsis have changed with large, randomized controlled trials, pregnancy has consistently been among the exclusion criteria. The two pregnancy-specific sepsis scoring systems, the modified obstetric early warning scoring system (MOEWS) and Sepsis in Obstetrics Score (SOS), present a number of limitations for application in the emergency department (ED) setting. Methods of generation and subsequently limited validation leave significant gaps in identification of septic pregnant patients. Management requires consideration of a variety of sources in the septic pregnant patient. The underlying physiologic nature of pregnancy also highlights the need to individualize resuscitation and critical care efforts in this unique patient population. Pregnant septic patients require specific considerations and treatment goals to provide optimal care for this particular population. Guidelines and scoring systems currently exist, but further studies are required.

The association between the APACHE-II scores and age groups for predicting mortality in an intensive care unit: a retrospective study

BACKGROUND AND AIMS

In this study, we aimed to evaluate whether the age or the APACHE-II score was a better predictor of mortality in each group. The secondary objective was to investigate the factors affecting the mortality in each individual age group.

METHODS

We designed this retrospective study between 2016-2017. Age groups were classified into 3 classes: Patients < 60 years were Group 1, patients between 60-70 years were Group 2, and patients > 70 years were Group 3. We recorded patients' age, ICU indication, demographic data, APACHE-II, ASA, length of hospital stays and mortality.

RESULTS

We analysed 150 patients and reported mortality for 58 patients (38.7%). We did not detect any association between age and mortality for all groups. ASA, length of ICU stays and predicted mortality rate, were significantly higher for exitus patients (p < 0.001). The ROC curve for the APACHE-II score, with a cut-off point of 23, demonstrated 74.14% sensitivity, 60.87% specificity, an area under the curve (AUC) of 67.3%, with 4.5% standard deviation (SD). The ODDS ratio for APACHE-II scores was 4.459 (95% CI: 2.167-9.176). For the adjusted mortality rate, ROC analysis identified a cut-off of 60.8 with 70.69% sensitivity, 52.17% specificity, AUC of 61.2% and 4.6% SD. The ODDS ratio for the adjusted mortality rate was 2.631 (95% CI: 1.309-5.287).

CONCLUSION

We could not demonstrate any correlation between age and mortality. We consider APACHE-II as a valuable scoring system to predict mortality. We do not consider age as a predictor of mortality. Therefore, we do not suggest its use as a sole prognostic marker in ICU patients.

Among Trauma Patients, Younger Men with Ventilator-Associated Pneumonia Have Worse Outcomes Compared to Older Men-An Exploratory Study

Background: Ventilator-associated pneumonia is associated with significant morbidity. Although the association of gender with outcomes in trauma patients has been debated for years, recently, certain authors have demonstrated a difference. We sought to compare the outcomes of younger men and women to older men and women, among critically ill trauma patients with ventilator-associated pneumonia (VAP). Methods: We reviewed our trauma data base for trauma patients with ventilator-associated pneumonia admitted to our trauma intensive care unit between January 2016 and June 2018. Data collected included demographics, injury mechanism and severity (ISS), admission vital signs and laboratory data and outcome measures including hospital length of stay, ICU stay and survival. Patients were also divided into younger (<50) and older (≥50) to account for hormonal status. Linear regression and binary logistic regression models were performed to compare younger men to older men and younger women to older women, and to examine the association between gender and hospital length of stay (LOS), ICU stay (ICUS), and survival. Results: Forty-five trauma patients admitted to our trauma intensive care unit during the study period (January 2016 to August 2018) had ventilator-associated pneumonia. The average age was 58.9 ± 19.6 years with mean ISS of 18.2 ± 9.8. There were 32 (71.1%) men, 27 (60.0%) White, and 41 (91.1%) had blunt trauma. Mean ICU stay was 14.9 ± 11.4 days and mean total hospital length of stay (LOS) was 21.5 ± 14.6 days. Younger men with VAP had longer hospital LOS 28.6 ± 17.1 days compared to older men 16.7 ± 6.6 days, (p < 0.001) and longer intensive care unit stay 21.6 ± 15.6 days compared to older men 11.9 ± 7.3 days (p = 0.02), there was no significant difference in injury severity (ISS was 22.2 ± 8.4 vs. 17 ± 8, p = 0.09). Conclusions: Among trauma patients with VAP, younger men had longer hospital length of stay and a trend towards longer ICU stay. Further research should focus on the mechanisms behind this difference in outcome using a larger database.

The effect of aspirin in preventing the acute respiratory distress syndrome/acute lung injury: A meta-analysis

BACKGROUND

The effects of aspirin in preventing the occurrence of acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) among adult patients are controversial. We aimed to further determine the effectiveness of aspirin in reducing the rate of ARDS/ALI.

METHODS

The Pubmed, Embase, Medline, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all controlled studies that research the role of aspirin in adult patients who have the risk of ARDS/ALI. The outcomes were the ARDS/ALI rate and the mortality. Cochrane systematic review software, Review Manager (RevMan), the R software for statistical computing version 3.2.0, and the metafor package were used to test the hypothesis by Mann-Whitney U test. The heterogeneity test and sensitivity analyses were conducted, and random-effects or fixed-effects model was applied to calculate odds ratio (OR) and mean difference (MD) for dichotomous and continuous data, respectively.

RESULTS

Six trials involving 6562 patients were pooled in our final study. No significant heterogeneity was found in outcome measures. Aspirin could reduce the rate of ARDS/ALI (OR 0.71, 95% confidence interval (CI) 0.58-0.86) but not the mortality (OR 0.87, 95% CI 0.71-1.07).

CONCLUSIONS

In patients with risk of ARDS/ALI, aspirin could provide protective effect on the rate of ARDS/ALI, but it could not reduce the mortality.

Enhancing research publications and advancing scientific writing in health research collaborations: sharing lessons learnt from the trenches

BACKGROUND

Disseminating research protocols, processes, methods or findings via peer-reviewed publications has substantive merits and benefits to various stakeholders.

PURPOSE

In this article, we share strategies to enhance research publication contents (ie, what to write about) and to facilitate scientific writing (ie, how to write) in health research collaborations.

METHODS

Empirical experience sharing.

RESULTS

To enhance research publication contents, we encourage identifying appropriate opportunities for publications, publishing protocols ahead of results papers, seeking publications related to methodological issues, considering justified secondary analyses, and sharing academic process or experience. To advance writing, we suggest setting up scientific writing as a goal, seeking an appropriate mentorship, making full use of scientific meetings and presentations, taking some necessary formal training in areas such as effective communication and time and stress management, and embracing the iterative process of writing.

CONCLUSION

All the strategies we share are dependent upon each other; and they advocate gradual academic accomplishments through study and training in a "success-breeds-success" way. It is expected that the foregoing shared strategies in this paper, together with other previous guidance articles, can assist one with enhancing research publications, and eventually one's academic success in health research collaborations.

Can high-flow nasal cannula reduce the rate of reintubation in adult patients after extubation? A meta-analysis

BACKGROUND

The effects of high flow nasal cannula (HFNC) on adult patients after extubation remain controversial. We aimed to further determine the effectiveness of HFNC in comparison to noninvasive positive pressure ventilation (NIPPV) and conventional oxygen therapy (COT).

METHODS

The Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trails (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all the controlled study comparing HFNC with NIPPV and COT in adult patients after extubation. The primary outcome was rate of reintubation and the secondary outcomes were intensive care unit (ICU) mortality and length of ICU stay (ICU LOS).

RESULTS

Eight trials with a total of 2936 patients were pooled in our final studies. No significant heterogeneity was found in outcome measures. Compared with COT, HFNC was associated with lower rate of reintubation (Z = 2.97, P = 0.003), and the same result was found in the comparison between HFNC and NIPPV (Z = 0.87, P = 0.38). As for the ICU mortality and ICU LOS, we did not find any advantage of HFNC over COT or NIPPV.

CONCLUSIONS

In patients after extubation, HFNC is a reliable alternative of NIPPV to reduce rate of reintubation compared with COT.

The effect of high-flow nasal cannula in reducing the mortality and the rate of endotracheal intubation when used before mechanical ventilation compared with conventional oxygen therapy and noninvasive positive pressure ventilation. A systematic review and meta-analysis

BACKGROUND

The effects of high flow nasal cannula (HFNC) on adult patients when used before mechanical ventilation (MV) are unclear. We aimed to determine the effectiveness of HFNC when used before MV by comparison to conventional oxygen therapy (COT) and noninvasive positive pressure ventilation (NIPPV).

METHODS

The Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all the controlled studies that compared HFNC with NIPPV and COT when used before MV in adult patients. The primary outcome was the rate of endotracheal intubation and the secondary outcomes were intensive care unit (ICU) mortality and length of ICU stay (ICU LOS).

RESULTS

Eight trials with a total of 1084 patients were pooled in our final studies. No significant heterogeneity was found in outcome measures. Compared both with COT and NIPPV, HFNC could reduce both of the rate of endotracheal intubation (OR 0.62, 95% CI 0.38-0.99, P=0.05; OR 0.48, 95% CI 0.31-0.73, P=0.0006) and ICU mortality (OR 0.47, 95% CI 0.24-0.93, P=0.03; OR 0.36, 95% CI 0.20-0.63, P=0.0004). As for the ICU LOS, we did not find any advantage of HFNC over COT or NIPPV.

CONCLUSIONS

When used before MV, HFNC can improve the prognosis of patients compared both with the COT and NIPPV.

Can High-flow Nasal Cannula Reduce the Rate of Endotracheal Intubation in Adult Patients With Acute Respiratory Failure Compared With Conventional Oxygen Therapy and Noninvasive Positive Pressure Ventilation?: A Systematic Review and Meta-analysis

BACKGROUND

The effects of high-flow nasal cannula (HFNC) on adult patients with acute respiratory failure (ARF) are controversial. We aimed to further determine the effectiveness of HFNC in reducing the rate of endotracheal intubation in adult patients with ARF by comparison to noninvasive positive pressure ventilation (NIPPV) and conventional oxygen therapy (COT).

METHODS

The PubMed, Embase, Medline, and the Cochrane Central Register of Controlled Trials databases, as well as the Information Sciences Institute Web of Science, were searched for all controlled studies that compared HFNC with NIPPV and COT in adult patients with ARF. The primary outcome was the rate of endotracheal intubation; the secondary outcomes were ICU mortality and length of ICU stay.

RESULTS

Eighteen trials with a total of 3,881 patients were pooled in our final studies. Except for ICU mortality (I² = 67%, χ² = 12.21, P = .02) and rate of endotracheal intubation (I² = 63%, χ² = 13.51, P = .02) between HFNC and NIPPV, no significant heterogeneity was found in outcome measures. Compared with COT, HFNC was associated with a lower rate of endotracheal intubation (z = 2.55, P = .01) while no significant difference was found in the comparison with NIPPV (z = 1.40, P = .16). As for ICU mortality and length of ICU stay, HFNC did not exhibit any advantage over either COT or NIPPV.

CONCLUSIONS

In patients with ARF, HFNC is a more reliable alternative than NIPPV to reduce the rate of endotracheal intubation than COT.