Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications

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Abstract

Background

Noninvasive positive-pressure ventilation (NIPPV) use has increased in the treatment of patients with respiratory failure. However, despite decreasing the need for intubation in some patients, there are no data regarding the risk of intubation-related complications associated with delayed intubation in adult patients who fail NIPPV. The objective of this study is to evaluate the odds of a composite complication of intubation following failed NIPPV compared to patients intubated primarily in the medical intensive care unit (ICU).

Methods

This is a single-center retrospective cohort study of 235 patients intubated between 1 January 2012 and 30 June 2013 in a medical ICU of a university medical center. A total of 125 patients were intubated after failing NIPPV, 110 patients were intubated without a trial of NIPPV. Intubation-related data were collected prospectively through a continuous quality improvement (CQI) program and retrospectively extracted from the medical record on all patients intubated on the medical ICU. A propensity adjustment for the factors expected to affect the decision to initially use NIPPV was used, and the adjusted multivariate regression analysis was performed to evaluate the odds of a composite complication (desaturation, hypotension, or aspiration) with intubation following failed NIPPV versus primary intubation.

Results

A propensity-adjusted multivariate regression analysis revealed that the odds of a composite complication of intubation in patients who fail NIPPV was 2.20 (CI 1.14 to 4.25), when corrected for the presence of pneumonia or acute respiratory distress syndrome (ARDS), and adjusted for factors known to increase complications of intubation (total attempts and operator experience). When a composite complication occurred, the unadjusted odds of death in the ICU were 1.79 (95% CI 1.03 to 3.12).

Conclusions

After controlling for potential confounders, this propensity-adjusted analysis demonstrates an increased odds of a composite complication with intubation following failed NIPPV. Further, the presence of a composite complication during intubation is associated with an increased odds of death in the ICU.

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Most cited references 36

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Effect of failed extubation on the outcome of mechanical ventilation.

Scott K Epstein, Ronald Ciubotaru, John B. Wong (1997)

To examine medical outcomes associated with reintubation for extubation failure after discontinuation of mechanical ventilation. Prospective cohort study of consecutive intubated medical ICU patients who underwent a trial of extubation at a tertiary-care teaching hospital. The failed extubation group consisted of all patients reintubated within 72 h or within 7 days (if continuous ICU care had been required) of extubation. All others were considered to be successfully extubated. Study end points included hospital death vs survival, the number of days spent in the ICU and in the hospital after the onset of mechanical ventilation, the likelihood of requiring > or = 7 or > or = 14 days of ICU care after extubation, and the need for transfer to either a long-term care or rehabilitation facility among the survivors. Of 289 intubated patients, 247 (85%) were successfully extubated, and 42 (15%) required reintubation for failed extubation (time to reintubation 1.5+/-0.2 days). Reintubation for extubation failure resulted in 12 additional days of mechanical ventilation. When compared with successfully extubated patients, reintubated patients were more likely to die in the hospital (43% vs 12%; p or = 14 days in the ICU after extubation, and six times (p<0.001) more likely to need transfer to a long-term care or rehabilitation facility if they survived. After adjusting for severity of illness and comorbid conditions, extubation failure had a significant independent association with increased risk for death, prolonged ICU stay, and transfer to a long-term care or rehabilitation facility. Extubation failure may serve as an additional independent marker of severity of illness. Alternatively, poor outcomes may be etiologically related to extubation failure. If the latter proves to be the case, identifying patients at risk for poor outcomes from extubation failure and instituting alternative care practices may reduce mortality, duration of ICU stay, and need for transfer to a long-term care facility.

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Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group.

A. Esteban, I Alía, M Tobin … (1999)

The duration of spontaneous breathing trials before extubation has been set at 2 h in research studies, but the optimal duration is not known. We conducted a prospective, multicenter study involving 526 ventilator-supported patients considered ready for weaning, to compare clinical outcomes for trials of spontaneous breathing with target durations of 30 and 120 min. Of the 270 and 256 patients in the 30- and 120-min trial groups, respectively, 237 (87.8%) and 216 (84.8%), respectively, completed the trial without distress and were extubated (p = 0.32); 32 (13.5%) and 29 (13.4%), respectively, of these patients required reintubation within 48 h. The percentage of patients who remained extubated for 48 h after a spontaneous breathing trial did not differ in the 30- and 120-min trial groups (75.9% versus 73.0%, respectively, p = 0.43). The 30- and 120-min trial groups had similar within-unit mortality rates (13 and 9%, respectively) and in-hospital mortality rates (19 and 18%, respectively). Reintubation was required in 61 (13.5%) patients, and these patients had a higher mortality (20 of 61, 32.8%) than did patients who tolerated extubation (18 of 392, 4.6%) (p < 0.001). Neither measurements of respiratory frequency, heart rate, systolic blood pressure, and oxygen saturation during the trial, nor other functional measurements before the trial discriminated between patients who required reintubation from those who tolerated extubation. In conclusion, after a first trial of spontaneous breathing, successful extubation was achieved equally effectively with trials targeted to last 30 and 120 min.

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Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group.

A. Esteban, I Alía, F Gordo … (1997)

A 2-h T-tube trial of spontaneous breathing was used in selecting patients ready for extubation and discontinuation of mechanical ventilation. However, some doubt remains as to whether it is the most appropriate method of performing a spontaneous breathing trial. We carried out a prospective, randomized, multicenter study involving patients who had received mechanical ventilation for more than 48 h and who were considered by their physicians to be ready for weaning according to clinical criteria and standard weaning parameters. Patients were randomly assigned to undergo a 2-h trial of spontaneous breathing in one of two ways: with a T-tube system or with pressure support ventilation of 7 cm H2O. If a patient had signs of poor tolerance at any time during the trial, mechanical ventilation was reinstituted. Patients without these features at the end of the trial were extubated. Of the 246 patients assigned to the T-tube group, 192 successfully completed the trial and were extubated; 36 of them required reintubation. Of the 238 patients in the group receiving pressure support ventilation, 205 were extubated and 38 of them required reintubation. The percentage of patients who remained extubated after 48 h was not different between the two groups (63% T-tube, 70% pressure support ventilation, p = 0.14). The percentage of patients falling the trial was significantly higher when the T-tube was used (22 versus 14%, p = 0.03). Clinical evolution during the trial was not different in patients reintubated and successfully extubated. ICU mortality among reintubated patients was significantly higher than in successfully extubated patients (27 versus 2.6%, p < 0.001). Spontaneous breathing trials with pressure support or T-tube are suitable methods for successful discontinuation of ventilator support in patients without problems to resume spontaneous breathing.

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Author and article information

Contributors

Jarrod M Mosier: jmosier@aemrc.arizona.edu

John C Sakles: sakles@aemrc.arizona.edu

Sage P Whitmore: swhitmor@med.umich.edu

Cameron D Hypes: chypes@aemrc.arizona.edu

Danielle K Hallett: dhallett@aemrc.arizona.edu

Katharine E Hawbaker: khawbaker@aemrc.arizona.edu

Linda S Snyder: lsnyder@deptofmed.arizona.edu

John W Bloom: jbloom@deptofmed.arizona.edu

Journal

Journal ID (nlm-ta): Ann Intensive Care

Journal ID (iso-abbrev): Ann Intensive Care

Title: Annals of Intensive Care

Publisher: Springer Paris (Paris )

ISSN (Electronic): 2110-5820

Publication date (Electronic): 6 March 2015

Publication date PMC-release: 6 March 2015

Publication date Collection: 2015

Volume: 5

Electronic Location Identifier: 4

Affiliations

[ ]Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA

[ ]Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA

[ ]Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, 1500 E Medical Center Drive, Ann Arbor, MI 48109 USA

[ ]University of Arizona, 1609N Warren, FOB 122C, Tucson, AZ 85719 USA

Article

Publisher ID: 44

DOI: 10.1186/s13613-015-0044-1

PMC ID: 4385202

PubMed ID: 25852964

SO-VID: 3267e880-f400-411e-b8e3-d9bf5285f13a

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

History

Date received : 14 November 2014

Date accepted : 17 February 2015

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intubation,critical care,nippv,noninvasive positive pressure,airway management,desaturation,hypotension,aspiration,delayed intubation

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intubation, critical care, nippv, noninvasive positive pressure, airway management, desaturation, hypotension, aspiration, delayed intubation

Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications

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Abstract

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Preventive and Emergency Medicine Insights

Most cited references 36

Effect of failed extubation on the outcome of mechanical ventilation.

Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group.

Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group.

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