Theme Issue Editorial
Missed opportunities for noninvasive positive pressure ventilation: A utilization review☆

https://doi.org/10.1016/j.jcrc.2007.04.002Get rights and content

Abstract

Background

Although noninvasive positive pressure ventilation (NPPV) improves outcomes in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), it may be underutilized outside the controlled trial setting.

Purpose

The purpose of this study is to determine the proportion of patients who met criteria for a trial of NPPV but were emergently intubated and mechanically ventilated without receiving a trial of NPPV.

Methods

We retrospectively reviewed charts of patients who were intubated and ventilated or who received NPPV on admission to one intensive care unit and who had an intensive care unit admitting diagnosis of either exacerbation of COPD or CHF during the period from November 1998 to July 2003.

Results

Of the 243 patients who had an admitting diagnosis of COPD or CHF, 59 (24.3%) met explicit criteria for a trial of NPPV. Only 20 (33.9%) of 59 had a trial of NPPV. The remaining 39 (66%) of 59 did not receive a trial of NPPV and were intubated.

Interpretation

Nearly two thirds of patients who appeared to meet criteria for NPPV did not receive a trial of this intervention. There is an opportunity to improve the use of NPPV in these patients. Systematic knowledge translation strategies such as guideline implementation and interactive educational interventions may optimize the appropriate use of NPPV.

Introduction

Randomized controlled trials have shown that noninvasive positive pressure ventilation (NPPV) reduces the rate of endotracheal intubation and hospital mortality in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD) [1], [2], [3], [4] and reduces the rate of endotracheal intubation in patients who have congestive heart failure (CHF) [5], [6], [7]. Noninvasive positive pressure ventilation may also improve clinical outcomes in other patients, including those who develop hypoxemic respiratory failure after thoracotomy [8], immunosuppressed patients [9], [10], and selected patients who are weaning from mechanical ventilation [11]. Respiratory muscle rest, increased alveolar ventilation, and reduced work of breathing are the most likely mechanisms for the decreased need for intubation in these patients [12]. Work of breathing in COPD may be decreased because the application of externally applied positive end-expiratory pressure helps overcome the additional work related to intrinsic positive end-expiratory pressure [13], [14]. The reduction in mortality is partly due to a lower incidence of nosocomial pneumonia in patients treated with NPPV compared with those who are treated with invasive mechanical ventilation [15].

To increase the appropriate use of NPPV, a practice guideline for the use of NPPV in patients who have acute respiratory failure due to COPD and CHF was recently developed and implemented [16]. Although the use of NPPV has increased, especially in European centers [17], [18], [19], the appropriate utilization of this ventilation strategy in Canada has only recently been investigated [20], [21]. These 2 studies suggest, and we hypothesized, that NPPV remains underutilized. The objective of this study was to determine the proportion of patients admitted to a tertiary care intensive care unit (ICU) who required assisted ventilation due to an exacerbation of COPD or CHF and who met criteria for NPPV but who did not receive it.

Section snippets

Methods

We conducted a retrospective chart review of ICU admissions between November 1998 and July 2003 at St. Paul's Hospital, a tertiary care teaching hospital in Vancouver, Canada, that has 400 acute care beds including a 13-bed medical-surgical ICU. Wards capable of caring for intubated patients include the ICU, cardiac care unit (CCU), and the cardiovascular surgery ICU, but most patients who have acute respiratory failure due to any cause are treated in the ICU. There currently is no high

Results

Between November 1998 and July 2003, 2619 patients were admitted to the ICU at St. Paul's Hospital. Of these, 243 patients (mean age, 63 ± 39 years; 35% females) had an ICU admitting diagnosis of exacerbation of COPD or CHF and were intubated and ventilated or receiving NPPV at the time of ICU admission or shortly thereafter. Ninety-six percent of all patients who received assisted ventilation due to exacerbation of COPD or CHF were either intubated and ventilated or received NPPV within the

Interpretation

Noninvasive positive pressure ventilation has been shown to reduce mortality, length of hospital stay, and the need for invasive mechanical ventilation [1], [2], [3], [4] in specific populations of patients. Despite these known potential benefits, we found that 66% of patients who appeared to be eligible for a trial of NPPV did not receive it. Given the demonstrated benefits of NPPV in large randomized controlled studies and systematic reviews, our findings suggest that there is an opportunity

References (32)

  • I. Auriant et al.

    Noninvasive ventilation reduces mortality in acute respiratory failure following lung resection

    Am J Respir Crit Care Med

    (2001)
  • M. Antonelli et al.

    Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation

    JAMA

    (2000)
  • G. Hilbert et al.

    Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure

    N Engl J Med

    (2001)
  • K. Burns et al.

    Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure

    Cochrane Lib Issue

    (2003)
  • S. Mehta et al.

    Noninvasive ventilation

    Am J Respir Crit Care Med

    (2001)
  • P. Goldberg et al.

    Efficacy of noninvasive CPAP in COPD with acute respiratory failure

    Eur Respir J

    (1995)

    • Cited by (29)

    • Noninvasive ventilation during procedural sedation in the ED: A case series

      2015, American Journal of Emergency Medicine

    • Embracing dissemination and implementation research in cardiac critical care

      2014, Global Heart
      Citation Excerpt :

      Despite the strength of the recommendation on the basis of high-quality evidence supporting the first-line use of NPPV in these settings, the majority of patients do not receive this intervention. In one review of patients who had intensive care unit admitting diagnoses of COPD or heart failure and met explicit criteria for a trial of NPPV, only 20 of 59 patients (33.9%) received a trial of NPPV; the remaining 39 patients (66%) were intubated [15]. Similarly, a survey of the directors of respiratory care of all 81 acute care hospitals in the states of Massachusetts and Rhode Island between September 2002 and January 2003 found an overall utilization rate for NPPV of 20% of ventilator starts, with enormous variation in the estimated utilization rates among different hospitals, from none to >50% [12].

    • Invasive and noninvasive mechanical ventilation

      2014, Medicine (Spain)

    • State-of-the-art mechanical ventilation

      2012, Journal of Cardiothoracic and Vascular Anesthesia
      Citation Excerpt :

      Conditions known to respond to NIV include exacerbations of COPD that are complicated by hypercapnic acidosis (PaCO2 >45 mmHg or pH <7.30), cardiogenic pulmonary edema, and hypoxemic respiratory failure. NIV also may be helpful for preventing postextubation respiratory failure.184 Despite evidence of efficacy, NIV may be underused among patients with cardiogenic pulmonary edema or hypercapnic COPD exacerbations.184

    • Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: A multicenter, inception cohort study

      2010, Journal of Critical Care
      Citation Excerpt :

      The decision whether to try NIV or to intubate immediately in COPD patients in respiratory distress is difficult for the attending staff. Many opportunities to try NIV are missed as shown in a recent Canadian study [29]. One reason may be the fear that a trial of NIV in this critically ill group of patients would increase the risk for death.

    • Recent advances in the use of high flow nasal oxygen therapies

      2022, Frontiers in Medicine
    View all citing articles on Scopus
    ☆

    This study was supported by St. Paul's Hospital and The Keenan Foundation; Dr Sinuff is supported by a Clinician Scientist award from the Canadian Institutes for Health Research.

    1

    Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada (conception and design, acquisition of data, analysis and interpretation of data).

    2

    Department of Medicine, Royal Columbian Hospital, University of British Columbia, Vancouver, BC, Canada (conception and design, analysis and interpretation of data).

    3

    Department of Critical Care Medicine and Interdepartmental Division of Critical Care Sunnybrook and Women's College Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada (conception and design, analysis and interpretation of data).

    4

    Program of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada (conception and design, analysis and interpretation of data).

    View full text
    Copyright © 2008 Elsevier Inc. All rights reserved.