Noninvasive positive pressure ventilation (NIV) had transformed the concept of mechanical ventilation with the main advantage of avoiding invasive mechanical ventilation (IMV) in selected patients. Clinical trials have shown that NIV improves outcomes in patients with hypercapnic respiratory failure due to COPD and several studies have reported an increase in NIV use in patients with COPD worldwide. However, there is a significant uncertainty about the efficacy of NIV in patients with asthma despite reports that the use of NIV in patients with asthma had increased.
The goal of this proposal was to examine current ventilation management practices and outcomes in patients with asthma and COPD in a large registry of hospitals and assess patient and hospital characteristics associated with the use of NIV in clinical practice. We hypothesized that the adoption of NIV as an alternative to IMV as initial ventilation strategy will vary substantially across hospitals and according to patient characteristics, and that, after adjusting for differences between patients, treatment with NIV will be associated with better clinical outcomes compared to IMV.
In the first aim of the proposal we examined trends in the use of NIV among more than 700, 000 patients with acute exacerbation of COPD over the period 2001 - 2011 in a large and representative network of 475 US hospitals and identified patient factors influencing its use. We found that initial NIV use increased (from 5.9% to 14.8%), and initial IMV declined (from 8.7% to 5.9%). Elderly patients had higher odds of receiving NIV, while blacks and Hispanics were less likely to be treated with NIV than whites. Cases with a high burden of comorbidities and those with concomitant pneumonia had high rates of NIV failure and were more likely to receive initial IMV.
For the second and third aim of the proposal we conducted a retrospective cohort study of more than 13,000 hospitalizations for an exacerbation of asthma at 100 hospitals using a detailed electronic medical record database. We found that NIV use had doubled in 4 years; similar with patients with COPD, elderly patients with asthma were more likely to receive initial NIV while those with higher acuity and those with concomitant pneumonia were less likely to receive NIV. Use of NIV was associated with significantly lower in-patient risk of dying and shorter lengths of stay. Patients with NIV failure had the highest mortality and pneumonia was a risk factor for failure. We found large variation in hospital use of NIV for patients with an acute exacerbation of asthma and hospitals with higher NIV rates did not have lower IMV rates suggesting an expansion in the use of assisted ventilation.
|Advisor:||Lindenauer, Peter K.|
|Commitee:||Goldberg, Robert, Kent, David, Pekow, Penelopw|
|School:||Sackler School of Graduate Biomedical Sciences (Tufts University)|
|Department:||Clinical & Translational Science|
|School Location:||United States -- Massachusetts|
|Source:||DAI-B 77/04(E), Dissertation Abstracts International|
|Keywords:||Asthma, Chronic obstructive pulmonary disease, Lung disease, Mechanical ventilation, Noninvasive ventilation, Respiratory failure|
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