Non-invasive positive pressure ventilation in pneumonia outside Intensive Care Unit: An Italian multicenter observational study

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Highlights

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    In pneumonia, CPAP was used mainly for non-hypercapnic ARF, NPPV for hypercapnic ARF.

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    Mortality was associated to patients' basal status rather than baseline degree of ARF.

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    Intolerance was responsible of clinical failure and death in only 5/60 cases (8%).

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    When CPAP failed, NPPV had a role as rescue treatment (56% survived after switch).

Abstract

Background and objective

Non-Invasive Ventilation (NIV) represents a standard of care to treat some acute respiratory failure (ARF). Data on its use in pneumonia are lacking, especially in a setting outside the Intensive Care Unit (ICU). The aims of this study were to evaluate the use of NIV in ARF due to pneumonia outside the ICU, and to identify risk factors for in-hospital mortality.

Methods

Prospective, observational study performed in 19 centers in Italy. Patients with ARF due to pneumonia treated outside the ICU with either continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) were enrolled over a period of at least 3 consecutive months in 2013. Independent factors related to in-hospital mortality were evaluated.

Results

Among the 347 patients enrolled, CPAP was applied as first treatment in 176 (50.7%) patients,NPPV in 171 (49.3%). The NPPV compared with CPAP group showed a significant higher PaCO2 (55 [47–78] vs 37 [32–43] mmHg, p < 0.001), a lower arterial pH (7.30 [7.21–7.37] vs 7.43 [7.35–7.47], p < 0.001), higher HCO3– (28 [24–33] vs 24 [21–27] mmol/L, p < 0.001). De-novo ARF was more prevalent in CPAP group than in NPPV group (86/176 vs 31/171 patients,p < 0.001). In-hospital mortality was 23% (83/347). Do Not Intubate (DNI) order and Charlson Comorbidity Index (CCI) ≥3 were independent risk factors for in-hospital mortality.

Conclusions

Outside ICU setting, CPAP was used mainly for hypoxemic non-hypercapnic ARF, NPPV for hypercapnic ARF. In-hospital mortality was mainly associated to patients' basal status (DNI status, CCI) rather than the baseline degree of ARF.

Introduction

Acute respiratory failure (ARF) represents a frequent complication in patients with pneumonia with rates up to 56% [1]. Although oxygen therapy is the cornerstone for ARF treatment, its efficacy might be minimized because of shunt effects due to the presence of pulmonary exudate and atelectasis.To improve oxygenation, alveolar recruitment obtained through the application of either invasive or non-invasive mechanical ventilation (NIV) might be necessary, especially in severe pneumonia [2,3].

The role of NIV as a tool to treat ARF has dramatically increased over the past decades and its efficacy has been well studied in clinical practice, especially in treating acute cardiogenic pulmonary edema (ACPE) and exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Concerning NIV treatment in ARF patients with pneumonia, its use has been proved to be effective only in patients with COPD [4] and in immunocompromised patients with lung infiltrates [5,6]. The lack of strong evidence in literature led international experts to suggest only cautious trials of NIV in well-selected patients with pneumonia and in trained settings with a clear caveat to avoid a delay in endotracheal intubation [7].

Recent audits reported a use of NIV in patients with ARF due to pneumonia in different settings. According to a recent European survey, up to 17% patients with non-hypercapnic ARF, including those with community-acquired pneumonia (CAP), were treated with NIV [8]. An Italian survey investigated NIV use outside the Intensive Care Unit (ICU) and reported 41% of the participating hospitals using NIV to treat pneumonia in non-immunocompromised patients and 63% pneumonia in immunocompromised patients[9]. Two recent randomized controlled trials (RCTs) also showed the efficacy of Continuous Positive Airway Pressure (CPAP) versus standard oxygen therapy in mild-to-severe pneumonia in a selected population [2,10]. Although supported by limited evidence, the application of NIV in ARF patients with pneumonia seems to be widely applied in clinical practice.

The aims of this study were to evaluate NIV use in “real life” to treat ARF due to pneumonia outside the ICU in Italy, comparing CPAP versus noninvasive positive pressure ventilation (NPPV), and to identify risk factors for in-hospital mortality in these patients.

Section snippets

Materialsandmethods

This was a prospective, multi-center, observational study enrolling consecutive patients with ARF due topneumonia admitted to 14 Emergency Departments (ERs) and 5 High Dependent Units (HDU) in Italy during a period of at least three consecutive months between 1st January 2013 to 31st December 2013. The study protocol was approved by the Ethic Committees of all the participating centers and all patients signed an informed consent.

Patients were included in the study if all of the following

General description of the population

A total of 347 patients (median age: 77 [IQR 66–85] years old, 57% men) with ARF due to pneumonia who were treated with either CPAP or NPPV were enrolled across 19 hospitals during the study period (Table 1).

Two hundred and ninety-six patients (85.4%) had CAP, while 51 patients (14.6%) had hospital acquired pneumonia (HAP). A microbiological diagnosis of pneumonia was obtained in 20% of the patients.

CPAP was applied in 176 (50.7%) and NPPV in 171 (49.3%) patients. NIV treatment was started in

Discussion

The main findings of our study were: a) CPAP was used mainly in patients with hypoxemic not-hypercapnic ARF and in the de novo ARF, in line with previous European literature [2,10] b) NPPV was preferred in patients with acute on chronic respiratory failure c) CPAP was applied mainly with high-flow stand-alone generators rather than ventilators and the helmet was the most used interface d) in-hospital mortality are mainly associated to global severity of patients (DNI status, CCI) rather than

Funding

This research received no specific funding.

Competing interests

Authors have no conflict of interests to disclose.

Data accessibility

Data are available by writing to corrisponding author.

Declarations of interest

none.

Acknowledgments

we thank all the clinicians and patients who took part in the study.

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