Chest
Volume 126, Issue 1, July 2004, Pages 165-172
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Clinical Investigations in Critical Care
The Use of Noninvasive Ventilation in Acute Respiratory Failure at a Tertiary Care Center

https://doi.org/10.1378/chest.126.1.165Get rights and content

Objective:

Financial constraints and bed limitations frequently prevent admission of ill patients to a critical care setting. We surveyed the use of treatment with noninvasive ventilation (NIV) in clinical practice by physicians in a tertiary care, university-based teaching hospital and compared our findings with published recommendations for the use of NIV.

Methods:

Data were collected prospectively on all patients with acute respiratory failure (ARF) for whom NIV was ordered over a 5-month period. The respiratory therapy department was responsible for administering NIV on written order by a physician. The respiratory therapist completed a survey form with patient tracking data for each initiation of NIV. The investigators then surveyed the clinical chart for clinical data.

Results:

NIV was utilized for the treatment of ARF on 75 occasions during the 5-month period. Fourteen patients (18%) received NIV for a COPD exacerbation, and 61 patients (82%) received it for respiratory failure of other etiologies. NIV was initiated in the emergency department in 32% of patients, in a critical care setting in 27% of patients, in a ward observation unit in 23% of patients, and on a general medical or surgical ward in 18% of patients. Arterial blood gases (ABGs) were measured on 68 occasions prior to the initiation of NIV, and 51 patients had an ABG measurement within the first 6 h of treatment. The mean pH at baseline was 7.29, and 33% of patients had a baseline pH of < 7.25. Seven patients required endotracheal intubation (ETI) [13%], and there were 18 deaths (24%) with patients having do-not-resuscitate orders, accounting for 12 deaths.

Conclusion:

NIV is commonly used outside of a critical care setting. Our outcomes of ETI and death were similar to those cited in the literature despite less aggressive monitoring of these patients.

Section snippets

Materials and Methods

Between June 6 and November 1, 2001, 81 consecutive applications of NIV at the Royal University Hospital in Saskatoon, Canada, were prospectively followed. The inclusion criterion was that NIV be initiated for the treatment of ARF on the decision of the ordering physician. The exclusion criterion was the initiation of NIV for suspected or established sleep-disordered breathing (SDB). Individual patients were eligible to be included in the study on more than one occasion if there were separate

Results

During the study period, 77 patients received NIV. Six were excluded for SDB. Seventy-one patients received NIV for the treatment of ARF. Of these patients, two had two separate hospital admissions and one patient had three separate hospital admissions for ARF requiring NIV. In total, 75 records were reviewed. As each utilization of NIV occurred during a separate hospital admission, each record was considered as a separate patient (75 records). Baseline characteristics of the patients are shown

Discussion

To the best of our knowledge, this is the first report of how NIV is being used in a tertiary care hospital in a nonstudy setting. Girault et al5 recently published an observational retrospective cohort study that assessed the outcomes of NIV in daily practice in a non-protocol-driven study, but those patients were all managed in a medical ICU.

Studies utilize NIV protocol strategies in closely monitored locations with experienced staff. Monthly training sessions on NIV are given to rotating

Conclusion

Our audit of NIV use in a university-based, tertiary care teaching hospital revealed results that were similar to those found in the literature. Several patients with significant respiratory acidosis and those not fit for ETI were discharged from the hospital after treatment with NIV. Patients in whom NIV was initiated outside of a critical care unit did not appear to have worse outcomes.

ACKNOWLEDGMENT

Special thanks to the respiratory therapy department at Royal University Hospital for their assistance in collecting data.

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