Mosier Jarrod M, Sakles John C, Whitmore Sage P, Hypes Cameron D, Hallett Danielle K, Hawbaker Katharine E, Snyder Linda S, Bloom John W
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 ; University of Arizona, 1609N Warren, FOB 122C, Tucson, AZ 85719 USA.
Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA.
Ann Intensive Care. 2015 Mar 6;5:4. doi: 10.1186/s13613-015-0044-1. eCollection 2015.
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).
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.
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).
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.
无创正压通气（NIPPV）在呼吸衰竭患者治疗中的应用有所增加。然而，尽管在某些患者中减少了插管需求，但对于NIPPV治疗失败的成年患者，关于延迟插管相关并发症风险的数据尚不存在。本研究的目的是评估与在医疗重症监护病房（ICU）直接插管的患者相比，NIPPV治疗失败后插管综合并发症的几率。
这是一项单中心回顾性队列研究，研究对象为2012年1月1日至2013年6月30日在一所大学医学中心的医疗ICU接受插管的235例患者。共有125例患者在NIPPV治疗失败后插管，110例患者未进行NIPPV试验即插管。通过持续质量改进（CQI）计划前瞻性收集插管相关数据，并从医疗ICU所有插管患者的病历中回顾性提取数据。对预期影响初始使用NIPPV决策的因素进行倾向调整，并进行调整后的多变量回归分析，以评估NIPPV治疗失败后插管与直接插管相比发生综合并发症（低氧血症、低血压或误吸）的几率。
倾向调整后的多变量回归分析显示，在校正肺炎或急性呼吸窘迫综合征（ARDS）的存在，并对已知会增加插管并发症的因素（总尝试次数和操作者经验）进行调整后，NIPPV治疗失败患者插管综合并发症的几率为2.20（95%CI 1.14至4.25）。当发生综合并发症时，ICU中未调整的死亡几率为1.79（95%CI 1.03至3.12）。
在控制潜在混杂因素后，这项倾向调整分析表明，NIPPV治疗失败后插管综合并发症的几率增加。此外，插管期间出现综合并发症与ICU中死亡几率增加相关。
