Vilaça Marta, Aragão Irene, Cardoso Teresa, Dias Cláudia, Cabral-Campello Glória
Medicine Integrated Master (MIM), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Oporto University (UP), Porto, Portugal.
Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal.
PLoS One. 2016 Feb 22;11(2):e0149649. doi: 10.1371/journal.pone.0149649. eCollection 2016.
Noninvasive ventilation (NIV) is being used increasingly in patients who have a "do not intubate" (DNI) order. However, the impact of NIV on the clinical and health-related quality of life (HRQOL) in the emergency setting is not known, nor is its effectiveness for relieving symptoms in end-of-life care.
The aim of this prospective study was to determine the outcome and HRQOL impact of regular use of NIV outcomes on patients with a DNI order who were admitted to the emergency room department (ED).
Eligible for participation were DNI-status patients who receive NIV for acute or acute-on-chronic respiratory failure when admitted to the ED of a tertiary care, university-affiliated, 600-bed hospital between January 2014 and December 2014. Patients were divided into 2 groups: (1) those whose DNI order related to a decision to withhold therapy and (2) those for whom any treatment, including NIV, was provided for symptom relief only. HRQOL was evaluated only in group 1, using the 12-item Short Form Health Survey (SF-12). Long-term outcome was evaluated 90 days after hospital discharge by means of a telephone interview.
During the study period 1727 patients were admitted to the ED, 243 were submitted to NIV and 70 (29%) were included in the study. Twenty-nine (41%) of the 70 enrollees received NIV for symptom relief only (group2). Active cancer [7% vs 35%, p = 0,004] and neuromuscular diseases [0% vs. 17%] were more prevalent in this group. NIV was stopped in 59% of the patients in group 2 due to lake of clinical benefit. The in-hospital mortality rate was 37% for group 1 and 86% for group 2 0,001). Among patients who were discharged from hospital, 23% of the group 1 and all patients in group 2 died within 90 days. Relative to baseline, no significant decline in HRQOL occurred in group 1 by 90 days postdischarge.
The survival rate was 49% among DNI-status patients for whom NIV was used as a treatment in ED, and these patients did not experience a decline in HRQOL throughout the study. NIV did not provide significant relief of symptoms in more than half the patients who receive it for that purpose.
无创通气（NIV）在有“不插管”（DNI）医嘱的患者中使用越来越多。然而，在急诊环境中NIV对临床及健康相关生活质量（HRQOL）的影响尚不清楚，其在临终关怀中缓解症状的有效性也未知。
这项前瞻性研究的目的是确定对入住急诊室（ED）的有DNI医嘱的患者定期使用NIV的结果及对HRQOL的影响。
符合参与条件的是2014年1月至2014年12月期间入住一家拥有600张床位的大学附属医院三级医疗中心急诊室、因急性或慢性呼吸衰竭接受NIV的DNI状态患者。患者分为两组：（1）DNI医嘱与决定停止治疗相关的患者；（2）仅为缓解症状而接受包括NIV在内任何治疗的患者。仅在第1组中使用12项简短健康调查问卷（SF - 12）评估HRQOL。出院90天后通过电话访谈评估长期结果。
研究期间，1727名患者入住急诊室，243名接受NIV，70名（29%）纳入研究。70名受试者中有29名（41%）仅为缓解症状接受NIV（第2组）。该组中活动性癌症[7%对35%，p = 0.004]和神经肌肉疾病[0%对17%]更为常见。第2组中59%的患者因缺乏临床益处而停用NIV。第1组的院内死亡率为37%，第2组为86%（p = 0.001）。出院患者中，第1组的23%和第2组的所有患者在90天内死亡。相对于基线，出院后90天第1组的HRQOL没有显著下降。
在急诊中使用NIV治疗的DNI状态患者生存率为49%，且在整个研究过程中这些患者的HRQOL没有下降。NIV对超过半数为此目的接受治疗的患者没有显著缓解症状的作用。
