Noninvasive Ventilation in Patients with Asthma and Chronic Obstructive Lung Disease:.
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 wit... read moreh 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
Thesis (Ph.D.)--Tufts University, 2015.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: Peter Lindenauer.
Committee: Penelopw Pekow, David Kent, and Robert Goldberg.
Keyword: Medicine.read less