Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study

Luciano C P Azevedo, Marcelo Park, Jorge I F Salluh, Alvaro Rea-Neto, Vicente C Souza-Dantas, Pedro Varaschin, Mirella C Oliveira, Paulo Fernando G M M Tierno, Felipe dal-Pizzol, Ulysses V A Silva, Marcos Knibel, Antonio P Nassar Jr, Rossine A Alves, Juliana C Ferreira, Cassiano Teixeira, Valeria Rezende, Amadeu Martinez, Paula M Luciano, Guilherme Schettino, Marcio Soares, ERICC (Epidemiology of Respiratory Insufficiency in Critical Care) investigators, Amadeu Martinez, Lívia Leal, Antonio Jorge Pereira, Marcelo de Oliveira Maia, José Aires Neto, Claudio Piras, Eliana Bernadete Caser, Cora Lavigne Moreira, Pablo Braga Gusman, Dyanne Moysés Dalcomune, Alexandre Guilherme Ribeiro de Carvalho, Louise Aline Romão Gondim, Lívia Mariane Castelo Branco Reis, Daniel da Cunha Ribeiro, Leonardo de Assis Simões, Rafaela Siqueira Campos, José Carlos Fernandez Versiani dos Anjos, Frederico Bruzzi Carvalho, Rossine Ambrosio Alves, Lilian Batista Nunes, Álvaro Réa-Neto, Mirella Cristine de Oliveira, Luana Tannous, Brenno Cardoso Gomes, Vicente Cés de Souza Dantas, Fernando Borges Rodriguez, Priscila Abelha, Marcelo E Lugarinho, Andre Japiassu, Hélder Konrad de Melo, Alton Afonso Lopes, Pedro Varaschin, Marcos Freitas Knibel, Micheli Ponte, Pedro Mendes de Azambuja Rodrigues, Rubens Carmo Costa Filho, Felipe Saddy, Théia Forny Wanderley Castellões, Suzana Alves Silva, Luiz Antonio Gomes Osorio, Dora Mannarino, Rodolfo Espinoza, Cassia Righy, Marcio Soares, Jorge Salluh, Lilian Tanaka, Daniel Aragão, Maria Eudarda Tavares, Maura Goncalves Pereira Kehdi, Valéria Maria Campos Rezende, Roberto Carlos Cruz Carbonell, Cassiano Teizeira, Roselaine Pinheiro de Oliveira, Juçara Gasparetto Maccari, Priscylla Souza Castro, Paula Berto, Patricia Schwarz, André Peretti Torelly, Thiago Lisboa, Edison Moraes, Felipe Dal-Pizzol, Cristiane Tomasi Damiani, Cristiane Ritter, Juliana Carvalho Ferreira, Ramon Teizeira Costa, Pedro Caruso, Cristina Prata Amendola, Amanda Maria R R de Oliveira, Ulysses V A Silva, Luciana Coelho Sanches, Rosana D S Almeida, Luciano Cesar Azevedo, Marcelo Park, Guilherme Schettino, Murillo Santucci Assunção, Eliezer Silva, Carlos Eduardo Barboza, Antonio Paulo Nassar Junior, Luciano Cesar Azevedo, Marcelo Park, Paulo Fernando Guimarães Morando Marzocchi Tierno, Luis Marcelo Malbouisson, Lucas Oliveira, Davi Cristovao, Manoel Leitão Neto, Ênio Rego, Fernanda Eugênia Fernandes Fernandes, Marcelo Luz Pereira Romano, Alexandre Biasi Cavalcanti, Dalton de Souza Barros, Érica Aranha Suzumura, Karla Loureiro Meira, Gustavo Affonso de Oliveira, Paula Menezes Luciano, Evelin Drociunas Pacheco, Bruno Franco Mazza, Flavia Ribeiro Machado, Elaine Ferreira, Ronaldo Batista dos Santos, Alexandra Siqueira Colombo, Antonio Carlos Nogueira, Juliana Baroni Fernandes, Raquel Siqueira Nóbrega, Barbara do C S Martins, Francisco Soriano, Rafaela Deczka Morsch, Andre Luiz Baptiston Nunes, Juliano Pinheiro de Almeida, Ludhmila Hajjar, Sílvia Moulin, Fábio Poianas Giannini, Luciano C P Azevedo, Marcelo Park, Jorge I F Salluh, Alvaro Rea-Neto, Vicente C Souza-Dantas, Pedro Varaschin, Mirella C Oliveira, Paulo Fernando G M M Tierno, Felipe dal-Pizzol, Ulysses V A Silva, Marcos Knibel, Antonio P Nassar Jr, Rossine A Alves, Juliana C Ferreira, Cassiano Teixeira, Valeria Rezende, Amadeu Martinez, Paula M Luciano, Guilherme Schettino, Marcio Soares, ERICC (Epidemiology of Respiratory Insufficiency in Critical Care) investigators, Amadeu Martinez, Lívia Leal, Antonio Jorge Pereira, Marcelo de Oliveira Maia, José Aires Neto, Claudio Piras, Eliana Bernadete Caser, Cora Lavigne Moreira, Pablo Braga Gusman, Dyanne Moysés Dalcomune, Alexandre Guilherme Ribeiro de Carvalho, Louise Aline Romão Gondim, Lívia Mariane Castelo Branco Reis, Daniel da Cunha Ribeiro, Leonardo de Assis Simões, Rafaela Siqueira Campos, José Carlos Fernandez Versiani dos Anjos, Frederico Bruzzi Carvalho, Rossine Ambrosio Alves, Lilian Batista Nunes, Álvaro Réa-Neto, Mirella Cristine de Oliveira, Luana Tannous, Brenno Cardoso Gomes, Vicente Cés de Souza Dantas, Fernando Borges Rodriguez, Priscila Abelha, Marcelo E Lugarinho, Andre Japiassu, Hélder Konrad de Melo, Alton Afonso Lopes, Pedro Varaschin, Marcos Freitas Knibel, Micheli Ponte, Pedro Mendes de Azambuja Rodrigues, Rubens Carmo Costa Filho, Felipe Saddy, Théia Forny Wanderley Castellões, Suzana Alves Silva, Luiz Antonio Gomes Osorio, Dora Mannarino, Rodolfo Espinoza, Cassia Righy, Marcio Soares, Jorge Salluh, Lilian Tanaka, Daniel Aragão, Maria Eudarda Tavares, Maura Goncalves Pereira Kehdi, Valéria Maria Campos Rezende, Roberto Carlos Cruz Carbonell, Cassiano Teizeira, Roselaine Pinheiro de Oliveira, Juçara Gasparetto Maccari, Priscylla Souza Castro, Paula Berto, Patricia Schwarz, André Peretti Torelly, Thiago Lisboa, Edison Moraes, Felipe Dal-Pizzol, Cristiane Tomasi Damiani, Cristiane Ritter, Juliana Carvalho Ferreira, Ramon Teizeira Costa, Pedro Caruso, Cristina Prata Amendola, Amanda Maria R R de Oliveira, Ulysses V A Silva, Luciana Coelho Sanches, Rosana D S Almeida, Luciano Cesar Azevedo, Marcelo Park, Guilherme Schettino, Murillo Santucci Assunção, Eliezer Silva, Carlos Eduardo Barboza, Antonio Paulo Nassar Junior, Luciano Cesar Azevedo, Marcelo Park, Paulo Fernando Guimarães Morando Marzocchi Tierno, Luis Marcelo Malbouisson, Lucas Oliveira, Davi Cristovao, Manoel Leitão Neto, Ênio Rego, Fernanda Eugênia Fernandes Fernandes, Marcelo Luz Pereira Romano, Alexandre Biasi Cavalcanti, Dalton de Souza Barros, Érica Aranha Suzumura, Karla Loureiro Meira, Gustavo Affonso de Oliveira, Paula Menezes Luciano, Evelin Drociunas Pacheco, Bruno Franco Mazza, Flavia Ribeiro Machado, Elaine Ferreira, Ronaldo Batista dos Santos, Alexandra Siqueira Colombo, Antonio Carlos Nogueira, Juliana Baroni Fernandes, Raquel Siqueira Nóbrega, Barbara do C S Martins, Francisco Soriano, Rafaela Deczka Morsch, Andre Luiz Baptiston Nunes, Juliano Pinheiro de Almeida, Ludhmila Hajjar, Sílvia Moulin, Fábio Poianas Giannini

Abstract

Introduction: Contemporary information on mechanical ventilation (MV) use in emerging countries is limited. Moreover, most epidemiological studies on ventilatory support were carried out before significant developments, such as lung protective ventilation or broader application of non-invasive ventilation (NIV). We aimed to evaluate the clinical characteristics, outcomes and risk factors for hospital mortality and failure of NIV in patients requiring ventilatory support in Brazilian intensive care units (ICU).

Methods: In a multicenter, prospective, cohort study, a total of 773 adult patients admitted to 45 ICUs over a two-month period requiring invasive ventilation or NIV for more than 24 hours were evaluated. Causes of ventilatory support, prior chronic health status and physiological data were assessed. Multivariate analysis was used to identifiy variables associated with hospital mortality and NIV failure.

Results: Invasive MV and NIV were used as initial ventilatory support in 622 (80%) and 151 (20%) patients. Failure with subsequent intubation occurred in 54% of NIV patients. The main reasons for ventilatory support were pneumonia (27%), neurologic disorders (19%) and non-pulmonary sepsis (12%). ICU and hospital mortality rates were 34% and 42%. Using the Berlin definition, acute respiratory distress syndrome (ARDS) was diagnosed in 31% of the patients with a hospital mortality of 52%. In the multivariate analysis, age (odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01 to 1.03), comorbidities (OR, 2.30; 95% CI, 1.28 to 3.17), associated organ failures (OR, 1.12; 95% CI, 1.05 to 1.20), moderate (OR, 1.92; 95% CI, 1.10 to 3.35) to severe ARDS (OR, 2.12; 95% CI, 1.01 to 4.41), cumulative fluid balance over the first 72 h of ICU (OR, 2.44; 95% CI, 1.39 to 4.28), higher lactate (OR, 1.78; 95% CI, 1.27 to 2.50), invasive MV (OR, 2.67; 95% CI, 1.32 to 5.39) and NIV failure (OR, 3.95; 95% CI, 1.74 to 8.99) were independently associated with hospital mortality. The predictors of NIV failure were the severity of associated organ dysfunctions (OR, 1.20; 95% CI, 1.05 to 1.34), ARDS (OR, 2.31; 95% CI, 1.10 to 4.82) and positive fluid balance (OR, 2.09; 95% CI, 1.02 to 4.30).

Conclusions: Current mortality of ventilated patients in Brazil is elevated. Implementation of judicious fluid therapy and a watchful use and monitoring of NIV patients are potential targets to improve outcomes in this setting.

Trial registration: ClinicalTrials.gov NCT01268410.

Figures

Figure 1
Figure 1
Flowchart of the study.
Figure 2
Figure 2
ICU and hospital mortality rates according to ventilatory support, ARDS diagnosis and NIV failure. ARDS, acute respiratory distress syndrome; ICU, intensive care unit; MV, mechanical ventilation.
Figure 3
Figure 3
ICU and hospital mortality rates according to the Berlin definition of ARDS. P < 0.001 (Pearson Chi-square test) for the comparison of hospital mortality and ARDS classification. ARDS, acute respiratory distress syndrome; ICU, intensive care unit.
Figure 4
Figure 4
Interaction of risk factors for failure of non-invasive ventilation and hospital mortality. Fluid balance denotes cumulative fluid balance ≥ 2 L in the first 72 hours of intensive care unit stay. SOFA score denotes Sequential Organ Failure Assessment punctuation ≥ 4 (excluding respiratory component). ARDS denotes Acute Respiratory Distress Syndrome. P < 0.001 (Pearson Chi-square test) for both the comparisons of hospital mortality and non-invasive ventilation failure and risk factors interaction.

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