Comparative Effectiveness of Noninvasive and Invasive Ventilation in Critically Ill Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Mihaela S Stefan, Brian H Nathanson, Thomas L Higgins, Jay S Steingrub, Tara Lagu, Michael B Rothberg, Peter K Lindenauer, Mihaela S Stefan, Brian H Nathanson, Thomas L Higgins, Jay S Steingrub, Tara Lagu, Michael B Rothberg, Peter K Lindenauer

Abstract

Objectives: To compare the characteristics and hospital outcomes of patients with an acute exacerbation of chronic obstructive pulmonary disease treated in the ICU with initial noninvasive ventilation or invasive mechanical ventilation.

Design: Retrospective, multicenter cohort study of prospectively collected data. We used propensity matching to compare the outcomes of patients treated with noninvasive ventilation to those treated with invasive mechanical ventilation. We also assessed predictors for noninvasive ventilation failure.

Setting: Thirty-eight hospitals participating in the Acute Physiology and Chronic Health Evaluation database from 2008 through 2012.

Subjects: A total of 3,520 patients with a diagnosis of chronic obstructive pulmonary disease exacerbation including 27.7% who received noninvasive ventilation and 45.5% who received invasive mechanical ventilation.

Interventions: None.

Measurements and main results: Noninvasive ventilation failure was recorded in 13.7% from patients ventilated noninvasively. Hospital mortality was 7.4% for patients treated with noninvasive ventilation; 16.1% for those treated with invasive mechanical ventilation; and 22.5% for those who failed noninvasive ventilation. In the propensity-matched analysis, patients initially treated with noninvasive ventilation had a 41% lower risk of death compared with those treated with invasive mechanical ventilation (relative risk, 0.59; 95% CI, 0.36-0.97). Factors that were independently associated with noninvasive ventilation failure were Simplified Acute Physiology Score II (relative risk = 1.04 per point increase; 95% CI, 1.03-1.04) and the presence of cancer (2.29; 95% CI, 0.96-5.45).

Conclusions: Among critically ill adults with chronic obstructive pulmonary disease exacerbation, the receipt of noninvasive ventilation was associated with a lower risk of in-hospital mortality compared with that of invasive mechanical ventilation; noninvasive ventilation failure was associated with the worst outcomes. These results support the use of noninvasive ventilation as a first-line therapy in appropriately selected critically ill patients with chronic obstructive pulmonary disease while also highlighting the risks associated with noninvasive ventilation failure and the need to be cautious in the face of severe disease.