Noninvasive positive-pressure ventilation in acute respiratory failure outside clinical trials: Experience at the Massachusetts General Hospital*

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Abstract
Noninvasive positive-pressure ventilation (NPPV) has been shown to be effective in select patients enrolled in clinical trials. However, few data are available on the use of NPPV as routine standard medical care for patients with respiratory failure outside of controlled trials. All patients receiving NPPV for a 1-yr period for acute or acute on chronic respiratory failure who did not select do not intubate/resuscitate status were evaluated. Demographic, physiological, and laboratory data were collected for as long as NPPV was provided. Data were recorded on 449 patients. Intubation rate was 18%, 24%, 38%, 40%, and 60%, respectively, for patients with cardiogenic pulmonary edema (n = 97), acute exacerbation of chronic obstructive pulmonary disease (n = 87), non-chronic obstructive pulmonary disease acute hypercapnic respiratory failure (n = 35), postextubation respiratory failure patients (n = 95), and acute hypoxemic respiratory failure (n = 144). The hospital mortality for patients with acute hypoxemic respiratory failure who failed NPPV was 64%. A logistic regression showed that baseline Simplified Acute Physiology Score II (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.05-1.10; p <.0001), Glasgow Coma Scale (OR, 0.76; 95% CI, 0.66-0.87; p <.0001), PaO2/FIO2 ratio (OR, 0.98; 95% CI, 0.93-0.99; p = .02), and serum albumin (OR, 0.30; 95% CI, 0.16-0.57; p < .001) were the variables associated with NPPV failure. NPPV as routine standard medical care resulted in the intubation of a similar percentage of patients with respiratory failure due to cardiogenic pulmonary edema and chronic obstructive pulmonary disease exacerbation as shown in randomized controlled trials but in a higher percent of patients with hypoxemic respiratory failure than reported in these trials. NPPV failure was associated with high hospital mortality for patients with hypoxemic respiratory failure.