A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome*

TLDR

Noninvasive positive‑pressure ventilation has reduced intubation rates in hypoxemic respiratory failure, but its effectiveness in ARDS remains uncertain, with older age, higher SAPS II, and greater PEEP or pressure‑support use linked to higher intubation risk. The study aimed to evaluate the use of NPPV as a first‑line intervention for early ARDS in expert European intensive‑care units. A prospective, multicenter cohort of 147 eligible ARDS patients in three European ICUs applied NPPV as first‑line therapy, improving gas exchange and avoiding intubation in 54 % of cases. First‑line NPPV avoided intubation in 54 % of early ARDS patients, reducing ventilator‑associated pneumonia (2 % vs 20 %) and ICU mortality (6 % vs 53 %), while SAPS II > 34 and failure to improve PaO₂/FiO₂ within one hour predicted NPPV failure.

Abstract

In randomized studies of heterogeneous patients with hypoxemic acute respiratory failure, noninvasive positive pressure ventilation (NPPV) was associated with a significant reduction in endotracheal intubation. The role of NPPV in patients with acute respiratory distress syndrome (ARDS) is still unclear. The objective was to investigate the application of NPPV as a first-line intervention in patients with early ARDS, describing what happens in everyday clinical practice in centers having expertise with NPPV.Prospective, multiple-center cohort study.Three European intensive care units having expertise with NPPV.Between March 2002 and April 2004, 479 patients with ARDS were admitted to the intensive care units. Three hundred and thirty-two ARDS patients were already intubated, so 147 were eligible for the study.Application of NPPV.NPPV improved gas exchange and avoided intubation in 79 patients (54%). Avoidance of intubation was associated with less ventilator-associated pneumonia (2% vs. 20%; p < .001) and a lower intensive care unit mortality rate (6% vs. 53%; p < .001). Intubation was more likely in patients who were older (p = .02), had a higher Simplified Acute Physiology Score (SAPS) II (p < .001), or needed a higher level of positive end-expiratory pressure (p = .03) and pressure support ventilation (p = .02). Only SAPS II >34 and a Pao2/Fio2 < or =175 after 1 hr of NPPV were independently associated with NPPV failure and need for endotracheal intubation.In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients. A SAPS II >34 and the inability to improve Pao2/Fio2 after 1 hr of NPPV were predictors of failure.