Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. Effect of Noninvasive Ventilation vs Oxygen Therapy on Mortality Among Immunocompromised Patients With Acute Respiratory Failure: A Randomized Clinical Trial. Noninvasive pressure support ventilation in non-COPD patients with acute cardiogenic pulmonary edema and severe community-acquired pneumonia: acute effects and outcome Acute respiratory distress syndrome: Predictors of noninvasive ventilation failure and intensive care unit mortality in clinical practice. Noninvasive pressure support ventilation in patients with acute respiratory failure. A randomized comparison with conventional therapy. A multicentre randomised controlled trial of the use of continuous positive airway pressure and non-invasive positive pressure ventilation in the early treatment of patients presenting to the emergency department with severe acute cardiogenic pulmonary oedema: the 3CPO trial. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery: A Randomized Clinical Trial. Noninvasive ventilation in acute hypercapnic respiratory failure.
Introduction Noninvasive ventilation ( NIV ) , as a weaning-facilitating strategy in predominantly chronic obstructive pulmonary disease ( COPD ) mechanically ventilated patients , is associated with reduced ventilator-associated pneumonia , total duration of mechanical ventilation , length of intensive care unit ( ICU ) and hospital stay , and mortality . However , this benefit after planned extubation in patients with acute respiratory failure of various etiologies remains to be eluci date d. The aim of this study was to determine the efficacy of NIV applied immediately after planned extubation in contrast to oxygen mask ( OM ) in patients with acute respiratory failure ( ARF ) . Methods A r and omized , prospect i ve , controlled , unblinded clinical study in a single center of a 24-bed adult general ICU in a university hospital was carried out in a 12-month period . Included patients met extubation criteria with at least 72 hours of mechanical ventilation due to acute respiratory failure , after following the ICU weaning protocol . Patients were r and omized immediately before elective extubation , being r and omly allocated to one of the study groups : NIV or OM . We compared both groups regarding gas exchange 15 minutes , 2 hours , and 24 hours after extubation , reintubation rate after 48 hours , duration of mechanical ventilation , ICU length of stay , and hospital mortality . Results Forty patients were r and omized to receive NIV ( 20 patients ) or OM ( 20 patients ) after the following extubation criteria were met : pressure support ( PSV ) of 7 cm H2O , positive end-expiratory pressure ( PEEP ) of 5 cm H2O , oxygen inspiratory fraction ( FiO2 ) ≤ 40 % , arterial oxygen saturation ( SaO2 ) ≥ 90 % , and ratio of respiratory rate and tidal volume in liters ( f/TV ) < 105 . Comparing the 20 patients ( NIV ) with the 18 patients ( OM ) that finished the study 48 hours after extubation , the rate of reintubation  in NIV group was 5 % and 39 % in OM group ( P = 0.016 ) . Relative risk for reintubation was 0.13 ( CI = 0.017 to 0.946 ) . Absolute risk reduction for reintubation showed a decrease of 33.9 % , and analysis of the number needed to treat was three . No difference was found in the length of ICU stay ( P = 0.681 ) . Hospital mortality was zero in NIV group and 22.2 % in OM group ( P = 0.041 ) . Conclusions In this study population , NIV prevented 48 hours reintubation if applied immediately after elective extubation in patients with more than 3 days of ARF when compared with the OM group . Trial Registration numberIS RCT N : 41524441 RATIONALE Respiratory failure after extubation and reintubation is associated with increased morbidity and mortality . OBJECTIVES To assess the efficacy of noninvasive ventilation in averting respiratory failure after extubation in patients at increased risk . METHODS A prospect i ve r and omized controlled trial was conducted in 162 mechanically ventilated patients who tolerated a spontaneous breathing trial after recovery from the acute episode but had increased risk for respiratory failure after extubation . Patients were r and omly allocated after extubation to receive noninvasive ventilation for 24 h ( n = 79 ) , or conventional management with oxygen therapy ( control group , n = 83 ) . MEASUREMENTS AND MAIN RESULTS The primary end-point variable was the decrease in respiratory failure after extubation . In the noninvasive ventilation group , respiratory failure after extubation was less frequent ( 13 , 16 vs. 27 , 33 % ; p = 0.029 ) and the intensive care unit mortality was lower ( 2 , 3 versus 12 , 14 % ; p = 0.015 ) . However , 90-d survival did not change significantly between groups . Separate analyses of patients without and with hypercapnia ( arterial CO(2 ) tension greater than 45 mm Hg ) during the spontaneous breathing trial showed that noninvasive ventilation improved intensive care unit mortality ( 0 vs. 4 , 18 % ; p = 0.035 ) and 90-d survival ( p = 0.006 ) in hypercapnic patients only ; of them , 98 % had chronic respiratory disorders . CONCLUSIONS The early use of noninvasive ventilation averted respiratory failure after extubation and decreased intensive care unit mortality among patients at increased risk . The beneficial effect of noninvasive ventilation in improving survival of hypercapnic patients with chronic respiratory disorders warrants a new prospect i ve clinical trial 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 aim ed 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 , prospect i ve , 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 Clinical Trials.gov NCT01268410 BACKGROUND Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated . Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia . METHODS We performed a multicenter , open-label trial in which we r and omly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy , st and ard oxygen therapy delivered through a face mask , or noninvasive positive-pressure ventilation . The primary outcome was the proportion of patients intubated at day 28 ; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28 . RESULTS A total of 310 patients were included in the analyses .  The intubation rate ( primary outcome ) was 38 % ( 40 of 106 patients ) in the high-flow-oxygen group , 47 % ( 44 of 94 ) in the st and ard group , and 50 % ( 55 of 110 ) in the noninvasive-ventilation group ( P=0.18 for all comparisons ) . The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group ( 24±8 days , vs. 22±10 in the st and ard-oxygen group and 19±12 in the noninvasive-ventilation group ; P=0.02 for all comparisons ) . The hazard ratio for death at 90 days was 2.01 ( 95 % confidence interval [ CI ] , 1.01 to 3.99 ) with st and ard oxygen versus high-flow oxygen ( P=0.046 ) and 2.50 ( 95 % CI , 1.31 to 4.78 ) with noninvasive ventilation versus high-flow oxygen ( P=0.006 ) . CONCLUSIONS In patients with nonhypercapnic acute hypoxemic respiratory failure , treatment with high-flow oxygen , st and ard oxygen , or noninvasive ventilation did not result in significantly different intubation rates . There was a significant difference in favor of high-flow oxygen in 90-day mortality . ( Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health ; FLORALI Clinical Trials.gov number , NCT01320384 . ) IMPORTANCE Noninvasive ventilation has been recommended to decrease mortality among immunocompromised patients with hypoxemic acute respiratory failure . However , its effectiveness for this indication remains unclear . OBJECTIVE To determine whether early noninvasive ventilation improved survival in immunocompromised patients with nonhypercapnic acute hypoxemic respiratory failure . DESIGN , SETTING , AND PARTICIPANTS Multicenter r and omized trial conducted among 374 critically ill immunocompromised patients , of whom 317 ( 84.7 % ) were receiving treatment for hematologic malignancies or solid tumors , at 28 intensive care units ( ICUs ) in France and Belgium between August 12 , 2013 , and January 2 , 2015 . INTERVENTIONS Patients were r and omly assigned to early noninvasive ventilation ( n = 191 ) or oxygen therapy alone ( n = 183 ) . MAIN OUTCOMES AND MEASURES The primary outcome was day-28 mortality . Secondary outcomes were intubation , Sequential Organ Failure Assessment score on day 3 , ICU-acquired infections , duration of mechanical ventilation , and ICU length of stay . RESULTS At r and omization , median oxygen flow was 9 L/min ( interquartile range , 5 - 15 ) in the noninvasive ventilation group and 9 L/min ( interquartile range , 6 - 15 ) in the oxygen group . All patients in the noninvasive ventilation group received the first noninvasive ventilation session immediately after r and omization . On day 28 after r and omization , 46 deaths ( 24.1 % ) had occurred in the noninvasive ventilation group vs 50 ( 27.3 % ) in the oxygen group ( absolute difference , -3.2 [ 95 % CI , -12.1 to 5.6 ] ; P = .47 ) . Oxygenation failure occurred in 155 patients overall ( 41.4 % ) , 73 ( 38.2 % ) in the noninvasive ventilation group and 82 ( 44.8 % ) in the oxygen group ( absolute difference , -6.6 [ 95 % CI , -16.6 to 3.4 ] ; P = .20 ) . There were no significant differences in ICU-acquired infections , duration of mechanical ventilation , or lengths of ICU or hospital stays . CONCLUSIONS AND RELEVANCE Among immunocompromised patients admitted to the ICU with hypoxemic acute respiratory failure , early noninvasive ventilation compared with oxygen therapy alone did not reduce 28-day mortality . However , study power was limited . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01915719 Abstract Objective . To compare the acute effects of noninvasive pressure support ventilation ( NIPSV ) in non- COPD patients with acute cardiogenic pulmonary edema ( CPE ) and severe community-acquired pneumonia ( CAP ) presenting with a similar hypoxemic respiratory failure and exploring the ensuing impact on outcome . Design . Prospect i ve , observational study . Setting . Multidisciplinary ICU , regional teaching hospital . Patients . Non- COPD patients with CPE or severe CAP . Measurements and results . Fifteen patients with CPE and eighteen with CAP were included . Both groups had similar low PaO2/FiO2 ratios at admission ; SAPS II , baseline pHa were lower in the CPE group than in the CAP group . Within the first NIPSV observation period ( 60 min ) , the oxygenation improved significantly in both CPE and CAP-groups ; respiratory rate ( RR ) significantly decreased in the CPE group ( P=0.005 ) , but it remained unchanged in the whole CAP group ; heart rate and mean arterial pressure significantly decreased in both groups . One patient ( 6.6 % ) in the CPE group and seven patients ( 38 % ) in the CAP group were intubated ( P=0.04 ) . The mean total time spent on NIPSV was 9.6±6.3 h in the CPE and 37.2±36 h in the CAP group ( P=0.01 ) . Unit mortality rate was 6.6 % in the CPE and 28 % in the CAP group ( P=0.2 ) . Upon inclusion , all but one CAP patients who were subsequently intubated had a bacteremic pneumonia ; unit mortality rate was 57 % in intubated- and 9 % in non-intubated CAP patients ( P=0.05 ) . Conclusions . NIPSV equally and rapidly improved oxygenation in non- COPD patients with CPE and severe CAP presenting with a similar hypoxemic respiratory failure , but the subsequent outcome was definitely different in the two groups , depending on the nature of the acute lung injury PURPOSE Noninvasive ventilation ( NIV ) is used as an initial ventilatory support in acute respiratory distress syndrome ( ARDS ) , but its utility is unclear , and persistence in those who do not improve may delay intubation and lead to adverse outcomes . Hence , it becomes imperative to have a clear underst and ing of selecting patients who will benefit from this modality . METHODS In this prospect i ve observational study , we included all consecutive adults , over a 3-year period , who fulfilled criteria for ARDS by the Berlin definition . Basic demographics , ventilatory support , intensive care unit course , and outcome were recorded . RESULTS Of 170 patients , 96 ( 56.47 % ) were initially managed with NIV .  Noninvasive ventilation failure was seen in 42 ( 43.75 % ) of 96 , and low baseline PaO2/FIO2 , shock , and ARDS severity were associated with NIV failure . Overall intensive care unit mortality was 63 ( 37.1 % ) of 170 , and high Acute Physiology and Chronic Health Evaluation II score , low PaO2/FIO2 , shock , and ARDS severity were associated with increased mortality . Noninvasive ventilation failure and mortality were significantly higher in moderate and severe ARDS . CONCLUSIONS Noninvasive ventilation maybe useful in selected patients with mild ARDS but should be used with great caution in moderate and severe ARDS , as failure risk is high . In addition , low PaO2/FIO2 and shock are associated with NIV failure . Acute Physiology and Chronic Health Evaluation II score , shock , low PaO2/FIO2 , and ARDS severity are associated with increased mortality The benefit of noninvasive pressure support ventilation ( NIPSV ) in avoiding the need for endotracheal intubation and reducing morbidity and mortality associated with endotracheal intubation was evaluated in 41 patients who presented with acute respiratory failure not related to chronic obstructive pulmonary disease ( COPD ) . Patients were r and omly assigned to receive conventional therapy ( n = 20 ) or conventional therapy plus NIPSV ( n = 21 ) . NIPSV was delivered to the patient by a face mask connected to a ventilator ( Puritan-Bennett 7200a ) set in inspiratory pressure support ( IPS ) mode . The mean levels of IPS , positive end-expiratory pressure ( PEEP ) , and fraction of inspired oxygen ( FIO2 ) were respectively 15 + /- 3 cm H2O , 4 + /- 2 cm H2O , and 57 + /- 22 % . The rate of endotracheal intubation ( 62 vs 70 % , p = 0.88 ) , the length of ICU stay ( 17 + /- 19 days vs 25 + /- 23 days , p = 0.16 ) , and the mortality rate ( 33 vs 50 % , p = 0.46 ) were not different between patients treated with NIPSV and those treated conventionally . Post hoc analysis suggested that in patients with PaCO2 > 45 mm Hg ( n = 17 ) , NIPSV was associated with a reduction in the rate of endotracheal intubation ( 36 vs 100 % , p = 0.02 ) , in the length of ICU stay ( 13 + /- 15 days vs 32 + /- 30 days , p = 0.04 ) , and in the mortality rate ( 9 vs 66 % , p = 0.06 ) . We conclude that NIPSV is of no benefit when used systematic ally in all forms of acute respiratory failure not related to COPD . A subgroup of patients , characterized by acute ventilatory failure and hypercapnia , may potentially benefit from this therapy and further studies are needed to focus on this aspect OBJECTIVES To determine whether non-invasive ventilation reduces mortality and whether there are important differences in outcome by treatment modality . DESIGN Multicentre open prospect i ve r and omised controlled trial . SETTING Patients presenting with severe acute cardiogenic pulmonary oedema in 26 emergency departments in the UK . PARTICIPANTS Inclusion criteria were age > 16 years , clinical diagnosis of acute cardiogenic pulmonary oedema , pulmonary oedema on chest radiograph , respiratory rate > 20 breaths per minute , and arterial hydrogen ion concentration > 45 nmol/l ( pH < 7.35 ) . INTERVENTIONS Patients were  r and omised to st and ard oxygen therapy , continuous positive airway pressure ( CPAP ) ( 5 - 15 cmH2O ) or non-invasive positive pressure ventilation ( NIPPV ) ( inspiratory pressure 8 - 20 cmH2O , expiratory pressure 4 - 10 cmH2O ) on a 1:1:1 basis for a minimum of 2 hours . MAIN OUTCOME MEASURES The primary end point for the comparison between NIPPV or CPAP and st and ard therapy was 7-day mortality . The composite primary end point for the comparison of NIPPV and CPAP was 7-day mortality and tracheal intubation rate . Secondary end points were breathlessness , physiological variables , intubation rate , length of hospital stay and critical care admission rate . Economic evaluation took the form of a cost-utility analysis , taken from an NHS ( and personal social services ) perspective . RESULTS In total , 1069 patients [ mean age 78 ( SD 10 ) years ; 43 % male ] were recruited to st and ard therapy ( n = 367 ) , CPAP [ n = 346 ; mean 10 ( SD 4 ) cmH2O ] or NIPPV  [ n = 356 ; mean 14 ( SD 5)/7 ( SD 2 ) cmH2O ] . There was no difference in 7-day mortality for st and ard oxygen therapy ( 9.8 % ) and non-invasive ventilation ( 9.5 % ; p = 0.87 ) . The combined end point of 7-day death and intubation rate was similar , irrespective of non-invasive ventilation modality ( CPAP 11.7 % versus NIPPV 11.1 % ; p = 0.81 ) . Compared with st and ard therapy , non-invasive ventilation was associated with greater reductions ( treatment difference , 95 % confidence intervals ) in breathlessness ( visual analogue scale score 0.7 , 0.2 - 1.3 ; p = 0.008 ) and heart rate ( 4/min , 1 - 6 ; p = 0.004 ) and improvement in acidosis ( pH 0.03 , 0.02 - 0.04 ; p < 0.001 ) and hypercapnia ( 0.7 kPa , 0.4 - 0.9 ; p < 0.001 ) at 1 hour . There were no treatment-related adverse events or differences in other secondary outcomes such as myocardial infa rct ion rate , length of hospital stay , critical care admission rate and requirement for endotracheal intubation . Economic evaluation showed that mean costs and QALYs up to 6 months were 3023 pounds and 0.202 for st and ard therapy , 3224 pounds and 0.213 for CPAP , and 3208 pounds and 0.210 for NIPPV . Modelling of lifetime costs and QALYs produced values of 15,764 pounds and 1.597 for st and ard therapy , 17,525 pounds and 1.841 for CPAP , and 17,021 pounds and 1.707 for NIPPV . These results suggest that both CPAP and NIPPV accrue more QALYs but at higher cost than st and ard therapy . However , these estimates are subject to substantial uncertainty . CONCLUSIONS Non-invasive ventilatory support delivered by either CPAP or NIPPV safely provides earlier improvement and resolution of breathlessness , respiratory distress and metabolic abnormality . However , this does not translate into improved short- or longer-term survival . We recommend that CPAP or NIPPV should be considered as adjunctive therapy in patients with severe acute cardiogenic pulmonary oedema in the presence of severe respiratory distress or when there is a failure to improve with pharmacological therapy . TRIAL REGISTRATION Current Controlled Trials IS RCT N07448447 BACKGROUND Avoiding intubation is a major goal in the management of respiratory failure , particularly in immunosuppressed patients . Nevertheless , there are only limited data on the efficacy of noninvasive ventilation in these high-risk patients . METHODS We conducted a prospect i ve , r and omized trial of intermittent noninvasive ventilation , as compared with st and ard treatment with supplemental oxygen and no ventilatory support , in 52 immunosuppressed patients with pulmonary infiltrates , fever , and an early stage of hypoxemic acute respiratory failure .  Periods of noninvasive ventilation delivered through a face mask were alternated every three hours with periods of spontaneous breathing with supplemental oxygen . The ventilation periods lasted at least 45 minutes . Decisions to intubate were made according to st and ard , predetermined criteria . RESULTS The base-line characteristics of the two groups were similar ; each group of 26 patients included 15 patients with hematologic cancer and neutropenia . Fewer patients in the noninvasive-ventilation group than in the st and ard-treatment group required endotracheal intubation ( 12 vs. 20 , P=0.03 ) , had serious complications ( 13 vs. 21 , P=0.02 ) , died in the intensive care unit ( 10 vs. 18 , P=0.03 ) , or died in the hospital ( 13 vs. 21 , P=0.02 ) . CONCLUSIONS In selected immunosuppressed patients with pneumonitis and acute respiratory failure , early initiation of noninvasive ventilation is associated with significant reductions in the rates of endotracheal intubation and serious complications and an improved likelihood of survival to hospital discharge BACKGROUND : Despite the clinical improvements attributed to noninvasive ventilation ( NIV ) during asthma crises , and the well established effects of nebulization , there are few studies on the effects of these interventions together . We hypothesized that nebulization coupled to NIV should raise radio-aerosol pulmonary deposition in asthmatics . The aims of this study were to assess the effects of coupling β-agonist nebulization and NIV during asthma exacerbations on radio-aerosol pulmonary deposition , using scintigraphy and cardiopulmonary parameters , to correlate pulmonary function with radio-aerosol deposition index , radio-aerosol penetration index , and pulmonary clearance . METHODS : In this controlled trial , 21 adults with moderate to severe asthma attack were r and omized to a control group ( n = 11 ) or  experimental group ( NIV + nebulizer group , n = 10 ) . All subjects inhaled bronchodilators for 9 minutes , and after particles were counted with a gamma camera to analyze regions of interest and pulmonary clearance at 0 , 15 , 30 , 45 , and 60 min . RESULTS : Breathing frequency ( P = < .001 ) and minute ventilation ( P = .01 ) were reduced , and tidal volume was increased ( P = .01 ) in the NIV + nebulizer group , compared with the control group . The NIV + nebulizer group had improvement from baseline values , compared to the control group in the following parameters : FEV1 46.7 ± 0.5 % of predicted vs 29.8 ± 8.9 % of predicted , P = .02 ) , FVC ( 41.2 ± 1.5 % of predicted vs 23.2 ± 7.1 % of predicted , P = .02 ) , peak expiratory flow ( 67.3 ± 38.3 % of predicted vs 26.9 ± 12.1 % of predicted , P = .01 ) , and inspiratory capacity ( 54.9 ± 28.8 % of predicted vs 31.2 ± 9.1 % of predicted , P = .01 ) . No differences were observed between groups regarding radio-aerosol deposition index or pulmonary clearance . Negative correlations were found between FEV1 , forced expiratory flow during the middle half of the FVC maneuver ( FEF25–75 % ) , inspiratory capacity , and radio-aerosol penetration index . CONCLUSIONS : Coupling nebulization and NIV during asthma exacerbation did not improve radio-aerosol pulmonary deposition , but we observed clinical improvement of pulmonary function in these subjects . ( Clinical Trials.gov registration NCT01012050 The efficacy of noninvasive ventilation ( NIV ) to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure ( arterial O2 tension or saturation persistently 60 mm Hg or less or 90 % or less , respectively ; breathing conventional Venturi oxygen at a maximal concentration [ 50 % ] ) , excluding hypercapnia , admitted into intensive care units of three hospitals . Patients were r and omly allocated within 24 hours of fulfilling inclusion criteria to receive NIV ( n=51 ) or high-concentration oxygen therapy ( n=54 ) . The primary end-point variable was the decrease in the intubation rate . Both groups had similar characteristics . Compared with oxygen therapy , NIV decreased the need for intubation ( 13 , 25 % vs. 28 , 52 % , p=0.010 ) , the incidence of septic shock ( 6 , 12 % vs. 17 , 31 % , p=0.028 ) , and the intensive care unit mortality ( 9 , 18 % vs. 21 , 39 % , p=0.028 ) and increased the cumulative 90-day survival ( p=0.025 ) . The improvement of arterial hypoxemia and tachypnea was higher in the noninvasive ventilation group with time ( p=0.029 each ) . Multivariate analyses showed NIV to be independently associated with decreased risks of intubation ( odds ratio , 0.20 ; p=0.003 ) and 90-day mortality ( odds ratio , 0.39 ; p=0.017 ) . The use of noninvasive ventilation prevented intubation , reduced the incidence of septic shock , and improved survival in these patients compared with high-concentration oxygen therapy OBJECTIVE To develop and vali date a new Simplified Acute Physiology Score , the SAPS II , from a large sample of surgical and medical patients , and to provide a method to convert the score to a probability of hospital mortality . DESIGN AND SETTING The SAPS II and the probability of hospital mortality were developed and vali date d using data from consecutive admissions to 137 adult medical and /or surgical intensive care units in 12 countries . PATIENTS The 13,152 patients were r and omly divided into developmental ( 65 % ) and validation ( 35 % ) sample s. Patients younger than 18 years , burn patients , coronary care patients , and cardiac surgery patients were excluded . OUTCOME MEASURE Vital status at hospital discharge . RESULTS The SAPS II includes only 17 variables : 12 physiology variables , age , type of admission ( scheduled surgical , unscheduled surgical , or medical ) , and three underlying disease variables ( acquired immunodeficiency syndrome , metastatic cancer , and hematologic malignancy ) . Goodness-of-fit tests indicated that the model performed well in the developmental sample and vali date d well in an independent sample of patients ( P = .883 and P = .104 in the developmental and validation sample s , respectively ) . The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample . CONCLUSION The SAPS II , based on a large international sample of patients , provides an estimate of the risk of death without having to specify a primary diagnosis . This is a starting point for future evaluation of the efficiency of intensive care units CONTEXT Noninvasive positive-pressure ventilation ( NPPV ) has been demonstrated to be effective in preventing the need for endotracheal intubation in some patients who present with acute respiratory failure . It is also used for patients who develop acute respiratory distress after extubation , but there are no r and omized controlled trials that address its effectiveness in this population . OBJECTIVE To determine the effectiveness of NPPV compared with st and ard medical therapy in preventing the need for endotracheal reintubation in high-risk patients who develop respiratory distress during the first 48 hours after extubation . DESIGN R and omized , controlled , unblinded study with concealed allocation conducted between August 1 , 1996 and October 31 , 1999 . SETTING An intensive care unit ( ICU ) in an academic , tertiary care hospital in Ontario . PATIENTS Eighty-one patients with a history of cardiac or respiratory disease or who initially required ventilatory support for more than 2 days and who developed respiratory distress within 48 hours of extubation . INTERVENTIONS Patients were r and omly assigned to receive st and ard medical therapy alone ( supplemental oxygen to maintain oxygen saturation by pulse oximetry > or = 95 % ; n = 42 ) or NPPV by face mask plus st and ard medical therapy ( n = 39 ) . MAIN OUTCOME MEASURES Rates of reintubation , duration of mechanical ventilation , lengths of ICU and hospital stay , and hospital mortality . RESULTS Comparing the NPPV group with the st and ard-therapy group , there was no difference in the rate of reintubation ( 72 % vs 69 % ; relative risk , 1.04 ; 95 % confidence interval , 0.78 - 1.38 ) or hospital mortality ( 31 % for both groups ; relative risk , 0.99 ; 95 % confidence interval , 0.52 - 1.91 ) . Similarly , no difference was found in duration of mechanical ventilation or length of ICU or hospital stay . CONCLUSIONS The addition of NPPV to st and ard medical therapy does not improve outcome in heterogeneous groups of patients who develop respiratory distress during the first 48 hours after extubation IMPORTANCE It has not been established whether noninvasive ventilation ( NIV ) reduces the need for invasive mechanical ventilation in patients who develop hypoxemic acute respiratory failure after abdominal surgery . OBJECTIVE To evaluate whether noninvasive ventilation improves outcomes among patients developing hypoxemic acute respiratory failure after abdominal surgery . DESIGN , SETTING , AND PARTICIPANTS Multicenter , r and omized , parallel-group clinical trial conducted between May 2013 and September 2014 in 20 French intensive care units among 293 patients who had undergone abdominal surgery and developed hypoxemic respiratory failure ( partial oxygen pressure < 60 mm Hg or oxygen saturation [ SpO2 ] ≤90 % when breathing room air or < 80 mm Hg when breathing 15 L/min of oxygen , plus either [ 1 ] a respiratory rate above 30/min or [ 2 ] clinical signs suggestive of intense respiratory muscle work and /or labored breathing ) if it occurred within 7 days after surgical procedure . INTERVENTIONS Patients were r and omly assigned to receive st and ard oxygen therapy ( up to 15 L/min to maintain SpO2 of 94 % or higher ) ( n = 145 ) or NIV delivered via facial mask ( inspiratory pressure support level , 5 - 15 cm H2O ; positive end-expiratory pressure , 5 - 10 cm H2O ; fraction of inspired oxygen titrated to maintain SpO2 ≥94 % ) ( n = 148 ) . MAIN OUTCOMES AND MEASURES The primary outcome was tracheal reintubation for any cause within 7 days of r and omization . Secondary outcomes were gas exchange , invasive ventilation-free days at day 30 , health care-associated infections , and 90-day mortality . RESULTS Among the 293 patients ( mean age , 63.4 [ SD , 13.8 ] years ; n=224 men ) included in the intention-to-treat analysis , reintubation occurred in 49 of 148 ( 33.1 % ) in the NIV group and in 66 of 145 ( 45.5 % ) in the st and ard oxygen therapy group within+ 7 days after r and omization ( absolute difference , -12.4 % ; 95 % CI , -23.5 % to -1.3 % ; P = .03 ) . Noninvasive ventilation was associated with significantly more invasive ventilation-free days compared with st and ard oxygen therapy ( 25.4 vs 23.2 days ; absolute difference , -2.2 days ; 95 % CI , -0.1 to 4.6 days ; P = .04 ) , while fewer patients developed health care-associated infections ( 43/137 [ 31.4 % ] vs 63/128 [ 49.2 % ] ; absolute difference , -17.8 % ; 95 % CI , -30.2 % to -5.4 % ; P = .003 ) . At 90 days , 22 of 148 patients ( 14.9 % ) in the NIV group and 31 of 144 ( 21.5 % ) in the st and ard oxygen therapy group had died ( absolute difference , -6.5 % ; 95 % CI , -16.0 % to 3.0 % ; P = .15 ) . There were no significant differences in gas exchange . CONCLUSIONS AND RELEVANCE Among patients with hypoxemic respiratory failure following abdominal surgery , use of NIV compared with st and ard oxygen therapy reduced the risk of tracheal reintubation within 7 days . These findings support use of NIV in this setting . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01971892 Noninvasive mechanical ventilation ( NIV ) improves gas exchange and clinical outcome in various types of acute respiratory failure . Acute exacerbation of chronic obstructive pulmonary disease is a frequent cause of acute hypercapnic respiratory failure ( AHRF ) . According to several r and omized controlled trials , the addition of NIV to st and ard medical therapy reduces mortality , intubation rate , and hospital length of stay in these patients . Indications for the use of NIV have exp and ed over the past decade . In this article , we discuss the clinical indications and goals of NIV in the management of AHRF
Purpose : Evaluate current recommendation for the use of noninvasive ventilation ( Bi‐level positive airway pressure‐ BiPAP modality ) in hypoxemic acute respiratory failure , excluding chronic obstructive pulmonary disease .