Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial. Benefits and risks of success or failure of noninvasive ventilation A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest Respiratory failure in patients undergoing allogeneic hematopoietic SCT—a randomized trial on early non-invasive ventilation based on standard care hematology wards Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials A prospective randomized controlled trial on the efficacy of noninvasive ventilation in severe acute asthma. The Rapid Shallow Breathing Index as a Predictor of Failure of Noninvasive Ventilation for Patients With Acute Respiratory Failure Easily identified at-risk patients for extubation failure may benefit from noninvasive ventilation: a prospective before-after study Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial. Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. Ventilator-Associated Events: Prevalence, Outcome, and Relationship With Ventilator-Associated Pneumonia* Helmet CPAP vs. oxygen therapy in severe hypoxemic respiratory failure due to pneumonia Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Cardiopulmonary effects of non-invasive positive pressure ventilation (NPPV)--a controlled, prospective study. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial. Helmet continuous positive airway pressure vs oxygen therapy to improve oxygenation in community-acquired pneumonia: a randomized, controlled trial. Noninvasive pressure support ventilation in patients with acute respiratory failure. A randomized comparison with conventional therapy. Effects of noninvasive positive pressure ventilatory support in non-COPD patients with acute respiratory insufficiency after early extubation Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomised feasibility trial. Pulmonary compliance values provide prognosis in mechanically ventilated patients--a randomized prospective study. The Prognosis of Acute Respiratory Failure in Critically Ill Cancer Patients
CONTEXT Continuous positive airway pressure ( CPAP ) is widely used in the belief that it may reduce the need for intubation and mechanical ventilation in patients with acute hypoxemic respiratory insufficiency . OBJECTIVE To compare the physiologic effects and the clinical efficacy of CPAP vs st and ard oxygen therapy in patients with acute hypoxemic , nonhypercapnic respiratory insufficiency . DESIGN , SETTING , AND PATIENTS R and omized , concealed , and unblinded trial of 123 consecutive adult patients who were admitted to 6 intensive care units between September 1997 and January 1999 with a PaO(2)/FIO(2 ) ratio of 300 mm Hg or less due to bilateral pulmonary edema ( n = 102 with acute lung injury and n = 21 with cardiac disease ) . INTERVENTIONS Patients were r and omly assigned to receive oxygen therapy alone ( n = 61 ) or oxygen therapy plus CPAP ( n = 62 ) . MAIN OUTCOME MEASURES Improvement in PaO(2)/FIO(2 ) ratio , rate of endotracheal intubation at any time during the study , adverse events , length of hospital stay , mortality , and duration of ventilatory assistance , compared between the CPAP and st and ard treatment groups . RESULTS Among the CPAP vs st and ard therapy groups , respectively , causes of respiratory failure ( pneumonia , 54 % and 55 % ) , presence of cardiac disease ( 33 % and 35 % ) , severity at admission , and hypoxemia ( median [ 5th-95th percentile ] PaO(2)/FIO(2 ) ratio , 140 [ 59 - 288 ] mm Hg vs 148 [ 62 - 283 ] mm Hg ; P = .43 ) were similarly distributed . After 1 hour of treatment , subjective responses to treatment ( P<.001 ) and median ( 5th-95th percentile ) PaO(2)/FIO(2 ) ratios were greater with CPAP ( 203 [ 45 - 431 ] mm Hg vs 151 [ 73 - 482 ] mm Hg ; P = .02 ) . No further difference in respiratory indices was observed between the groups . Treatment with CPAP failed to reduce the endotracheal intubation rate ( 21 [ 34 % ] vs 24 [ 39 % ] in the st and ard therapy group ; P = .53 ) , hospital mortality ( 19 [ 31 % ] vs 18 [ 30 % ] ; P = .89 ) , or median ( 5th-95th percentile ) intensive care unit length of stay ( 6.5 [ 1 - 57 ] days vs 6.0 [ 1 - 36 ] days ; P = .43 ) . A higher number of adverse events occurred with CPAP treatment ( 18 vs 6 ; P = .01 ) . CONCLUSION In this study , despite early physiologic improvement , CPAP neither reduced the need for intubation nor improved outcomes in patients with acute hypoxemic , nonhypercapnic respiratory insufficiency primarily due to acute lung injury . JAMA . 2000;284:2352 - 2360 Objective Noninvasive ventilation ( NIV ) fails more frequently for de novo acute respiratory failure ( de novo ) than for cardiogenic pulmonary edema ( CPE ) or acute-on-chronic respiratory failure ( AOC ) . The impact of NIV failure and success was compared between de novo and CPE or AOC after adjustment for disease severity . Setting s Patients requiring ventilatory support were enrolled in a prospect i ve survey in 70 French ICUs . Of 1076 patients requiring ventilatory support , 524 were eligible , including 299 de novo ( NIV use , 30 % ) and 225 CPE-AOC ( NIV use , 55 % ) . Design and analysis Independent risk factors associated with mortality and length of stay were identified by logistic regression analysis . The adjusted outcome of NIV success or failure was compared to that with endotracheal intubation without NIV . Results  NIV success was independently associated with survival in both de novo , adjusted OR 0.05 ( 95 % CI 0.01–0.42 ) , and CPE-AOC OR 0.03 ( CI 0.01–0.24 ) . NIV failure was associated with ICU mortality in the de novo group ( OR 3.24 , CI 1.61–6.53 ) but not in the CPE-AOC group . Nosocomial pneumonia was less common in patients successful with NIV .  NIV failure was associated with a longer ICU stay in CPE-AOC only . The overall use of NIV was independently associated with a better outcome only in CPE-AOC patients ( OR 0.33 , CI 0.15–0.73 ) . Conclusion The effect of NIV differs between de novo and CPE-AOC patients because NIV failure is associated with increased mortality for de novo patients . This finding should raise a note of caution when applying NIV in this indication Introduction : The role of non-invasive positive pressure ventilation delivered through a face mask in patients with flail chest is uncertain . We conducted a prospect i ve , r and omised study of continuous positive airway pressure ( CPAP ) given via a face mask to spontaneously breathing patients compared with intermittent positive pressure ventilation ( IPPV ) with endotracheal intubation ( ETI ) in 52 patients with flail chest who required mechanical ventilation . Method : The 52 mechanically ventilated patients were r and omly divided into two treatment groups : the ET group ( n = 27 ) received mechanical ventilation with ETI , whereas patients in the CPAP group ( n = 25 ) received CPAP via a face mask with patient controlled analgesia ( PCA ) .  Major complications , arterial blood gas levels , length of intensive care unit ( ICU ) stay and ICU survival rate were recorded . Results : Nosocomial infection was diagnosed in 10 of 21 patients in the ET group , but only in 4 of 22 in the CPAP group ( p = 0.001 ) . Mean PO2 was significantly higher in the ET group in the first 2 days ( p<0.05 ) . There were no significant differences in length of ICU stay between groups . Twenty CPAP patients survived , but only 14 of 21 intubated patients who received IPPV ( p<0.01 ) . Conclusion : Non-invasive CPAP with PCA led to lower mortality and a lower nosocomial infection rate , but similar oxygenation and length of ICU stay . The study supports the application of CPAP at least as a first line of treatment for flail chest caused by blunt thoracic trauma The prognosis of patients suffering from respiratory failure ( RF ) after allogeneic hematopoietic SCT ( HSCT ) is poor . However , early treatment for using non-invasive ventilation ( NIV ) may be of benefit . We conducted a r and omized trial to prove the impact of early NIV  in patients in the early post-transplant period . A total of 526 patients undergoing HSCT in a single center were monitored for signs of RF . Patients with RF were enrolled into either treatment arm A ( oxygen supply only ) or treatment arm B ( oxygen+intermittent NIV ) . RF had to be diagnosed in 86 patients ( 16 % ) . RF was an independent risk factor for both short-term ( 100 day mortality/ OR 2.76 ; P<0.001 ) and long-term survival ( OR 1.57 ; P<0.01 ) . Although early RF treatment with NIV was associated with a decreased rate of failure to achieve sufficient oxygenation ( 39 % in arm A vs 24 % in arm B , P=0.17 ) , neither intensive care unit admission rate , nor need for intubation or survival parameters were affected by the treatment strategy . An early interventional strategy using NIV was not associated with improvement of the prognosis of the patients . The limited influence of NIV may be related to the study design allowing for switching of treatment in case of unsatisfactory efficacy CONTEXT Noninvasive ventilation ( NIV ) has been associated with lower rates of endotracheal intubation in population s of patients with acute respiratory failure . OBJECTIVE To compare NIV with st and ard treatment using supplemental oxygen administration to avoid endotracheal intubation in recipients of solid organ transplantation with acute hypoxemic respiratory failure . DESIGN AND SETTING Prospect i ve r and omized study conducted at a 14-bed , general intensive care unit of a university hospital . PATIENTS Of 238 patients who underwent solid organ transplantation from December 1995 to October 1997 , 51 were treated for acute respiratory failure . Of these , 40 were eligible and 20 were r and omized to each group . INTERVENTION Noninvasive ventilation vs st and ard treatment with supplemental oxygen administration . MAIN OUTCOME MEASURES The need for endotracheal intubation and mechanical ventilation at any time during the study , complications not present on admission , duration of ventilatory assistance , length of hospital stay , and intensive care unit mortality . RESULTS The 2 groups were similar at study entry . Within the first hour of treatment , 14 patients ( 70 % ) in the NIV group , and 5 patients ( 25 % ) in the st and ard treatment group improved their ratio of the PaO2 to the fraction of inspired oxygen ( FIO2 ) . Over time , a sustained improvement in PaO2 to FIO2 was noted in 12 patients ( 60 % ) in the NIV group , and in 5 patients ( 25 % ) r and omized to st and ard treatment ( P = .03 ) . The use of NIV was associated with a significant reduction in the rate of endotracheal intubation ( 20 % vs 70 % ; P = .002 ) , rate of fatal complications ( 20 % vs 50 % ; P = .05 ) , length of stay in the intensive care unit by survivors ( mean [ SD ] days , 5.5 [ 3 ] vs 9 [ 4 ] ; P = .03 ) , and intensive care unit mortality ( 20 % vs 50 % ; P = .05 ) . Hospital mortality did not differ . CONCLUSIONS These results indicate that transplantation programs should consider NIV in the treatment of selected recipients of transplantation with acute respiratory failure STUDY OBJECTIVE Noninvasive mechanical ventilation ( NIMV ) is beneficial for patients with acute respiratory failure ( ARF ) when added to medical treatment . However , its role as an alternative to conventional mechanical ventilation ( CMV ) remains controversial . Our aim was to compare the efficacy and re source consumption of NIMV against CMV in patients with ARF . DESIGN A r and omized , multicenter , controlled trial . SETTING Seven multi purpose ICUs . PATIENTS Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation . INTERVENTION The noninvasive group received ventilation through a face mask in pressure-support mode plus positive end-expiratory pressure ; the conventional group received ventilation through a tracheal tube . MEASUREMENTS AND RESULTS Avoidance of intubation , mortality , and consumption of re sources were the outcome variables . Thirty-one patients were assigned to the noninvasive group , and 33 were assigned to the conventional group . In the noninvasive group , 58 % patients were intubated , vs 100 % in the conventional group ( relative risk reduction , 43 % ; p < 0.001 ) . Stratification by type of ARF gave similar results . In the ICU , death occurred in 23 % and 39 % ( p = 0.09 ) and complications occurred in 52 % and 70 % ( p = 0.07 ) in the noninvasive and conventional groups , respectively . There were no differences in length of stay . The Therapeutic Intervention Score System-28 , but not the direct nursing activity time , was lower in the noninvasive group during the first 3 days . CONCLUSIONS NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes . There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more BACKGROUND Noninvasive ventilation ( NIV ) is an emerging modality in the management of patients with acute respiratory failure . However , its role in severe acute asthma is not well defined . OBJECTIVE Evaluate the efficacy of NIV in severe acute asthma . METHODS Patients with severe acute asthma were r and omized to receive either st and ard medical therapy or NIV in addition to medical therapy . The primary outcomes were improvement in forced expiratory volume in the first second ( FEV1 ) , intensive care unit ( ICU ) stay , and hospital stay . The secondary outcomes were rate of improvement in respiratory rate , blood pH , ratio of PaO2 to fraction of inspired oxygen ( F(I)O2 ) , PaCO2 , requirement for inhaled medications , and failure of primary therapy . RESULTS Fifty-three patients with severe acute asthma ( 42 females and 11 males , mean + /- SD age 44 + /- 15 y , FEV1 < 30 % of predicted ) were r and omized to NIV ( n = 28 ) or st and ard medical therapy ( n = 25 ) . The baseline variables were similar in the 2 groups except for the mean duration of asthma , which was shorter in the st and ard-medical-therapy group . The median inspiratory and expiratory airway pressures applied were 12 cm H2O and 5 cm H2O , respectively . There was a significant improvement in respiratory rate , FEV1 , and PaO2/F(I)O2 ( but not pH or PaCO2 ) in both the groups , but no significant difference between the 2 groups . The number of patients who had a > or = 50 % improvement in FEV1 at 1 , 2 , and 4 hours was nonsignificantly greater in the NIV arm . ICU and hospital stay was significantly shorter in the NIV group . The mean dose of inhaled bronchodilator was significantly less in the NIV group . There were 4 instances of st and ard-medical-therapy failure , and all those patients improved with NIV . Two patients in the NIV arm required invasive ventilation . There was no mortality in either of the arms . CONCLUSION In patients with severe acute asthma , the addition of NIV to st and ard medical therapy probably accelerates the improvement in lung function , decreases the inhaled bronchodilator requirement , and shortens the ICU and hospital stay , but a larger study is required to settle this issue BACKGROUND : Noninvasive ventilation ( NIV ) may reduce the need for intubation in acute respiratory failure ( ARF ) . However , there is no st and ard method to predict success or failure with NIV . The rapid shallow breathing index ( RSBI ) is a vali date d tool for predicting readiness for extubation . We evaluated the ability of the RSBI to predict failure of NIV and mortality in ARF . METHODS : Prospect i ve , observational trial of patients with ARF treated with NIV . NIV was initiated at the discretion of the clinicians , and an RSBI was recorded on the initial level of support ( design ated as assisted RSBI [ aRSBI ] ) . Patients were categorized by initial aRSBI value as either high ( aRSBI > 105 ) or low ( aRSBI ≤ 105 ) . The primary end point was need for intubation , and the secondary end point was in-hospital mortality . Patients in the low and high aRSBI groups were compared using univariate analysis , followed by multivariable logistic regression to determine the association between aRSBI groups and outcome . RESULTS : A total of 101 patients were included . The majority of patients had an inspiratory pressure of 5–10 cm H2O in addition to an expiratory pressure of 5–8 cm H2O . Of 83 patients with an aRSBI ≤ 105 , 26 ( 31 % ) required intubation , compared to 10/18 ( 55 % ) with an aRSBI > 105 ( multivariate odds ratio 3.70 , 95 % CI 1.14–11.99 , P = .03 ) . When comparing mortality , 7/83 patients ( 8.4 % ) with an aRSBI ≤ 105 died , compared to 6/18 ( 33 % ) patients in the group with an aRSBI > 105 ( multivariate odds ratio 4.51 , 95 % CI 1.19–17.11 , P = .03 ) . CONCLUSIONS : An aRSBI of > 105 is associated with need for intubation and increased in-hospital mortality . Whether patients with an elevated aRSBI could also have benefitted from an increase in NIV setting s remains unclear . Validation of this concept in a larger patient population is warranted Background While studies have suggested that prophylactic noninvasive ventilation ( NIV ) could prevent post-extubation respiratory failure in the intensive care unit , they appear inconsistent with regard to reintubation . We assessed the impact of a prophylactic NIV protocol on reintubation in a large population of at-risk patients . Methods Prospect i ve before-after study performed in the medical ICU of a teaching referral hospital . In the control cohort , we determined that patients older than 65 years and those with underlying cardiac or respiratory disease were at high-risk for reintubation . In the interventional cohort , we implemented a protocol using prophylactic NIV in all patients intubated at least 24 h and having one of these risk factors .  NIV was immediately applied after planned extubation during at least the first 24 hours . Extubation failure was defined by the need for reintubation within seven days following extubation . Results We included 83 patients at high-risk among 132 extubated patients in the control cohort ( 12-month period ) and 150 patients at high-risk among 225 extubated patients in the NIV cohort ( 18-month period ) . The reintubation rate was significantly decreased from 28 % in the control cohort ( 23/83 ) to 15 % ( 23/150 ) in the NIV cohort ( p = 0.02 log-rank test ) , whereas the non-at-risk patients did not significantly differ in the two periods ( 10.2 % vs. 10.7 % , p = 0.93 ) . After multivariate logistic-regression analysis , the use of prophylactic NIV protocol was independently associated with extubation success . Conclusions The implementation of prophylactic NIV after extubation may reduce the reintubation rate in a large population of patients with easily identified risk factors for extubation failure Introduction We assessed rates and predictive factors of  non-invasive ventilation ( NIV ) failure in patients admitted to the intensive care unit ( ICU ) for non-hypercapnic acute hypoxemic respiratory failure ( AHRF ) . Methods This is an observational cohort study using data prospect ively collected over a three-year period in a medical ICU of a university hospital . Results Among 113 patients receiving NIV for AHRF , 82 had acute respiratory distress syndrome ( ARDS ) and 31 had non-ARDS .  Intubation rates significantly differed between ARDS and non-ARDS patients ( 61 % versus 35 % , P = 0.015 ) and according to clinical severity of ARDS : 31 % in mild , 62 % in moderate , and 84 % in severe ARDS ( P = 0.0016 ) . In-ICU mortality rates were 13 % in non-ARDS , and , respectively , 19 % , 32 % and 32 % in mild , moderate and severe ARDS ( P = 0.22 ) . Among patients with moderate ARDS ,  NIV failure was lower among those having a PaO2/FiO2 > 150 mmHg ( 45 % vs. 74 % , p = 0.04 ) .  NIV  failure was associated with active cancer , shock , moderate/severe ARDS , lower Glasgow coma score and lower positive end-expiratory pressure level at NIV initiation . Among intubated patients , ICU mortality rate was 46 % overall and did not differ according to the time to intubation . Conclusions With intubation rates below 35 % in non-ARDS and mild ARDS , NIV st and s as the first-line approach ; NIV may be attempted in ARDS patients with a PaO2/FiO2 > 150 . By contrast , 84 % of severe ARDS required intubation and NIV did not appear beneficial in this subset of patients . However , the time to intubation had no influence on mortality BACKGROUND AND METHODS The role of noninvasive positive-pressure ventilation delivered through a face mask in patients with acute respiratory failure is uncertain . We conducted a prospect i ve , r and omized trial of noninvasive positive-pressure ventilation as compared with endotracheal intubation with conventional mechanical ventilation in 64 patients with hypoxemic acute respiratory failure who required mechanical ventilation . RESULTS Within the first hour of ventilation , 20 of 32 patients ( 62 percent ) in the noninvasive-ventilation group and 15 of 32 ( 47 percent ) in the conventional-ventilation group had an improved ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen ( PaO2:FiO2 ) ( P=0.21 ) . Ten patients in the noninvasive-ventilation group subsequently required endotracheal intubation . Seventeen patients in the conventional-ventilation group ( 53 percent ) and 23 in the noninvasive-ventilation group ( 72 percent ) survived their stay in the intensive care unit ( odds ratio , 0.4 ; 95 percent confidence interval , 0.1 to 1.4 ; P=0.19 ) ; 16 patients in the conventional-ventilation group and 22 patients in the noninvasive-ventilation group were discharged from the hospital . More patients in the conventional-ventilation group had serious complications ( 66 percent vs. 38 percent , P=0.02 ) and had pneumonia or sinusitis related to the endotracheal tube ( 31 percent vs. 3 percent , P=0.003 ) . Among the survivors , patients in the noninvasive-ventilation group had shorter periods of ventilation ( P=0.006 ) and shorter stays in the intensive care unit ( P=0.002 ) . CONCLUSIONS In patients with acute respiratory failure , noninvasive ventilation was as effective as conventional ventilation in improving gas exchange and was associated with fewer serious complications and shorter stays in the intensive care unit OBJECTIVE To determine whether the use of noninvasive positive pressure ventilation ( NPPV )  in the emergency department ( ED ) will reduce the need for tracheal intubation and mechanical ventilation . DESIGN R and omized , controlled , prospect i ve clinical trial . SETTING ED of Barnes-Jewish Hospital , a university-affiliated teaching hospital . PATIENTS Twenty-seven patients meeting a predetermined definition of acute respiratory distress requiring hospital admission . INTERVENTIONS Conventional medical therapy for the various etiologies of acute respiratory distress and the application of NPPV . MEASUREMENTS AND RESULTS The primary outcome measure was the need for tracheal intubation and mechanical ventilation . Secondary outcomes also assessed included hospital mortality , hospital length of stay , acquired organ system derangements , and the utilization of respiratory care personnel . Sixteen patients ( 59.3 % ) were r and omly assigned to receive conventional medical therapy plus NPPV , and 11 patients ( 40.7 % ) were r and omly assigned to receive conventional medical therapy without NPPV . The two groups were similar at the time of r and omization in the ED with regard to demographic characteristics , hospital admission diagnoses , and severity of illness . Tracheal intubation and mechanical ventilation was required in seven patients ( 43.8 % ) receiving conventional medical therapy plus NPPV and in five patients ( 45.5 % ) receiving conventional medical therapy alone ( relative risk=0.96 ; 95 % confidence interval=0.41 to 2.26 ; p=0.930 ) . There was a trend towards a greater hospital mortality rate among patients in the  NPPV  group ( 25 % ) compared to patients in the conventional medical therapy group ( 0.0 % ) ( p=0.123 ) . Among patients who subsequently required mechanical ventilation , those in the NPPV group had a longer time interval from ED arrival to the start of mechanical ventilation compared to patients in the conventional medical therapy group ( 26.0+/-27.0 h vs 4.8+/-6.9 h ; p=0.055 ) . CONCLUSIONS We conclude that the application of NPPV in the ED may delay tracheal intubation and the initiation of mechanical ventilation in some patients with acute respiratory distress . We also demonstrated that the application of NPPV was associated with an increased hospital mortality rate . Based on these preliminary observations , larger clinical investigations are required to determine if adverse patient outcomes can be attributed to the early application of NPPV in the ED . Additionally , improved patient selection criteria for the optimal administration of NPPV in the ED need to be developed BACKGROUND Evidence is weak for the ability of long-term non-invasive positive pressure ventilation ( NPPV ) to improve survival in patients with stable hypercapnic chronic obstructive pulmonary disease ( COPD ) . Previous prospect i ve studies did not target a reduction in hypercapnia when adjusting ventilator setting s. This study investigated the effect of long-term NPPV , targeted to markedly reduce hypercapnia , on survival in patients with advanced , stable hypercapnic COPD . METHODS This investigator-initiated , prospect i ve , multicentre , r and omised , controlled clinical trial enrolled patients with stable GOLD stage IV COPD and a partial carbon dioxide pressure ( PaCO2 ) of 7 kPa ( 51.9 mm Hg ) or higher and pH higher than 7.35 .  NPPV was targeted to reduce baseline PaCO2 by at least 20 % or to achieve PaCO2 values lower than 6.5 kPa ( 48.1 mm Hg ) . Patients were r and omly assigned ( in a 1:1 ratio ) via a computer-generated r and omisation sequence with a block size of four , to continue optimised st and ard treatment ( control group ) or to receive additional NPPV for at least 12 months ( intervention group ) . The primary outcome was 1-year all-cause mortality . Analysis was by intention to treat . The intervention was unblinded , but outcome assessment was blinded to treatment assignment . This study is registered with Clinical Trials.gov , number NCT00710541 . FINDINGS Patients were recruited from 36 respiratory units in Germany and Austria , starting on Oct 29 , 2004 , and terminated with a record of the vital status on July 31 , 2011 . 195 patients were r and omly assigned to the NPPV group ( n=102 ) or to the control group ( n=93 ) . All patients from the control group and the NPPV group were included in the primary analysis . 1-year mortality was 12 % ( 12 of 102 patients ) in the intervention group and 33 % ( 31 of 93 patients ) in the control group ; hazard ratio 0.24 ( 95 % CI 0.11 - 0.49 ; p=0.0004 ) . 14 ( 14 % ) patients reported facial skin rash , which could be managed by changing the type of the mask . No other intervention-related adverse events were reported . INTERPRETATION The addition of long-term NPPV to st and ard treatment improves survival of patients with hypercapnic , stable COPD when NPPV is targeted to greatly reduce hypercapnia . FUNDING German Lung Foundation ; ResMed , Germany ; Tyco Healthcare , Germany ; and Weinmann , Germany Objectives : Centers for Disease Control and Prevention built up new surveillance paradigms for the patients on mechanical ventilation and the ventilator-associated events , comprising ventilator-associated conditions and infection-related ventilator-associated complications . We assess 1 ) the current epidemiology of ventilator-associated event , 2 ) the relationship between ventilator-associated event and ventilator-associated pneumonia , and 3 ) the impact of ventilator-associated event on antimicrobials consumption and mechanical ventilation duration . Design : Inception cohort study from the longitudinal prospect i ve French multicenter OUTCOME REA data base ( 1996 - 2012 ) . Patients : Patients on mechanical ventilation for greater than or equal to 5 consecutive days were classified as to the presence of a ventilator-associated event episode , using slightly modified Centers for Disease Control and Prevention definitions . Intervention : None . Measurements and Main Results : Among the 3,028 patients , 2,331 patients ( 77 % ) had at least one ventilator-associated condition , and 869 patients ( 29 % ) had one infection-related ventilator-associated complication episode . Multiple causes , or the lack of identified cause , were frequent . The leading causes associated with ventilator-associated condition and infection-related ventilator-associated complication were nosocomial infections ( 27.3 % and 43.8 % ) , including ventilator-associated pneumonia ( 14.5 % and 27.6 % ) . Sensitivity and specificity of diagnosing ventilator-associated pneumonia were 0.92 and 0.28 for ventilator-associated condition and 0.67 and 0.75 for infection-related ventilator-associated complication , respectively . A good correlation was observed between ventilator-associated condition and infection-related ventilator-associated complication episodes , and ventilator-associated pneumonia occurrence : R2 = 0.69 and 0.82 ( p < 0.0001 ) . The median number of days alive without antibiotics and mechanical ventilation at day 28 was significantly higher in patients without any ventilator-associated event ( p < 0.05 ) . Ventilator-associated condition and infection-related ventilator-associated complication rates were closely correlated with antibiotic use within each ICU : R2 = 0.987 and 0.99 , respectively ( p < 0.0001 ) . Conclusions : Ventilator-associated event is very common in a population at risk and more importantly highly related to antimicrobial consumption and may serve as surrogate quality indicator for improvement programs Purpose The efficacy of noninvasive continuous positive airway pressure ( CPAP ) to improve outcomes in  severe hypoxemic acute respiratory failure ( hARF ) due to pneumonia has not been clearly established . The aim of this study was to compare CPAP vs. oxygen therapy to reduce the risk of meeting criteria for endotracheal intubation ( ETI ) . Methods In a multicenter r and omized controlled trial conducted in four Italian centers patients with severe hARF due to pneumonia were r and omized to receive helmet CPAP ( CPAP group ) or oxygen delivered with a Venturi mask ( control group ) . The primary endpoint was the percentage of patients meeting criteria for ETI , including either one or more major criteria ( respiratory arrest , respiratory pauses with unconsciousness , severe hemodynamic instability , intolerance ) or at least two minor criteria ( reduction of at least 30 % of basal PaO2/FiO2 ratio , increase of 20 % of PaCO2 , worsening of alertness , respiratory distress , SpO2 less than 90 % , exhaustion ) . Results Between February 2010 and 2013 , 40 patients were r and omized to CPAP and 41 to Venturi mask . The proportion of patients meeting ETI criteria in the CPAP group was significantly lower compared to those in the control group ( 6/40 = 15 % vs. 26/41 = 63 % , respectively , p < 0.001 ; relative risk 0.24 , 95 % CI 0.11–0.51 ; number needed to treat , 2 ) two patients were intubated in the CPAP group and one in the control group . The CPAP group showed a faster and greater improvement in oxygenation in comparison to controls ( p < 0.001 ) . In either study group , no relevant adverse events were detected . Conclusions Helmet CPAP reduces the risk of meeting ETI criteria compared to oxygen therapy in patients with severe hARF due to pneumonia Recent studies suggest that noninvasive positive pressure ventilation ( NPPV ) administered by nasal or oronasal mask avoids the need for endotracheal intubation , rapidly improves vital signs , gas exchange , and sense of dyspnea , and may reduce mortality in selected patients with acute respiratory failure , but few controlled trials have been done . The present study used a r and omized prospect i ve design to evaluate the possible benefits of NPPV plus st and ard therapy versus st and ard therapy alone in patients with acute respiratory failure . Patients to receive NPPV were comfortably fitted with a st and ard nasal mask connected to a BiPAP ventilatory assist device ( Respironics , Inc. , Murrysville , PA ) in the patient flow-triggered/time-triggered ( S/T ) mode , and st and ard therapy consisted of all other treatments deemed necessary by the primary physician , including endotracheal intubation . The need for intubation was reduced from 73 % in the st and ard therapy group ( 11 of 15 patients ) to 31 % in the NPPV group ( 5 of 16 patients , p < 0.05 ) . Among chronic obstructive pulmonary disease ( COPD ) patients , the reduction was even more striking , with 8 of 12 ( 67 % ) control patients requiring intubation compared with 1 of 11 ( 9 % ) NPPV patients ( p < 0.05 ) . Heart and respiratory rates were significantly lower in the NPPV group than in control patients within 1 h , and PaO2 was significantly improved in the NPPV group for the first 6 h. Dyspnea scores and maximal inspiratory pressures were better in the NPPV than in control patients at 6 h , and nurses and therapists spent similar amounts of time at the bedside for both groups . ( ABSTRACT TRUNCATED AT 250 WORDS BACKGROUND This study was undertaken to investigate the haemodynamic effect of non-invasive positive pressure ventilation ( NPPV ) in patients after cardiac surgery .  NPPV has recently become popular as method for treating acute respiratory failure . Its influence on cardiopulmonary haemodynamics is still unknown . METHODS 30 extubated low-risk patients were included in four study intervals after cardiac surgery . During the first and the third interval , the patients breathed spontaneously and received oxygen via face mask for 45 min . Both intervals were followed by 45 min on NPPV . RESULTS Cardiac index increased significantly from 2.8 to 3.1 ml/min/m2 during NPPV ( p < 0.001 ) and from 2.7 to 3.2 ml/ min/m2 ( p < 0.001 ) . Mixed venous saturation rose significantly from 72.4 to 74.8 % ( p < 0.001 ) and from 72.1 to 75.4 % ( p < 0.001 ) during NPPV while the oxygen extraction ratio decreased from 25.5 and 26.1 % to 23.0 ( p < 0.001 ) and 22.6 % ( p < 0.001 ) during NPPV . At the same time , urine production increased significantly from 182 to 328 ml/h and from 186 to 285 ml/h ( p < 0.001 ) . Heart rate and mean arterial blood pressure rose significantly during NPPV . There were no significant changes in systemic and pulmonary haemodynamics , oxygenation or CO 2 elimination . CONCLUSIONS NPPV improves CI significantly in stable cardiac surgery patients . Factors other than blood pressure , vascular resistance or blood gases must exert an additional influence on CI . They are still not identified . Changes in transmural pressure during NPPV may play an important role BACKGROUND Non-invasive pressure support ventilation ( NIPSV ) is an effective treatment for acute respiratory failure in patients with chronic obstructive pulmonary disease . We assessed the efficacy of this therapy in acute cardiogenic pulmonary oedema in a r and omised comparison with conventional oxygen therapy . METHODS 40 patients were r and omly assigned conventional oxygen therapy or NIPSV supplied by a st and ard ventilator through a face mask , with adjustment of tidal volume and pressure support in addition to a positive end-expiratory pressure of 5 cm water . Physiological measurements were obtained in the first 2 h and at 3 h , 4 h , and 10 h. The main endpoints were intubation rate and resolution time . Analyses were by intention to treat . FINDINGS Three patients were withdrawn on the basis of clinical and chest radiography results . Endotracheal intubation was required in one ( 5 % ) of 19 patients assigned NIPSV and in six ( 33 % ) of 18 assigned conventional oxygen therapy ( p=0.037 ) . Resolution time ( defined as a clinical improvement with oxygen saturation of 96 % or more and respiratory rate less than 30 breaths/min ) was significantly shorter in the NIPSV group ( median 30 [ IQR 15 - 53 ] vs 105 [ 50 - 230 ] min , p=0.002 ) . NIPSV led to a rapid improvement in oxygenation in the first 2 h. There were no differences in hospital length of stay or mortality . INTERPRETATION In this study of acute cardiogenic pulmonary oedema , NIPSV was superior to conventional oxygen therapy . Further studies should compare NIPSV with continuous positive airway pressure BACKGROUND Guidelines for noninvasive mechanical ventilation ( NIMV ) recommend continuous positive airway pressure in patients with thoracic trauma who remain hypoxic despite regional anesthesia . This recommendation is rated only by level C evidence because r and omized controlled trials in this specific population are lacking . Our aim was to determine whether NIMV reduces intubation in severe trauma-related hypoxemia . METHODS This was a single-center r and omized clinical trial in a nine-bed ICU of a level I trauma hospital . Inclusion criteria were patients with Pao(2)/Fio(2)<200 for > 8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma . Patients were r and omized to remain on high-flow oxygen mask or to receive NIMV . The interface was selected based on the associated injuries . Thoracic anesthesia was universally supplied unless contraindicated . The primary end point was intubation ; secondary end points included length of hospital stay and survival . Statistical analysis was based on multivariate analysis . RESULTS After 25 patients were enrolled in each group , the trial was prematurely stopped for efficacy because the intubation rate was much higher in controls than in NIMV patients ( 10 [ 40 % ] vs 3 [ 12 % ] , P = .02 ) . Multivariate analysis adjusted for age , gender , chronic heart failure , and Acute Physiology and Chronic Health Evaluation II at admission revealed NIMV as the only variable independently related to intubation ( odds ratio , 0.12 ; 95 % CI , 0.02 - 0.61 ; P = .01 ) . Length of hospital stay was shorter in NIMV patients ( 14 vs 21 days P = .001 ) , but no differences were observed in survival or other secondary end points . CONCLUSION NIMV reduced intubation compared with oxygen therapy in severe thoracic trauma-related hypoxemia OBJECTIVE Our objective was to evaluate the efficacy of noninvasive continuous positive airway pressure ( CPAP ) delivered by helmet in improving oxygenation in comparison with oxygen therapy in community-acquired pneumonia ( CAP ) . METHODS This was a multicenter , r and omized , controlled trial enrolling patients with CAP admitted to an ED with moderate hypoxemic acute respiratory failure ( ARF ) ( Pa(O(2))/Fi(O(2 ) ) ratio > or = 210 and < or = 285 ) . Patients were r and omized to helmet CPAP or st and ard oxygen therapy ( control group ) . The primary end point was the time to reach a Pa(O(2))/Fi(O(2 ) ) ratio > 315 . After reaching this value , patients r and omized to CPAP were switched to oxygen , and the proportion of subjects who could maintain a Pa(O(2))/Fi(O(2 ) ) ratio > 315 at 1 h was recorded . RESULTS Forty-seven patients were recruited : 20 r and omized to CPAP and 27 to controls . Patients r and omized to CPAP reached the end point in a median of 1.5 h , whereas controls reached the end point in 48 h ( P < .001 ) . The proportion of patients who reached the primary end point was 95 % ( 19/20 ) among the CPAP group and 30 % ( 8/27 ) among controls ( P < .001 ) . One hour after reaching the primary end point , 2/14 patients in the CPAP group maintained a Pa(O(2))/Fi(O(2 ) ) value > 315 . CONCLUSIONS CPAP delivered by helmet rapidly improves oxygenation in patients with CAP suffering from a moderate hypoxemic ARF . This trial represents a proof-of-concept evaluation of the potential usefulness of CPAP in patients with CAP 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 Objective : To investigate the effects of noninvasive positive pressure ventilation ( NPPV ) on pulmonary gas exchange , breathing pattern , intrapulmonary shunt fraction , oxygen consumption , and resting energy expenditure in patients with persistent acute respiratory failure but without chronic obstructive pulmonary disease ( COPD ) after early extubation . Design : Prospect i ve study . Setting : Multidisciplinary intensive care unit of a university hospital . Patients : 15 patients after prolonged mechanical ventilation ( > 72 h ) with acute respiratory insufficiency after early extubation . Interventions : Criteria for early extubation were arterial oxygen tension ( PaO2 ) L 40 mm Hg ( fractional inspired oxygen 0.21 ) , arterial carbon dioxide tension ( PaCO2 ) K 55 mm Hg , pH > 7.32 , respiratory rate K 40 breaths per min , tidal volume ( VT ) L 3 ml/kg , rapid shallow breathing index K 190 and negative inspiratory force L 20 cmH2O . After extubation , two modes of NPPV were applied [ continuous positive airway pressure ( CPAP ) of 5 cmH2O and pressure support ventilation ( PSV ) with 15 cmH2O pressure support ] . Measurements and main results : Oxygenation and ventilatory parameters improved during both modes of NPPV ( p < 0.05 ) : increase in PaO2 of 11 mm Hg during CPAP and 21 mm Hg during PSV ; decrease in intrapulmonary shunt fraction of 7 % during CPAP and 12 % during PSV ; increase in tidal volume of 1 ml/kg during CPAP and 4 ml/kg during PSV ; decrease in respiratory rate 6 breaths/min during CPAP and 9 breaths/min during PSV . Oxygen consumption ( 15 % during CPAP , 22 % during PSV ) and resting energy expenditure ( 12 % during CPAP , 20 % during PSV ) were reduced ( p < 0.05 ) . PaCO2 decreased , whereas minute ventilation and pH increased during PSV ( p < 0.05 ) . The median duration of NPPV was 2 days . Two patients had to be reintubated . Conclusions : In non- COPD patients with persistent acute respiratory failure after early extubation , NPPV improved pulmonary gas exchange and breathing pattern , decreased intrapulmonary shunt fraction , and reduced the work of breathing 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 We compared noninvasive positive-pressure ventilation ( NPPV ) , using bilevel positive airway pressure , with usual medical care ( UMC ) in the therapy of patients with acute respiratory failure ( ARF ) in a prospect i ve , r and omized trial . Patients were subgrouped according to the disease leading to ARF ( chronic obstructive pulmonary disease [ COPD ] , a non- COPD -related pulmonary process , neuromuscular disease , and status postextubation ) , and were then r and omized to NPPV or UMC .  Thirty-two patients were evaluated in the NPPV group and 29 in the UMC group . The rate of endotracheal intubation ( ETI ) was significantly lower in the NPPV than in the UMC group ( 6.38 intubations versus 21.25 intubations per 100 ICU days , p = 0.002 ) . Mortality rates in the intensive care unit ( ICU ) were similar for the two treatment groups ( 2.39 deaths versus 4.27 deaths per 100 ICU days , p = 0.21 , NPPV versus UMC , respectively ) . Patients with hypoxemic ARF in the  NPPV  group had a significantly lower ETI rate than those in the UMC group ( 7.46 intubations versus 22.64 intubations per 100 ICU days , p = 0.026 ) ; a similar trend was noted for patients with hypercapnic ARF ( 5.41 intubations versus 18.52 intubations per 100 ICU days , p = 0.064 , NPPV versus UMC , respectively ) . Patients with ARF in the non- COPD category had a lower rate of ETI with NPPV than with UMC ( 8.45 intubations versus 30.30 intubations per 100 ICU days , p = 0.01 ) . Although the rate of ETI was lower among COPD patients receiving NPPV , this trend did not reach statistical significance ( 5.26 intubations versus 15.63 intubations per 100 ICU days , p = 0.12 , NPPV versus UMC , respectively ) . In conclusion , NPPV with bilevel positive airway pressure reduces the rate of ETI in patients with ARF of various etiologies 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 BACKGROUND Despite best-possible medical management , many patients with end-stage cancer experience breathlessness , especially towards the end of their lives . We assessed the acceptability and effectiveness of non-invasive mechanical ventilation ( NIV ) versus oxygen therapy in decreasing dyspnoea and the amount of opiates needed . METHODS In this r and omised feasibility study , we recruited patients from seven centres in Italy , Spain , and Taiwan , who had solid tumours and acute respiratory failure and had a life expectancy of less than 6 months . We r and omly allocated patients to receive either NIV ( using the Pressure Support mode and scheduled on patients ' request and mask comfort ) or oxygen therapy ( using a Venturi or a reservoir mask ) . We used a computer-generated sequence for r and omisation , stratified on the basis of patients ' hypercapnic status ( PaCO2 > 45 mm Hg or PaCO2 ≤45 mm Hg ) , and assigned treatment allocation using opaque , sealed envelopes . Patients in both groups were given sufficient subcutaneous morphine to reduce their dyspnoea score by at least one point on the Borg scale . Our primary endpoints were to assess the acceptability of NIV  used solely as a palliative measure and to assess its effectiveness in reducing dyspnoea and the amount of opiates needed compared with oxygen therapy . Analysis was done by intention to treat . This study is registered with Clinical Trials.gov , number NCT00533143 . FINDINGS We recruited patients between Jan 15 , 2008 , and March 9 , 2011 . Of 234 patients eligible for recruitment , we r and omly allocated 200 ( 85 % ) to treatment : 99 to NIV and 101 to oxygen . 11 ( 11 % ) patients in the NIV group discontinued treatment ; no patients in the oxygen group discontinued treatment . Dyspnoea decreased more rapidly in the NIV group compared with the oxygen group ( average change in Borg scale -0·58 , 95 % CI -0·92 to -0·23 , p=0·0012 ) , with most benefit seen after the first hour of treatment and in hypercapnic patients . The total dose of morphine during the first 48 h was lower in the NIV group than it was in the oxygen group ( 26·9 mg [ 37·3 ] for NIV vs 59·4 mg [ SD 67·1 ] for oxygen ; mean difference -32·4 mg , 95 % CI -47·5 to -17·4 ) . Adverse events leading to NIV discontinuation were mainly related to mask intolerance and anxiety . Morphine was suspended because of severe vomiting and nausea ( one patient in each group ) , sudden respiratory arrest ( one patient in the NIV group ) , and myocardial infa rct ion ( one patient in the oxygen group ) . INTERPRETATION Our findings suggest that NIV is more effective compared with oxygen in reducing dyspnoea and decreasing the doses of morphine needed in patients with end-stage cancer . Further studies are needed to confirm our findings and to assess the effectiveness of NIV on other outcomes such as survival . The use of NIV is , however , restricted to centres with NIV equipment , our findings are not generalisable to all cancer or palliative care units . FUNDING None Our aim was to evaluate the influence of static pulmonary compliance ( Cst ) on the choice of Mechanical Ventilation(MV ) method and treatment outcome . A prospect i ve , r and omized trial conducted out at the multidisciplinary Intensive Care Unit ( ICU ) included 387 patients , r and omized in two groups : noninvasive MV group and invasive MV group . Furthermore , each group was divided in two groups : Cst < or = 0.025 and Cst > 0.025 L/cm H2O . In patients with Cst > 0.025 L/cm H2O MV duration , noninvasive vs invasive , was 92 vs 114 h , p = 0.039 , time spent in ICU 118 vs 164 h , p = 0.004 . In patients with Cst < or = 0.025 , MV duration was 141 vs 189 h , p < 0.001 , time spent in ICU 190 vs 246 h , p = 0.001 , all patients were intubated . Need for tracheostomy was 6 ( 11 % ) vs 39 ( 46 % ) patients , p = 0.005 , and ICU mortality was 15 ( 26 % ) vs 21 ( 25 % ) patients . Statistical significance in favor of noninvasive method was confirmed in patients with Cst > 0.025 L/cm H2O in MV duration , time spent in ICU , need for tracheostomy and intubation rate . In the group with Cst < or = 0.025 no significant difference in treatment failure was recorded between the two MV methods Abstract : Acute respiratory failure ( ARF ) in patients with cancer is frequently a fatal event . To identify factors associated with survival of cancer patients admitted to an intensive care unit ( ICU ) for ARF , we conducted a prospect i ve 5-year observational study in a medical ICU in a teaching hospital in Paris , France . The patients were 203 cancer patients with ARF mainly due to infectious pneumonia ( 58 % ) , but also noninfectious pneumonia ( 9 % ) , congestive heart failure ( 12 % ) , and no identifiable cause ( 21 % ) . We measured clinical characteristics and ICU and hospital mortality rates . ICU mortality was 44.8 % and hospital mortality was 47.8 % . Noninvasive mechanical ventilation was used in 79 ( 39 % ) patients and conventional mechanical ventilation in 114 ( 56 % ) , the mortality rates being 48.1 % and 75.4 % , respectively . Among the 14 patients with late noninvasive mechanical ventilation failure ( > 48 hours ) , only 1 survived . The mortality rate was 100 % in the 19 noncardiac patients in whom  conventional mechanical ventilation was started after 72 hours . By multivariable analysis , factors associated with increased mortality were documented invasive aspergillosis ( odds ratio [ OR ] , 2.13 ; 95 % confidence intervals [ CI ] , 1.05 - 14.74 ) , no definite diagnosis ( OR , 3.85 ; 95 % CI , 1.26 - 11.70 ) , vasopressors ( OR , 3.19 ; 95 % CI , 1.28 - 7.95 ) , first-line conventional mechanical ventilation ( OR , 8.75 ; 95 % CI , 2.35 - 35.24 ) , conventional mechanical ventilation after noninvasive mechanical ventilation failure ( OR , 17.46 ; 95 % CI , 5.04 - 60.52 ) , and late noninvasive mechanical ventilation failure ( OR , 10.64 ; 95 % CI , 1.05 - 107.83 ) . Hospital mortality was lower in patients with cardiac pulmonary edema ( OR , 0.16 ; 95 % CI , 0.03 - 0.72 ) . Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance . The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient 's response to noninvasive mechanical ventilation . Abbreviations : ARDS = acute respiratory distress syndrome , ARF = acute respiratory failure , BAL = bronchoalveolar lavage , HSCT = human stem-cell transplant , ICU = intensive care unit , MV = mechanical ventilation , NIMV = noninvasive mechanical ventilation
Background This meta- analysis compared the effects of non-invasive ventilation ( NIV ) with invasive mechanical ventilation ( InMV ) and st and ard oxygen ( O2 ) therapy on mortality and rate of tracheal intubation in patients presenting acute respiratory failure ( ARF ) .