1. For patients admitted with chronic obstructive pulmonary disease (COPD) exacerbations requiring ventilatory support, non-invasive ventilation (NIV) was associated with a lower rate of mortality in the hospital as compared to invasive mechanical ventilation (IMV).
2. In addition, NIV was also associated with fewer days in the hospital, decreased cost, and decreased incidence of developing pneumonia while in the hospital compared with IMV.
Evidence Rating Level: 2 (Good)
Study Rundown: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the US, and leads to about 800,000 hospitalizations per year in this country. The standard of care for management of COPD exacerbations includes supplemental oxygen, bronchodilators, systemic corticosteroids, and antibiotics. For those patients that require ventilation support, there has been some suggestion that non-invasive ventilation (NIV) may have better outcomes than invasive mechanical ventilation (IMV). This study used data from a large number of US hospital to help determine the outcomes for COPD patients who received NIV compared to IMV. The results of this study suggest that for patients admitted to the hospital with COPD exacerbations and who required ventilatory support, NIV was associated with a lower chance of mortality in the hospital compared to IMV. In addition, NIV was also associated with fewer days in the hospital, decreased cost, and decreased incidence of developing pneumonia while in the hospital compared with IMV.
A major strength of the study is the geographically varied hospitals from which the data were obtained, which makes the results more generalizable. The investigators also attempted to account for many of the demographic and comorbid condition differences to make the comparison between NIV and IMV outcomes more valid. However, since this was a retrospective study, causality is difficult to establish. Rather, it opens doors for future prospective studies. Lastly, relying on ICD9 codes, especially for comorbid conditions, often leads to unreliable data, which adds uncertainty to the results.
In-Depth [retrospective cohort]: The data for this study was obtained from patient admissions from January 2008 to June 2011 at 420 hospitals that are enrolled in the database Premier Healthcare Informatics. The inclusion criteria were age greater than 40 years old, ICD9 codes for COPD exacerbation or acute respiratory failure in the setting of COPD, and patients who received mechanical ventilation within the first two days of hospitalization. The primary outcome of the study was in-hospital mortality. Important secondary outcomes included length of stay, cost, readmission, development of pneumonia in the hospital, and necessity to escalate from NIV to IMV if the former was initially chosen.
Amongst the almost 200,000 COPD exacerbation admissions during the study period, about 16.6% received ventilatory support, and 70.1% of those were initially treated with NIV. After adjusting for a number of patient, physician, and hospital characteristics, initial use of NIV was associated with decreased in-hospital mortality compared to IMV (OR, 0.54; 95% CI, 0.48-0.61). NIV was also associated with fewer pneumonia cases (OR, 0.53; 95% CI, 0.44-0.64), decreased length of hospital stay (ratio, 0.81; 95% CI, 0.79-0.82), and lower cost of care (ratio, 0.68; 95% CI, 0.67-0.69). There was no difference in the rate of readmission in regardless of the type of ventilation provided.
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