Browsing by keyword "mechanical ventilation"
Now showing items 1-3 of 3
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Dementia and Outcomes of Mechanical VentilationOBJECTIVES: To describe the effect of dementia on hospital outcomes of individuals requiring invasive mechanical ventilation (IMV). DESIGN: Retrospective cohort study. SETTING: 2011 Nationwide Inpatient Sample. PARTICIPANTS: Hospitalized individuals with and without dementia undergoing IMV. MEASUREMENTS: The adjusted predicted probability of undergoing IMV was examined in individuals with and without dementia. Then the dataset was limited to individuals who received IMV, and a multivariable logistic regression model was created in which dementia was the primary predictor and mortality was the outcome. RESULTS: Of the 13,816,586 hospitalizations of older adults in the United States in 2011, 2,204,506 (16%) with a dementia diagnosis code were identified. Individuals with dementia had statistically significantly lower predicted probability of undergoing IMV (5.7%, 95% confidence interval (CI) = 5.6-5.8% than those without (6.5%, 95% CI = 6.4-6.6%). When the dataset was limited to individuals undergoing IMV, those with dementia were older (mean age 80 vs 76, P < .001) and had a higher combined Gagne comorbidity score (4.4 vs 4.1, P < .001) than those without. In a multivariable model, dementia was associated with greater likelihood of survival to hospital discharge (odds ratio (OR) = 0.79, P < .001). Individuals with dementia also had shorter mean length of stay (12.5 +/- 0.2 vs 13.1 +/- 0.2, P = .01) and lower cost per hospitalization for survivors ($37,213 vs $44,557, P < .001). CONCLUSION: Older critically ill adults with dementia undergoing IMV had better in-hospital outcomes than those without dementia. Because a lower adjusted percentage of individuals with dementia underwent IMV, it is likely that patient selection drove outcome differences. These findings suggest that individuals, families, and clinicians are carefully considering prognosis, quality of life, and appropriate use of intensive care unit resources when deciding whether to use IMV in individuals with dementia.
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Early High-Frequency Oscillatory Ventilation in Pediatric Acute Respiratory Failure. A Propensity Score AnalysisRATIONALE: The use of high-frequency oscillatory ventilation (HFOV) for acute respiratory failure in children is prevalent despite the lack of efficacy data. OBJECTIVES: To compare the outcomes of patients with acute respiratory failure managed with HFOV within 24-48 hours of endotracheal intubation with those receiving conventional mechanical ventilation (CMV) and/or late HFOV. METHODS: This is a secondary analysis of data from the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) study, a prospective cluster randomized clinical trial conducted between 2009 and 2013 in 31 U.S. pediatric intensive care units. Propensity score analysis, including degree of hypoxia in the model, compared the duration of mechanical ventilation and mortality of patients treated with early HFOV matched with those treated with CMV/late HFOV. MEASUREMENTS AND MAIN RESULTS: Among 2,449 subjects enrolled in RESTORE, 353 patients (14%) were ever supported on HFOV, of which 210 (59%) had HFOV initiated within 24-48 hours of intubation. The propensity score model predicting the probability of receiving early HFOV included 1,064 patients (181 early HFOV vs. 883 CMV/late HFOV) with significant hypoxia (oxygenation index > /= 8). The degree of hypoxia was the most significant contributor to the propensity score model. After adjusting for risk category, early HFOV use was associated with a longer duration of mechanical ventilation (hazard ratio, 0.75; 95% confidence interval, 0.64-0.89; P = 0.001) but not with mortality (odds ratio, 1.28; 95% confidence interval, 0.92-1.79; P = 0.15) compared with CMV/late HFOV. CONCLUSIONS: In adjusted models including important oxygenation variables, early HFOV was associated with a longer duration of mechanical ventilation. These analyses make supporting the current approach to HFOV less convincing.
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Hospitals' Patterns of Use of Noninvasive Ventilation in Patients With Asthma ExacerbationBACKGROUND: Limited data are available on the use of noninvasive ventilation in patients with asthma exacerbations. The objective of this study was to characterize hospital patterns of noninvasive ventilation use in patients with asthma and to evaluate the association with the use of invasive mechanical ventilation and case fatality rate. METHODS: This cross-sectional study used an electronic medical record dataset, which includes comprehensive pharmacy and laboratory results from 58 hospitals. Data on 13,558 patients admitted from 2009 to 2012 were analyzed. Initial noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV) was defined as the first ventilation method during hospitalization. Hospital-level risk-standardized rates of NIV among all admissions with asthma were calculated by using a hierarchical regression model. Hospitals were grouped into quartiles of NIV to compare the outcomes. RESULTS: Overall, 90.3% of patients with asthma were not ventilated, 4.0% were ventilated with NIV, and 5.7% were ventilated with IMV. Twenty-two (38%) hospitals did not use NIV for any included admissions. Hospital-level adjusted NIV rates varied considerably (range, 0.4-33.1; median, 5.2%). Hospitals in the highest quartile of NIV did not have lower IMV use (5.4% vs 5.7%), but they did have a small but significantly shorter length of stay. Higher NIV rates were not associated with lower risk-adjusted case fatality rates. CONCLUSIONS: Large variation exists in hospital use of NIV for patients with an acute exacerbation of asthma. Higher hospital rates of NIV use does not seem to be associated with lower IMV rates. These results indicate a need to understand contextual and organizational factors contributing to this variability.