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Utilization of mechanical ventilation for asthma exacerbations: analysis of a national database.

ABSTRACT: The current frequency of noninvasive (NIV) and invasive mechanical ventilation use in asthma exacerbations (AEs) and the relationship to outcomes are unknown.We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients discharged with a principal diagnosis of AE. For each discharge, we determined whether NIV or invasive mechanical ventilation was initiated during the first 2 hospital days. Using multivariate logistic regression to adjust for potential confounders, we determined whether use of mechanical ventilation and in-hospital mortality changed between 2000 and 2008.The number of AEs increased by 15.8% from 2000 to 2008. The proportion of admissions for which invasive mechanical ventilation was used during the first 2 days decreased from 1.4% in 2000 to 0.73% in 2008, whereas NIV use increased from 0.34% to 1.9%. The adjusted mortality from AEs requiring NIV or invasive mechanical ventilation was unchanged from 2000 to 2008. The hospital stay was also unchanged.There was a substantial increase in the use of mechanical ventilation, accompanied by a shift from invasive mechanical ventilation to NIV. Although we could not determine the clinical reasons for this increase, hospital stay and mortality were unchanged. A randomized trial is needed to determine whether NIV can improve outcomes in AEs before widespread adoption makes it impossible to conduct such a trial.

SUBMITTER: Nanchal R

PROVIDER: S-EPMC4580276 | biostudies-literature | 2014 May

REPOSITORIES: biostudies-literature

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Utilization of mechanical ventilation for asthma exacerbations: analysis of a national database.

Nanchal Rahul R Kumar Gagan G Majumdar Tillotama T Taneja Amit A Patel Jayshil J Dagar Gaurav G Jacobs Elizabeth R ER Whittle Jeff J

Respiratory care 20131008 5

<h4>Background</h4>The current frequency of noninvasive (NIV) and invasive mechanical ventilation use in asthma exacerbations (AEs) and the relationship to outcomes are unknown.<h4>Methods</h4>We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients discharged with a principal diagnosis of AE. For each discharge, we determined whether NIV or invasive mechanical ventilation was initiated during the first 2 hospital days. Using multivariate logistic regr ...[more]

PMID: 24106317

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Project description:BackgroundSeveral countries reported a substantial reduction in asthma exacerbations associated with COVID-19 pandemic-related restrictions. However, it is not known if these early reported declines were short-term and if these have rebounded to pre-pandemic levels following easing of lockdown restrictions.MethodsWe undertook a retrospective, cohort study of all asthma patients in a national primary care database of almost 10 million patients, Optimum Patient Care Database (OPCRD), identified from January 1, 2010, to December 31, 2015, using a previously validated algorithm. We subsequently followed the identified cohort of asthma patients from January 1, 2016, to October 3, 2021, and identified every asthma exacerbation episode with a validated algorithm. To quantify any pandemic-related change in exacerbations, we created a control time-series (mean of 2016-2019) and then compared the change in exacerbation rate in 2020-2021 over quarterly periods when compared with the control period (the pre-pandemic period). We undertook overall and stratified analyses by age group, sex, and English region.FindingsWe identified 100,362 asthma patients (502,669 patient-years) from across England who experienced at least one exacerbation episode (298,390 exacerbation episodes during the entire follow-up). Except for the first quarter of 2020, the exacerbation rates were substantially lower (>25%) during all quarters in 2020-2021 when compared with the rates during 2016-2019 (39.7% (95% Confidence Interval (CI): 34.6, 44.9) in quarter-2, 2020; 46.5% (95%CI: 36.7, 56.4) in quarter-3, 2020; 56.3% (95%CI: 48.7, 63.9) in quarter-4, 2020; 63.2% (95%CI: 53.9, 72.5) in quarter-1, 2021; 57.7% (95%CI: 52.9, 62.4) in quarter-2, 2021; 53.3% (95%CI: 43.8, 62.8) in quarter-3, 2021).InterpretationThere was a substantial and persistent reduction in asthma exacerbations across England over the first 18 months after the first lockdown. This is unlikely to be adequately explained by changes in health-seeking behaviour, pandemic-related healthcare service disruption, or any air-quality improvements.FundingAsthma UK, Health Data Research UK (HDR UK), Medical Research Council (MRC), National Institute for Health Research (NIHR).

Project description:BackgroundExtracorporeal CO2 removal (ECCO2R) could be a valuable additional modality for invasive mechanical ventilation (IMV) in COPD patients suffering from severe acute exacerbation (AE). We aimed to evaluate in such patients the effects of a low-to-middle extracorporeal blood flow device on both gas exchanges and dynamic hyperinflation, as well as on work of breathing (WOB) during the IMV weaning process.Study design and methodsOpen prospective interventional study in 12 deeply sedated IMV AE-COPD patients studied before and after ECCO2R initiation. Gas exchange and dynamic hyperinflation were compared after stabilization without and with ECCO2R (Hemolung, Alung, Pittsburgh, USA) combined with a specific adjustment algorithm of the respiratory rate (RR) designed to improve arterial pH. When possible, WOB with and without ECCO2R was measured at the end of the weaning process. Due to study size, results are expressed as median (IQR) and a non-parametric approach was adopted.ResultsAn improvement in PaCO2, from 68 (63; 76) to 49 (46; 55) mmHg, p = 0.0005, and in pH, from 7.25 (7.23; 7.29) to 7.35 (7.32; 7.40), p = 0.0005, was observed after ECCO2R initiation and adjustment of respiratory rate, while intrinsic PEEP and Functional Residual Capacity remained unchanged, from 9.0 (7.0; 10.0) to 8.0 (5.0; 9.0) cmH2O and from 3604 (2631; 4850) to 3338 (2633; 4848) mL, p = 0.1191 and p = 0.3013, respectively. WOB measurements were possible in 5 patients, indicating near-significant higher values after stopping ECCO2R: 11.7 (7.5; 15.0) versus 22.6 (13.9; 34.7) Joules/min., p = 0.0625 and 1.1 (0.8; 1.4) versus 1.5 (0.9; 2.8) Joules/L, p = 0.0625. Three patients died in-ICU. Other patients were successfully hospital-discharged.ConclusionsUsing a formalized protocol of RR adjustment, ECCO2R permitted to effectively improve pH and diminish PaCO2 at the early phase of IMV in 12 AE-COPD patients, but not to diminish dynamic hyperinflation in the whole group. A trend toward a decrease in WOB was also observed during the weaning process. Trial registration ClinicalTrials.gov: Identifier: NCT02586948.

Project description:BackgroundHome mechanical ventilation is an established treatment for chronic respiratory failure resulting in improved survival and quality of life. Technological advancement, evolving health care reimbursement systems and newly implemented national guidelines result in increased utilization worldwide. Prevalence shows great geographical variations and data on East-Central European practice has been scarce to date. The aim of the current study was to evaluate prevalence and characteristics of home mechanical ventilation in Hungary.MethodsWe conducted a nationwide study using an online survey focusing on patients receiving ventilatory support at home. The survey focused on characterization of the site (affiliation, type), experience with home mechanical ventilation, number of patients treated, indication for home mechanical ventilation (disease type), description of home mechanical ventilation (invasive/noninvasive, ventilation hours, duration of ventilation) and description of the care provided (type of follow up visits, hospitalization need, reimbursement).ResultsOur survey uncovered a total of 384 patients amounting to a prevalence of 3.9/100,000 in Hungary. 10.4% of patients received invasive, while 89.6% received noninvasive ventilation. The most frequent diagnosis was central hypopnea syndromes (60%), while pulmonary (20%), neuromuscular (11%) and chest wall disorders (7%) were less frequent indications. Daily ventilation need was less than 8?h in 74.2%, between 8 and 16?h in 15.4% and more than 16?h in 10.4% of patients reported. When comparing sites with a limited (<?50 patients) versus substantial (>?50 patients) case number, we found the former had significantly higher ratio of neuromuscular conditions, were more likely to ventilate invasively, with more than 16?h/day ventilation need and were more likely to provide home visits and readmit patients (p <?0,001).ConclusionsOur results show a reasonable current estimate and characterization of home mechanical ventilation practice in Hungary. Although a growing practice can be assumed, current prevalence is still markedly reduced compared to international data reported, the duality of current data hinting to a possible gap in diagnosis and care for more dependent patients. This points to the importance of establishing home mechanical ventilation centers, where increased experience will enable state of the art care to more dependent patients as well, increasing overall prevalence.

Dataset Information

Utilization of mechanical ventilation for asthma exacerbations: analysis of a national database.

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Utilization of mechanical ventilation for asthma exacerbations: analysis of a national database.

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