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Prognostic nomogram for elderly patients with acute respiratory failure receiving invasive mechanical ventilation: a nationwide population-based cohort study in Taiwan.

ABSTRACT: Patients in critical care medicine are ageing. There is limited literature evaluating long-term outcomes and prognostic factors for the growing number of elderly patients with acute respiratory failure (ARF) receiving invasive mechanical ventilation (IMV). Data on elderly patients (≧ 65 years old) with ARF receiving intubation and IMV during 2003-2012 were retrospectively collected from the national health database in Taiwan. We included 7,095 elderly patients. The 28-day mortality was 33%, the 60-day mortality was 47.5%, and the 1-year mortality was 70.4%. Patients were divided into groups: young-old (65-74 years), middle-old (75-84 years), and oldest-old (≧ 85 years). Patients in the oldest-old and middle-old groups had higher 1-year mortality than the young-old group (p < 0.001). The multivariate logistic regression revealed 9 significant factors associated with 1-year mortality, and these factors were used to develop a prognostic nomogram. The present study showed that the long-term prognosis of elderly patients with ARF and IMV is very poor. This nomogram can help physicians estimate the 1-year mortality of elderly patients in the early stage of ARF and assist in clinical decision making.

SUBMITTER: Hsu CH

PROVIDER: S-EPMC7403322 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Prognostic nomogram for elderly patients with acute respiratory failure receiving invasive mechanical ventilation: a nationwide population-based cohort study in Taiwan.

Hsu Chun-Hsiang CH Hung Yao-Min YM Chu Kuo-An KA Chen Chiu-Fan CF Yin Chun-Hao CH Lee Ching-Chih CC

Scientific reports 20200804 1

Patients in critical care medicine are ageing. There is limited literature evaluating long-term outcomes and prognostic factors for the growing number of elderly patients with acute respiratory failure (ARF) receiving invasive mechanical ventilation (IMV). Data on elderly patients (≧ 65 years old) with ARF receiving intubation and IMV during 2003-2012 were retrospectively collected from the national health database in Taiwan. We included 7,095 elderly patients. The 28-day mortality was 33%, the ...[more]

PMID: 32753615

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Project description:BackgroundAcute kidney injury (AKI) is a severe complication in critical patients receiving invasive mechanical ventilation (MV). However, AKI which occurs in the first 48 h after MV (early AKI) and thus likely associated with the MV settings is probably different from AKI occurring following 48 h (late AKI). This study is aimed at exploring the incidence of early and late AKI in elderly patients receiving MV and identifying their different risk factors and outcomes.MethodsThis retrospective, observational, multicenter cohort study consecutively included 3271 elderly patients (≥ 75 years) receiving invasive MV at four medical centers of Chinese PLA General Hospital from 2008 to 2020. The diagnosis of AKI was made following the 2012 KDIGO criteria and categorized into early (≤ 48 h) or late (> 48 h-7 days) according to the time from MV.ResultsThere were totally 1292 cases enrolled for the final analysis. Among them, 376 patients (29.1%) developed early AKI versus 132 (10.2%) developed late AKI. The 28-day mortality rates of the non-AKI, early AKI, and late AKI patients were 14.4, 46.8, and 61.4%, respectively. After 90 days, mortality rates of three groups were 33.2, 60.6, and 72.7%, respectively. Risk factors for early AKI included PaO2/FIO2, serum creatinine, hemoglobin, and positive end-expiratory pressure at the beginning of MV, while those for late AKI were PaO2/FIO2, serum creatinine, and hemoglobin. In the multivariable adjusted analysis, both early AKI (HR = 4.035; 95% CI = 3.166-5.142; P < 0.001) and late AKI (HR = 6.272; 95% CI = 4.654-8.453; P < 0.001) were related to the increased 28-day mortality relative to non-AKI. AKI was significantly related to 90-day mortality: early AKI (HR = 2.569; 95% CI = 2.142-3.082; P < 0.001) and late AKI (HR = 3.692; 95% CI = 2.890-4.716; P < 0.001).ConclusionsAKI mostly develops in the initial 48 h following MV, which is related to the health and MV settings; while AKI occurring following 48 h is not associated with MV settings. Therefore, a strategy for kidney protection in patients with MV should take these differences into consideration.

Project description:ImportanceThe opioid crisis is impacting people across the country and deserves attention to be able to curb the rise in opioid-related deaths.ObjectivesTo evaluate practice patterns in opioid infusion administration and dosing for patients with acute respiratory failure receiving invasive mechanical ventilation.DesignRetrospective cohort study.Setting and participantsPatients from 21 hospitals in Kaiser Permanente Northern California and 96 hospitals in Philips electronic ICU Research Institute.Main outcomes and measuresWe assessed whether patients received opioid infusion and the dose of said opioid infusion.ResultsWe identified patients with a diagnosis of acute respiratory failure who were initiated on invasive mechanical ventilation. From each patient, we determined if opioid infusions were administered and, among those who received an opioid infusion, the median daily dose of fentanyl infusion. We used hierarchical regression models to quantify variation in opioid infusion use and the median daily dose of fentanyl equivalents across hospitals. We included 13,140 patients in the KPNC cohort and 52,033 patients in the eRI cohort. A total of 7,023 (53.4%) and 16,311 (31.1%) patients received an opioid infusion in the first 21 days of mechanical ventilation in the KPNC and eRI cohorts, respectively. After accounting for patient- and hospital-level fixed effects, the hospital that a patient was admitted to explained 7% (95% CI, 3-11%) and 39% (95% CI, 28-49%) of the variation in opioid infusion use in the KPNC and eRI cohorts, respectively. Among patients who received an opioid infusion, the median daily fentanyl equivalent dose was 692 µg (interquartile range [IQR], 129-1341 µg) in the KPNC cohort and 200 µg (IQR, 0-1050 µg) in the eRI cohort. Hospital explained 4% (95% CI, 1-7%) and 20% (95% CI, 15-26%) of the variation in median daily fentanyl equivalent dose in the KPNC and eRI cohorts, respectively.Conclusions and relevanceIn the context of efforts to limit healthcare-associated opioid exposure, our findings highlight the considerable opioid exposure that accompanies mechanical ventilation and suggest potential under and over-treatment with analgesia. Our results facilitate benchmarking of hospitals' analgesia practices against risk-adjusted averages and can be used to inform usual care control arms of analgesia and sedation clinical trials.

Project description:BackgroundRecruitment manoeuvres involve transient elevations in airway pressure applied during mechanical ventilation to open ('recruit') collapsed lung units and increase the number of alveoli participating in tidal ventilation. Recruitment manoeuvres are often used to treat patients in intensive care who have acute respiratory distress syndrome (ARDS), but the effect of this treatment on clinical outcomes has not been well established. This systematic review is an update of a Cochrane review originally published in 2009.ObjectivesOur primary objective was to determine the effects of recruitment manoeuvres on mortality in adults with acute respiratory distress syndrome.Our secondary objective was to determine, in the same population, the effects of recruitment manoeuvres on oxygenation and adverse events (e.g. rate of barotrauma).Search methodsFor this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), the Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO), Latin American and Caribbean Health Sciences (LILACS) and the International Standard Randomized Controlled Trial Number (ISRCTN) registry from inception to August 2016.Selection criteriaWe included randomized controlled trials (RCTs) of adults who were mechanically ventilated that compared recruitment manoeuvres versus standard care for patients given a diagnosis of ARDS.Data collection and analysisTwo review authors independently assessed trial quality and extracted data. We contacted study authors for additional information.Main resultsTen trials met the inclusion criteria for this review (n = 1658 participants). We found five trials to be at low risk of bias and five to be at moderate risk of bias. Six of the trials included recruitment manoeuvres as part of an open lung ventilation strategy that was different from control ventilation in aspects other than the recruitment manoeuvre (such as mode of ventilation, higher positive end-expiratory pressure (PEEP) titration and lower tidal volume or plateau pressure). Six studies reported mortality outcomes. Pooled data from five trials (1370 participants) showed a reduction in intensive care unit (ICU) mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.72 to 0.97, P = 0.02, low-quality evidence), pooled data from five trials (1450 participants) showed no difference in 28-day mortality (RR 0.86, 95% CI 0.74 to 1.01, P = 0.06, low-quality evidence) and pooled data from four trials (1313 participants) showed no difference in in-hospital mortality (RR 0.88, 95% CI 0.77 to 1.01, P = 0.07, low-quality evidence). Data revealed no differences in risk of barotrauma (RR 1.09, 95% CI 0.78 to 1.53, P = 0.60, seven studies, 1508 participants, moderate-quality evidence).Authors' conclusionsWe identified significant clinical heterogeneity in the 10 included trials. Results are based upon the findings of several (five) trials that included an "open lung ventilation strategy", whereby the intervention group differed from the control group in aspects other than the recruitment manoeuvre (including co-interventions such as higher PEEP, different modes of ventilation and higher plateau pressure), making interpretation of the results difficult. A ventilation strategy that included recruitment manoeuvres in participants with ARDS reduced intensive care unit mortality without increasing the risk of barotrauma but had no effect on 28-day and hospital mortality. We downgraded the quality of the evidence to low, as most of the included trials provided co-interventions as part of an open lung ventilation strategy, and this might have influenced results of the outcome.

Dataset Information

Prognostic nomogram for elderly patients with acute respiratory failure receiving invasive mechanical ventilation: a nationwide population-based cohort study in Taiwan.

Publications

Prognostic nomogram for elderly patients with acute respiratory failure receiving invasive mechanical ventilation: a nationwide population-based cohort study in Taiwan.

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