Refused Intubation Outcome?

[Hard24Get]

Wondering about the outcomes of those for those whom intubation was indicated but refused vs those who accepted intubation. Can't seem to find a good article, please help.

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[kungfufishing]

bet a whole bunch of em died. just guessing.

I have anecdotally had some success with bipap, and there are some articles out there about this, something like a 30% survival at 6 months or a year in a COPD population but I dont remember specifics, just skimmed it while looking up some noninvasive ventilation literature.

 

[VentdependenT]

nobody can say no to 300mg of IM ketamine. I dont care how combative they are. Lights out with spontaneous ventilation.

 

[kungfufishing]

and that glasseyed drooling look

 

[DropkickMurphy]

You all are in luck....I just wrote something about noninvasive ventilation for respiratory failure, so I have references on this sort of thing saved on my laptop

Honrubia et al: Noninvasive vs Conventional Mechanical Ventilation in Acute Respiratory Failure A Multicenter, Randomized Controlled Trial. CHEST 2005; 128:3916–3924

"Avoidance of intubation, mortality, and consumption of resources 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."

Wood et al: The Use of Noninvasive Positive Pressure Ventilation in the Emergency Department: Results of a Randomized Clinical Trial. CHEST 1999; 113: 1339-1346.

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 randomly assigned to receive conventional medical therapy plus NPPV,
and 11 patients (40.7%) were randomly assigned to receive conventional medical therapy without NPPV. The two groups were similar at the time of randomization 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 50.96; 95% confidence interval50.41 to 2.26; p50.930). 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%) (p50.123). 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 (26.0627.0 h vs 4.866.9 h; p50.055).

Lightowler JV, Jadwiga AW, Wedzicha A, Elliot MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ. 2003; 326:185


"NPPV should be the first line intervention in addition to usual medical care to manage respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease in all suitable patients. NPPV should be tried early in the course of respiratory failure and before severe acidosis, to reduce mortality, avoid endotracheal intubation, and decrease treatment failure.”

Other references:
Bott J, Carrol MP, Conway JH et al: Randomized controlled trial of nasal ventilation in acute ventilation failure due to chronic obstructive airway disease. Lancet 341:1555-1557. 1993
Antonelli M, Conti G, Rocco M, et al: A comparison of noninvasive positive-pressure ventiulation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429-435. 1998
Soroksky A, Stav D, and Shpirer I: A pilot prospective, randomized, placebo controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest 123:1018-1025. 2003
Acosta B, DiBenedetto R, Rahimi A et al: Hemodynamic effects of noninvasive bilevel positive airway pressure on patients with chronic congestive heart failure with systolic dysfunction. Chest 118:1004-1009. 2000
Poponick JM, Renston JP, Bennett RP, and Emerman CL: Use of a ventilatory support system (BiPAP) for scute respiratory failure in the emergency department. Chest 116:166-171, 1999.
Wang CH, Lin HC, Huang TJ et al: Differential effects of nasal continuous positive airway pressure on reversible and fixed upper and lower airway obstruction. Eur Respir J 9:952-95. 1996
Sacchetti A and Harris RH: Effectiveness of BIPAP for congestive heart failure. J Am Coll Cardiol 37:1754-1755, 2001.
Brouchard L, Mancebo J, Wysocki M, et al: Noninvasive positive pressure ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 333:817, 1995.
Hess D: Noninvasive positive pressure ventilation: predictors of success and failure for adult acute care applications. Respir Care 42:424-431, 1997.

 

[gutonc]

Thanks for those Dropkick. I'm a huge fan of NIPPV and almost always give it a shot before intubation. One great thing about it is that it's much easier to give a true trial off the vent than w/ a tube. Just unhook the mask and see how things go.

One thing that does bother me about NIPPV is that many people (from CCM attendings on down) think of it as a sort of really strong nasal cannula, rather than a vent w/o a tube. Sort of like people who consider a PICC just another IV rather than comparing it to a CVC.