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Pulmonary circulation disorders predict noninvasive vent failure



COPD patients with pulmonary circulation disorders were more than four times as likely to need invasive ventilation after noninvasive ventilation (NIV) failed for acute exacerbations, found a new study.

Dr. Di Pan, Mount Sinai Hospital, New York Tara Haelle/MDedge News

Dr. Di Pan

Patients with fluid and electrolyte abnormalities or alcohol abuse also had a greater risk of escalating beyond NIV for exacerbations, according to the findings.

“Patients with these underlying conditions should be monitored closely, especially individuals with existing pulmonary disorders as they are at highest risk,” Di Pan, DO, of Mount Sinai Hospital, New York, reported at annual meeting of the American College of Chest Physicians.

The researchers used the 2012-2014 Nationwide Inpatient Sample database to retrospectively analyze data from 73,480 patients, average age 67.8 years, who had a primary diagnosis of COPD exacerbation and who had received initial treatment with NIV in their first 24 hours after hospitalization. The report is in CHEST® Journal(2018 Oct. doi: 10.1016/j.chest.2018.08.340).

The researchers examined associations between NIV failure and 29 Elixhauser comorbidity measures to identify what clinical characteristics might predict the need for invasive ventilation. They defined NIV failure as requiring intubation at any time within 30 days of admission.

Pulmonary circulation disorders emerged as the strongest predictor of the need for intubation, with a fourfold increase in relative risk (hazard ratio [HR]: 4.19, P less than .001). Alcohol abuse (HR: 1.85, P = .01) and fluid and electrolyte abnormalities (HR: 1.3, P less than .001) followed as additional factors associated with NIV failure. The latter included irregularities in potassium or sodium, acid-base disorders, hypervolemia and hypovolemia.

Among the 3,740 patients with alcohol abuse, additional statistically significant associations with intubation included a slightly higher mean age, female sex, and the mean Charlson comorbidity index. Mean age of those requiring intubation in this group was 62.28 years, compared 61.47 years among those in whom NIV was adequate (P = .03). Among those intubated, 30.2% of the patients were female, compared with 26.3% female patients in the nonintubated group.

Among the 26,150 patients with fluid, electrolyte and acid-base disturbances, younger patients were more likely to require intubation: The average age of those needing intubation was 67.23 years, compared with 69.3 years for those non-intubated (P less than .001). While a higher Charlson index (2.83 vs. 2.53) was again correlated with greater risk of needing intubation (P less than .001), males were now more likely to require intubation: 58.1% of those without intubation were female, compared with 53.9% of those needing intubation (P less than .001).

Within the 890 patients with pulmonary circulation disorders, mean age was 68.03 years for intubation and 70.77 years for nonintubation (P less than .001). In this group, 56.4% of the patients requiring intubation were female, compared to 47.9% of patients not intubated. The average Charlson index was lower (3.11) among those requiring intubation than among those not needing it (3.57, P less than .001).

The findings were limited by the lack of disease severity stratification and use of now-outdated ICD-9 coding. The researchers also lacked detailed clinical data, such as lab values, imaging results, and vital signs, and Dr. Pan acknowledged the broad variation within the diagnoses of the also-broad Elixhauser comorbidity index.

“For the next steps, we can do a stratified analysis” to identify which specific pulmonary circulation diseases primarily account for the association with intubation, Dr. Pan said.

No external funding was noted. The authors reported having no disclosures.

SOURCE: Pan D. et al. CHEST 2018.

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