Top

Published in:

Open Access 01-12-2021 | Pneumonia | Research Article

A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure

Authors: Mihaela S. Stefan, Aruna Priya, Penelope S. Pekow, Jay S. Steingrub, Nicholas S. Hill, Tara Lagu, Karthik Raghunathan, Anusha G. Bhat, Peter K. Lindenauer

Published in: BMC Pulmonary Medicine | Issue 1/2021

Abstract

Objective

To develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients.

Design

Retrospective cohort study of a multihospital electronic health record database.

Patients

Non-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization.

Measurement

Primary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010–2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016.

Main results

Of all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%–2.8%] for low risk group; 9.3% [6.3%–13.5%] for intermediate risk category; and 35.7% [31.0%–45.8%] for high risk category.

Conclusions

In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.

Available only for authorised users

Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817–22. https://doi.org/10.1056/NEJM199509283331301.CrossRefPubMed

Girou E, Schortgen F, Delclaux C, et al. Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients. JAMA. 2000;284(18):2361–7.CrossRef

Nourdine K, Combes P, Carton MJ, Beuret P, Cannamela A, Ducreux JC. Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey. Intensive Care Med. 1999;25(6):567–73.CrossRef

Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017. https://doi.org/10.1183/13993003.02426-2016.CrossRefPubMed

Conti G, Antonelli M, Navalesi P, et al. Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med. 2002;28(12):1701–7. https://doi.org/10.1007/s00134-002-1478-0.CrossRefPubMed

Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of noninvasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet. 2006;367(9517):1155–63. https://doi.org/10.1016/S0140-6736(06)68506-1.CrossRefPubMed

Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142–51. https://doi.org/10.1056/NEJMoa0707992.CrossRefPubMed

Keenan SP, Sinuff T, Cook DJ, Hill NS. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med. 2004;32(12):2516–23.CrossRef

Stefan MS, Priya A, Pekow PS, et al. The comparative effectiveness of noninvasive and invasive ventilation in patients with pneumonia. J Crit Care. 2018;43:190–6. https://doi.org/10.1016/j.jcrc.2017.05.023.CrossRefPubMed

10.

Confalonieri M, Potena A, Carbone G, Porta RD, Tolley EA, Umberto MG. Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med. 1999;160(5 Pt 1):1585–91.CrossRef

11.

Chandra D, Stamm JA, Taylor B, et al. Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998–2008. Am J Respir Crit Care Med. 2011;185(2):152–9. https://doi.org/10.1164/rccm.201106-1094OC.CrossRefPubMed

12.

Lindenauer PK, Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Hill NS. Hospital patterns of mechanical ventilation for patients with exacerbations of COPD. Ann Am Thorac Soc. 2015;12(3):402–9. https://doi.org/10.1513/AnnalsATS.201407-293OC.CrossRefPubMedPubMedCentral

13.

Stefan MS, Nathanson BH, Priya A, et al. Hospitals’ patterns of use of noninvasive ventilation in patients with asthma exacerbation. Chest. 2016;149(3):729–36. https://doi.org/10.1016/j.chest.2015.12.013.CrossRefPubMed

14.

Ozsancak Ugurlu A, Sidhom SS, Khodabandeh A, et al. Use and outcomes of noninvasive positive pressure ventilation in acute care hospitals in Massachusetts. Chest. 2014;145(5):964–71. https://doi.org/10.1378/chest.13-1707.CrossRefPubMed

15.

Antonelli M, Conti G, Moro ML, et al. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med. 2001;27(11):1718–28. https://doi.org/10.1007/s00134-001-1114-4.CrossRefPubMed

16.

Stefan MS, Nathanson BH, Lagu T, et al. Outcomes of noninvasive and invasive ventilation in patients hospitalized with asthma exacerbation. Ann Am Thorac Soc. 2016. https://doi.org/10.1513/AnnalsATS.201510-701OC.CrossRefPubMedPubMedCentral

17.

Demoule A, Girou E, Richard JC, Taille S, Brochard L. Benefits and risks of success or failure of noninvasive ventilation. Intensive Care Med. 2006;32(11):1756–65. https://doi.org/10.1007/s00134-006-0324-1.CrossRefPubMed

18.

Davidson AC. British thoracic society guideline group for the ventilatory management of acute hypercapnic respiratory failure in adults. Managing acute hypercapnic respiratory failure in adults: where do we need to get to? Thorax. 2016;71(4):297–8. https://doi.org/10.1136/thoraxjnl-2016-208281.CrossRefPubMed

19.

Davies M, Allen M, Bentley A, et al. British thoracic society quality standards for acute noninvasive ventilation in adults. BMJ Open Respir Res. 2018;5(1):e000283. https://doi.org/10.1136/bmjresp-2018-000283.CrossRefPubMedPubMedCentral

20.

Hedsund C, Ankjærgaard KL, Rasmussen DB, et al. NIV for acute respiratory failure in COPD: high in-hospital mortality is determined by patient selection. Eur Clin Respir J. 2019;6(1):1571332. https://doi.org/10.1080/20018525.2019.1571332.CrossRefPubMedPubMedCentral

21.

Adda M, Coquet I, Darmon M, Thiery G, Schlemmer B, Azoulay E. Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure. Crit Care Med. 2008;36(10):2766–72. https://doi.org/10.1097/CCM.0b013e31818699f6.CrossRefPubMed

22.

Confalonieri M, Garuti G, Cattaruzza MS, et al. A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Eur Respir J. 2005;25(2):348–55. https://doi.org/10.1183/09031936.05.00085304.CrossRefPubMed

23.

Ucgun I, Metintas M, Moral H, Alatas F, Yildirim H, Erginel S. Predictors of hospital outcome and intubation in COPD patients admitted to the respiratory ICU for acute hypercapnic respiratory failure. Respir Med. 2006;100(1):66–74. https://doi.org/10.1016/j.rmed.2005.04.005.CrossRefPubMed

24.

Duan J, Han X, Bai L, Zhou L, Huang S. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med. 2017;43(2):192–9. https://doi.org/10.1007/s00134-016-4601-3.CrossRefPubMed

25.

Stefan MS, Nathanson BH, Higgins T, Steingrub JS, Lagu T, P.K. L. validity of noninvasive and invasive ventilation billing and procedure codes in patients with acute respiratory failure; 2014.

26.

Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003. Crit Care Med. 2007;35(5):1244–50. https://doi.org/10.1097/01.CCM.0000261890.41311.E9.CrossRefPubMed

27.

Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348(16):1546–54. https://doi.org/10.1056/NEJMoa022139.CrossRefPubMed

28.

Escobar GJ, Gardner MN, Greene JD, Draper D, Kipnis P. Risk-adjusting hospital mortality using a comprehensive electronic record in an integrated health care delivery system. Med Care. 2013;51(5):446–53. https://doi.org/10.1097/MLR.0b013e3182881c8e.CrossRefPubMed

29.

Escobar GJ, Greene JD, Gardner MN, Marelich GP, Quick B, Kipnis P. Intra-hospital transfers to a higher level of care: contribution to total hospital and intensive care unit (ICU) mortality and length of stay (LOS). J Hosp Med. 2011;6(2):74–80. https://doi.org/10.1002/jhm.817.CrossRefPubMed

30.

Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. Commun Stat Simul Comput. 2009;38(6):1228–34. https://doi.org/10.1080/03610910902859574.CrossRef

31.

Steyerberg EW. Clinical prediction models: a practical approach to development, validation, and updating. Berlin: Springer; 2008.

32.

Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143(1):29–36. https://doi.org/10.1148/radiology.143.1.7063747.CrossRefPubMed

33.

Tibshirani R. Regression shrinkage and selection via the LASSO. J R Stat Soc Ser B (Methodol). 1996;58(1):267–88.

34.

Kohavi R. A study of cross-validation and bootstrap for accuracy estimation and model selection. In: IJCAI’95: proceedings of the 14th international joint conference on Artificial intelligence, vol. 2. p. 7.

35.

Iasonos A, et al. How to build and interpret a nomogram for cancer prognosis.—PubMed—NCBI. http://www.ncbi.nlm.nih.gov/pubmed/?term=Jasonos+A%2C+Schrag+D%3B+JClin+Oncol+2008. Accessed 2 July 2019

36.

Parker K, Perikala V, Aminazad A, et al. Models of care for noninvasive ventilation in the acute COPD comparison of three tertiary hospitals (ACT3) study. Respirology. 2018;23(5):492–7. https://doi.org/10.1111/resp.13228.CrossRefPubMed

37.

Myers LC, Faridi MK, Currier P, Camargo CA. ICU utilization for patients with acute exacerbation of chronic obstructive pulmonary disease receiving noninvasive ventilation. Crit Care Med. 2019;47(5):677–84. https://doi.org/10.1097/CCM.0000000000003660.CrossRefPubMedPubMedCentral

38.

Fiorino S, Bacchi-Reggiani L, Detotto E, et al. Efficacy of noninvasive mechanical ventilation in the general ward in patients with chronic obstructive pulmonary disease admitted for hypercapnic acute respiratory failure and pH < 7.35: a feasibility pilot study. Intern Med J. 2015;45(5):527–37. https://doi.org/10.1111/imj.12726.CrossRefPubMed

39.

Yalcinsoy M, Salturk C, Oztas S, et al. Can patients with moderate to severe acute respiratory failure from COPD be treated safely with noninvasive mechanical ventilation on the ward? Int J Chron Obstruct Pulmon Dis. 2016;11:1151–60. https://doi.org/10.2147/COPD.S104801.CrossRefPubMedPubMedCentral

Title: A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure
Authors: Mihaela S. Stefan
Aruna Priya
Penelope S. Pekow
Jay S. Steingrub
Nicholas S. Hill
Tara Lagu
Karthik Raghunathan
Anusha G. Bhat
Peter K. Lindenauer
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Pneumonia
Substance Abuse
Substance Abuse
Published in: BMC Pulmonary Medicine / Issue 1/2021
Electronic ISSN: 1471-2466
DOI: https://doi.org/10.1186/s12890-021-01421-w

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure

Abstract

Objective

Design

Patients

Measurement

Main results

Conclusions

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Objective

Design

Patients

Measurement

Main results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2021

Effectiveness of one-on-one coaching in improving pressurized metered dose inhaler (pMDI) technique among COPD patients: a prospective clinical study

Emergency admission parameters for predicting in-hospital mortality in patients with acute exacerbations of chronic obstructive pulmonary disease with hypercapnic respiratory failure

Validation of rapid shallow breathing index displayed by the ventilator compared to the standard technique in patients with readiness for weaning

Disparities in access to food and chronic obstructive pulmonary disease (COPD)-related outcomes: a cross-sectional analysis

Rapid effect of benralizumab in exacerbation of severe eosinophilic asthma associated with eosinophilic granulomatosis with polyangiitis

Association between dual use of e-cigarette and cigarette and chronic obstructive pulmonary disease: an analysis of a nationwide representative sample from 2013 to 2018

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page