Acute respiratory failure in patients with severe community-acquired pneumonia : A prospective randomized evaluation of noninvasive ventilation

• Published in: American journal of respiratory and critical care medicine 1999-11, Vol.160 (5), p.1585-1591
• Main Authors: CONFALONIERI, M, POTENA, A, CARBONE, G, DELLA PORTA, R, TOLLEY, E. A, MEDURI, G. U
• Format: Article
• Language: English
• Subjects: Acute Disease; Adult; Aged; Aged, 80 and over; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Community-Acquired Infections - therapy; Emergency and intensive respiratory care; Female; Humans; Intensive care medicine; Intubation, Intratracheal; Length of Stay; Lung Diseases, Obstructive - complications; Male; Medical sciences; Middle Aged; Pneumonia, Bacterial - complications; Pneumonia, Bacterial - mortality; Positive-Pressure Respiration; Prospective Studies; Respiration, Artificial; Respiratory Insufficiency - etiology; Respiratory Insufficiency - mortality; Respiratory Insufficiency - therapy; Survival Rate
• ISSN: 1073-449X; 1535-4970
• DOI: 10.1164/ajrccm.160.5.9903015

In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) was found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe community-acquired pneumonia (CAP). We conducted a prospective, randomized study comparing standard treatment plus NPPV delivered through a face mask to standard treatment alone in patients with severe CAP and ARF. Patients fitting the American Thoracic Society criteria for severe CAP were included in presence of ARF (refractory hypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscitation, home mechanical ventilation or oxygen long-term supplementation, concomitant severe disease with a low expectation of life, inability to expectorate or contraindications to the use of the mask. Fifty-six consecutive patients (28 in each arm) were enrolled, and the two groups were similar at study entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubation (21% versus 50%; p = 0.03), and duration of intensive care unit (ICU) stay (1.8 +/- 0.7 d versus 6 +/- 1.8 d; p = 0.04). The two groups had a similar intensity of nursing care workload, time interval from study entry to endotracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those randomized to NPPV had a lower intensity of nursing care workload (p = 0.04) and improved 2-mo survival (88.9% versus 37.5%; p = 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated with a significant reduction in the rate of endotracheal intubation and duration of ICU stay. A 2-mo survival advantage was seen in patients with COPD.