Utilization of noninvasive ventilation in acute care hospitals: a regional survey.

PURPOSES: Little information is available on the utilization of noninvasive positive-pressure ventilation (NPPV) in the United States. Accordingly, we performed a survey on the use of NPPV at acute care hospitals in a region of the United States to determine variations in utilization and between hospitals, the reasons for lower rates of utilization, and the techniques used for application. METHODS: Using survey methodology, we developed a questionnaire consisting of 19 questions and distributed it by mail to directors of respiratory care at all 82 acute care hospitals in Massachusetts and Rhode Island. Nonresponders were contacted by phone to complete the survey. Responses were analyzed using standard statistics, including t tests and Mann-Whitney U tests where appropriate. RESULTS: We obtained responses from 71 of the 82 hospitals (88%). The overall utilization rate for NPPV was 20% of ventilator starts, but we found enormous variation in the estimated utilization rates among different hospitals, from none to > 50%. The top two reasons given for lower utilization rates were a lack of physician knowledge and inadequate equipment. In the 19 hospitals that provided detailed information, COPD and congestive heart failure constituted 82% of the diagnoses of patients receiving NPPV, but NPPV was still used in only 33% of patients with these diagnoses receiving any form of mechanical ventilation. CONCLUSIONS: The utilization rates for NPPV vary enormously among different acute care hospitals within the same region. The perceived reasons for lower utilization rates include lack of physician knowledge, insufficient respiratory therapist training, and inadequate equipment. Educational programs directed at individual institutions may be useful to enhance utilization rates.

Extubation failure: magnitude of the problem, impact on outcomes, and prevention.

Extubation failure, defined as the need for reinstitution of ventilatory support within 24 to 72 hours of planned endotracheal tube removal, occurs in 2 to 25% of extubated patients. The pathophysiologic causes of extubation failure include an imbalance between respiratory muscle capacity and work of breathing, upper airway obstruction, excess respiratory secretions, inadequate cough, encephalopathy, and cardiac dysfunction. Compared with patients who tolerate extubation, those who require reintubation have a higher incidence of hospital mortality, increased length of ICU and hospital stay, prolonged duration of mechanical ventilation, higher hospital costs, and an increased need for tracheostomy. Given the lack of proven treatments for extubation failure, clinicians must be aware of the factors that predict extubation outcome to improve clinical decision making. Risk factors for extubation failure include being a medical, multidisciplinary, or pediatric patient; age greater than 70 years; a longer duration of mechanical ventilation; continuous intravenous sedation; and anemia. Tests designed to assess for upper airway obstruction, secretion volume, and the effectiveness of cough can help to improve prediction of extubation failure. Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome.