Non-Invasive Ventilation Transition Associated With Increased Mortality

There is increased risk for death in those treated with home non-intensive ventilation compared with those who were not.

Home non-invasive ventilation (NIV) in patients discharged following acute hypercapnic hospital admission is associated with increased mortality mostly among older patients with heart failure. Decreased mortality is linked to subsequent follow-up attendance in this same patient population. These are among the study findings published in BMJ Open Respiratory Research.

Researchers conducted a retrospective cohort single-center study of participants (N=638) who were treated and discharged from the Shamir Medical Center in central Israel following acute hypercapnia between 2012 and 2017 with follow-up until November 2019. The study comprised participants who received NIV in-home following discharge (n=585) and control participants did not receive NIV following discharge (n=53). Participants were recruited following their query in the hospital’s electronic medical system for NIV consultations after discharge. Participants were deemed suitable for continued NIV at home or not based on a pulmonologist’s review. The primary endpoint was time from hospital discharge to readmission or death.

All participants in both cohorts were similar in age (median, 78 years; interquartile range, [IQR], 68-85 years) and Charlson Comorbidity Index (cardiac failure, 24%; chronic pulmonary disease, 60%; obstructive sleep apnea, 5%).

Compared with control participants, patients in the NIV cohort had increased risk for death (hazard ratio [HR], 1.88; 95% CI, 1.17-3.03). Found poor prognostic factors for all-cause mortality were due to failure to attend NIV follow-up (HR 2.33; 95% CI, 1.33-4.10), cardiac failure (HR 1.31; 95% CI, 1.01-1.67), and increasing age (HR 1.03; 95% CI, 1.02-1.04).

There is evidence of potential harm in older patients or those with cardiac failure who are hypercapnic during their index admission.

Sleep apnea (HR 0.44, 95% CI, 0.23-0.83) and chronic respiratory disease (HR 0.77, 95% CI, 0.61-0.97) were associated with improved prognosis. There was no difference in time-to-readmission between cases and control participants (HR 1.42; 95% CI, 0.99-2.02).

Limitations of the study include the retrospective design, potential confounding, patient selection by physician opinion, and possible selection bias in choosing patients with chronic pulmonary disease over patients with heart failure.

The study authors conclude, “In a large cohort of hospitalized patients who survived an acute hypercapnic hospitalization, transitioning to home NIV may be effective in reducing mortality in selected patients who are younger and suffer from chronic pulmonary disease or obstructive sleep apnea and who are co-operative with follow-up.” They add, “There is evidence of potential harm in older patients or those with cardiac failure who are hypercapnic during their index admission.

References:

Fox BD, Bondarenco M, Shpirer I, Natif N, Perl S. Transitioning from hospital to home with non-invasive ventilation: who benefits? Results of a cohort study. BMJ Open Respir Res. Published online November 10, 2022. doi:10.1136/bmjresp-2022-001267