Noninvasive ventilation in patients with “do-not-intubate” orders: medium-term efficacy depends critically on patient selection
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Randomized clinical trials demonstrating benefits of noninvasive ventilation (NIV) systematically exclude patients with “do-not-intubate” (DNI) orders, but in daily clinical practice these patients are frequently treated with NIV. A recent North American study found a 43% hospital survival rate in patients with DNI orders. Our hypothesis was that, due to the very different social and cultural setting, written DNI orders in a southern European country would be restricted to a population with a poor outcome, independently of whether they receive NIV, and we analyzed hospital survival in patients receiving NIV and the impact of DNI orders on survival.
Design and setting
Retrospective cohort study in a general ICU in a university-affiliated hospital.
Patients and methods
All 233 patients treated with NIV during 2002–2004. We recorded clinical characteristics on admission, mortality risk by APACHE II and ICU and hospital outcome, and 6-month outcome.
Hospital survival was 66%. Survival was better in the 199 patients without DNI orders than in the 36 with DNI orders both during hospitalization (74% vs. 26%, OR 7.9) and after 6 months (64% vs. 15%, OR 10.2). In both groups the presence of COPD was associated with better prognosis during hospitalization, but not in the medium-term.
Our study suggests that NIV offers low expectations for medium-term survival in DNI patients.