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Noninvasive mechanical ventilation in patients having declined tracheal intubation

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Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order.


Prospective observational cohort study in all patients who received NIV for acute respiratory failure in 54 ICUs in France and Belgium, in 2010/2011.


Goals of care, comfort, and vital status were assessed daily. On day 90, a telephone interview with patients and relatives recorded health-related quality of life (HRQOL), posttraumatic stress disorder-related symptoms, and symptoms of anxiety and depression. Post-ICU burden was compared between DNI patients and patients receiving NIV with no treatment-limitation decisions (TLD). Of 780 NIV patients, 574 received NIV with no TLD, and 134 had DNI orders. Hospital mortality was 44 % in DNI patients and 12 % in the no-TLD group. Mortality in the DNI group was lowest in COPD patients compared to other patients in the DNI group (34 vs. 51 %, P = 0.01). In the DNI group, HRQOL showed no significant decline on day 90 compared to baseline; day-90 data of patients and relatives did not differ from those in the no-TLD group.


Do-not-intubate status was present among one-fifth of ICU patients who received NIV. DNI patients who were alive on day 90 experienced no decrease in HRQOL compared to baseline. The prevalences of anxiety, depression, and PTSD-related symptoms in these patients and their relatives were similar to those seen after NIV was used as part of full-code management (clinicaltrial.govNCT01449331).

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We are grateful to Vincent Gobert and Zoé Cohen Solal for conducting the interviews and to Anita Allemchahian for her steadfast. This work was supported by a grant from the French Ministry of Health, Assistance-Publique Hôpitaux de Paris (AOM 09006) and the French Society for Critical Care. We are indebted to A. Wolfe, MD, for helping with this manuscript.

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Correspondence to Élie Azoulay.

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For the REVA and the FAMIREA study groups.

The collaborators are listed in the Appendix.

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Supplementary material 1 (DOC 40 kb)



See Table 4.

Table 4 List of contributors who included study patients

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Azoulay, É., Kouatchet, A., Jaber, S. et al. Noninvasive mechanical ventilation in patients having declined tracheal intubation. Intensive Care Med 39, 292–301 (2013).

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