title: Noninvasive ventilation in patients with "do-not-intubate" orders: medium-term efficacy depends critically on patient selection.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Retrospective cohort study in a general ICU in a university-affiliated hospital.
  
  
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Our study suggests that NIV offers low expectations for medium-term survival in DNI patients.
authors.affiliation: Critical Care Center, Hospital de Sabadell, Parc Taulí s/n, 08208, Sabadell, Spain. rfernandez@cspt.es
authors.forename: Rafael
authors.initials: R
authors.lastname: Fernandez
authors.forename: Francisco
authors.initials: F
authors.lastname: Baigorri
authors.forename: Antonio
authors.initials: A
authors.lastname: Artigas
mesh_terms: D018806:APACHE; D000368:Aged; D003428:Cross Infection / Q000150:complications* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D011175:Positive-Pressure Respiration / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016414:Resuscitation Orders; D012189:Retrospective Studies; D016019:Survival Analysis