title: Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial.
abstract: BACKGROUND
  Guidelines for noninvasive mechanical ventilation (NIMV) recommend continuous positive airway pressure in patients with thoracic trauma who remain hypoxic despite regional anesthesia. This recommendation is rated only by level C evidence because randomized controlled trials in this specific population are lacking. Our aim was to determine whether NIMV reduces intubation in severe trauma-related hypoxemia.
  
  
  METHODS
  This was a single-center randomized clinical trial in a nine-bed ICU of a level I trauma hospital. Inclusion criteria were patients with Pao(2)/Fio(2)<200 for >8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma. Patients were randomized to remain on high-flow oxygen mask or to receive NIMV. The interface was selected based on the associated injuries. Thoracic anesthesia was universally supplied unless contraindicated. The primary end point was intubation; secondary end points included length of hospital stay and survival. Statistical analysis was based on multivariate analysis.
  
  
  RESULTS
  After 25 patients were enrolled in each group, the trial was prematurely stopped for efficacy because the intubation rate was much higher in controls than in NIMV patients (10 [40%] vs 3 [12%], P = .02). Multivariate analysis adjusted for age, gender, chronic heart failure, and Acute Physiology and Chronic Health Evaluation II at admission revealed NIMV as the only variable independently related to intubation (odds ratio, 0.12; 95% CI, 0.02-0.61; P = .01). Length of hospital stay was shorter in NIMV patients (14 vs 21 days P = .001), but no differences were observed in survival or other secondary end points.
  
  
  CONCLUSIONS
  NIMV reduced intubation compared with oxygen therapy in severe thoracic trauma-related hypoxemia.
authors.affiliation: Critical Care Medicine, Hospital Virgen de la Salud, Toledo, Mezquite n degrees 12, 6 degrees A, 28045, Madrid, Spain. ghernandezm@telefonica.net
authors.forename: Gonzalo
authors.initials: G
authors.lastname: Hernandez
authors.forename: Rafael
authors.initials: R
authors.lastname: Fernandez
authors.forename: Pilar
authors.initials: P
authors.lastname: Lopez-Reina
authors.forename: Rafael
authors.initials: R
authors.lastname: Cuena
authors.forename: Ana
authors.initials: A
authors.lastname: Pedrosa
authors.forename: Ramon
authors.initials: R
authors.lastname: Ortiz
authors.forename: Paloma
authors.initials: P
authors.lastname: Hiradier
mesh_terms: D005500:Follow-Up Studies; D006801:Humans; D000860:Hypoxia / Q000209:etiology / Q000628:therapy*; D007384:Intermittent Positive-Pressure Breathing / Q000379:methods*; D007442:Intubation, Intratracheal / Q000639:trends*; D010102:Oxygen Inhalation Therapy / Q000379:methods*; D011446:Prospective Studies; D012307:Risk Factors; D013898:Thoracic Injuries / Q000150:complications* / Q000628:therapy; D016896:Treatment Outcome