title: Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications.
abstract: BACKGROUND
  Noninvasive positive-pressure ventilation (NIPPV) use has increased in the treatment of patients with respiratory failure. However, despite decreasing the need for intubation in some patients, there are no data regarding the risk of intubation-related complications associated with delayed intubation in adult patients who fail NIPPV. The objective of this study is to evaluate the odds of a composite complication of intubation following failed NIPPV compared to patients intubated primarily in the medical intensive care unit (ICU).
  
  
  METHODS
  This is a single-center retrospective cohort study of 235 patients intubated between 1 January 2012 and 30 June 2013 in a medical ICU of a university medical center. A total of 125 patients were intubated after failing NIPPV, 110 patients were intubated without a trial of NIPPV. Intubation-related data were collected prospectively through a continuous quality improvement (CQI) program and retrospectively extracted from the medical record on all patients intubated on the medical ICU. A propensity adjustment for the factors expected to affect the decision to initially use NIPPV was used, and the adjusted multivariate regression analysis was performed to evaluate the odds of a composite complication (desaturation, hypotension, or aspiration) with intubation following failed NIPPV versus primary intubation.
  
  
  RESULTS
  A propensity-adjusted multivariate regression analysis revealed that the odds of a composite complication of intubation in patients who fail NIPPV was 2.20 (CI 1.14 to 4.25), when corrected for the presence of pneumonia or acute respiratory distress syndrome (ARDS), and adjusted for factors known to increase complications of intubation (total attempts and operator experience). When a composite complication occurred, the unadjusted odds of death in the ICU were 1.79 (95% CI 1.03 to 3.12).
  
  
  CONCLUSIONS
  After controlling for potential confounders, this propensity-adjusted analysis demonstrates an increased odds of a composite complication with intubation following failed NIPPV. Further, the presence of a composite complication during intubation is associated with an increased odds of death in the ICU.
authors: Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA ; Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA ; University of Arizona, 1609N Warren, FOB 122C, Tucson, AZ 85719 USA.
authors: Jarrod M
authors: JM
authors: Mosier
authors: Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA.
authors: John C
authors: JC
authors: Sakles
authors: Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, 1500 E Medical Center Drive, Ann Arbor, MI 48109 USA.
authors: Sage P
authors: SP
authors: Whitmore
authors: Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA ; Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA.
authors: Cameron D
authors: CD
authors: Hypes
authors: Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA.
authors: Danielle K
authors: DK
authors: Hallett
authors: Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA.
authors: Katharine E
authors: KE
authors: Hawbaker
authors: Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA.
authors: Linda S
authors: LS
authors: Snyder
authors: Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA.
authors: John W
authors: JW
authors: Bloom
keywords: Airway management; Aspiration; Critical care; Delayed intubation; Desaturation; Hypotension; Intubation; NIPPV; Noninvasive positive pressure