title: Noninvasive ventilation for severely acidotic patients in respiratory intermediate care units : Precision medicine in intermediate care units.
abstract: Severe acidosis can cause noninvasive ventilation (NIV) failure in chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure (AHRF). NIV is therefore contraindicated outside of intensive care units (ICUs) in these patients. Less is known about NIV failure in patients with acute cardiogenic pulmonary edema (ACPE) and obesity hypoventilation syndrome (OHS). Therefore, the objective of the present study was to compare NIV failure rates between patients with severe and non-severe acidosis admitted to a respiratory intermediate care unit (RICU) with AHRF resulting from ACPE, COPD or OHS.
  
  
  
  We prospectively included acidotic patients admitted to seven RICUs, where they were provided NIV as an initial ventilatory support measure. The clinical characteristics, pH evolutions, hospitalization or RICU stay durations and NIV failure rates were compared between patients with a pH ≥ 7.25 and a pH < 7.25. Logistic regression analysis was performed to determine the independent risk factors contributing to NIV failure.
  
  
  
  We included 969 patients (240 with ACPE, 540 with COPD and 189 with OHS). The baseline rates of severe acidosis were similar among the groups (45 % in the ACPE group, 41 % in the COPD group, and 38 % in the OHS group). Most of the patients with severe acidosis had increased disease severity compared with those with non-severe acidosis: the APACHE II scores were 21 ± 7.2 and 19 ± 5.8 for the ACPE patients (p < 0.05), 20 ± 5.7 and 19 ± 5.1 for the COPD patients (p < 0.01) and 18 ± 5.9 and 17 ± 4.7 for the OHS patients, respectively (NS). The patients with severe acidosis also exhibited worse arterial blood gas parameters: the PaCO2 levels were 87 ± 22 and 70 ± 15 in the ACPE patients (p < 0.001), 87 ± 21 and 76 ± 14 in the COPD patients, and 83 ± 17 and 74 ± 14 in the OHS patients (NS)., respectively Further, the patients with severe acidosis required a longer duration to achieve pH normalization than those with non-severe acidosis (patients with a normalized pH after the first hour: ACPE, 8 % vs. 43 %, p < 0.001; COPD, 11 % vs. 43 %, p < 0.001; and OHS, 13 % vs. 51 %, p < 0.001), and they had longer RICU stays, particularly those in the COPD group (ACPE, 4 ± 3.1 vs. 3.6 ± 2.5, NS; COPD, 5.1 ± 3 vs. 3.6 ± 2.1, p < 0.001; and OHS, 4.3 ± 2.6 vs. 3.7 ± 3.2, NS). The NIV failure rates were similar between the patients with severe and non-severe acidosis in the three disease groups (ACPE, 16 % vs. 12 %; COPD, 7 % vs. 7 %; and OHS, 11 % vs. 4 %). No common predictive factor for NIV failure was identified among the groups.
  
  
  
  ACPE, COPD and OHS patients with AHRF and severe acidosis (pH ≤ 7.25) who are admitted to an RICU can be successfully treated with NIV in these units. These results may be used to determine precise RICU admission criteria.
authors.affiliation: San Pedro de Alcántara Hospital, C/Rafael Alberti 12, 10005, Cáceres, Spain. fmasa@separ.es.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain. fmasa@separ.es.
authors.forename: Juan F
authors.initials: JF
authors.lastname: Masa
authors.affiliation: San Pedro de Alcántara Hospital, C/Rafael Alberti 12, 10005, Cáceres, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Isabel
authors.initials: I
authors.lastname: Utrabo
authors.affiliation: San Pedro de Alcántara Hospital, C/Rafael Alberti 12, 10005, Cáceres, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Gomez de Terreros
authors.affiliation: Galdakao-Usansolo Hospital, Bilbao, Spain.
authors.forename: Myriam
authors.initials: M
authors.lastname: Aburto
authors.affiliation: Galdakao-Usansolo Hospital, Bilbao, Spain.
authors.forename: Cristóbal
authors.initials: C
authors.lastname: Esteban
authors.affiliation: Belvitge Hospital, Barcelona, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Enric
authors.initials: E
authors.lastname: Prats
authors.affiliation: Son Espases Hospital, Palma de Mallorca, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Belén
authors.initials: B
authors.lastname: Núñez
authors.affiliation: Nuestra Señora del Prado Hospital, Talavera de la Reina, Toledo, Spain.
authors.forename: Ángel
authors.initials: Á
authors.lastname: Ortega-González
authors.affiliation: Virgen del Rocío Hospital, Sevilla, Spain.
authors.forename: Luis
authors.initials: L
authors.lastname: Jara-Palomares
authors.affiliation: San Pedro de Alcántara Hospital, C/Rafael Alberti 12, 10005, Cáceres, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: M Jesus
authors.initials: MJ
authors.lastname: Martin-Vicente
authors.affiliation: Belvitge Hospital, Barcelona, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Eva
authors.initials: E
authors.lastname: Farrero
authors.affiliation: Son Espases Hospital, Palma de Mallorca, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Alicia
authors.initials: A
authors.lastname: Binimelis
authors.affiliation: Son Espases Hospital, Palma de Mallorca, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Ernest
authors.initials: E
authors.lastname: Sala
authors.affiliation: Nuestra Señora del Prado Hospital, Talavera de la Reina, Toledo, Spain.
authors.forename: José C
authors.initials: JC
authors.lastname: Serrano-Rebollo
authors.affiliation: Virgen del Rocío Hospital, Sevilla, Spain.
authors.forename: Emilia
authors.initials: E
authors.lastname: Barrot
authors.affiliation: Virgen del Rocío Hospital, Sevilla, Spain.
authors.forename: Raquel
authors.initials: R
authors.lastname: Sánchez-Oro-Gomez
authors.affiliation: Central de Asturias Hospital, Oviedo, Spain.
authors.forename: Ramón
authors.initials: R
authors.lastname: Fernández-Álvarez
authors.affiliation: Central de Asturias Hospital, Oviedo, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Rodríguez-Jerez
authors.affiliation: Doce de Octubre Hospital, Madrid, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Sayas
authors.affiliation: Doce de Octubre Hospital, Madrid, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Pedro
authors.initials: P
authors.lastname: Benavides
authors.affiliation: "Sant Joan" University Hospital, Universitat Rovira i Virgili, IISPV, Reus, Tarragona, Spain.
authors.forename: Raquel
authors.initials: R
authors.lastname: Català
authors.affiliation: Txaguritxu Hospital, Vitoria, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Rivas
authors.affiliation: Txaguritxu Hospital, Vitoria, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Carlos J
authors.initials: CJ
authors.lastname: Egea
authors.affiliation: Sant Pau Hospital, Barcelona, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Antón
authors.affiliation: Sant Pau Hospital, Barcelona, Spain.|CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
authors.forename: Patricia
authors.initials: P
authors.lastname: Peñacoba
authors.affiliation: La Paz Hospital, Madrid, Spain.
authors.forename: Ana
authors.initials: A
authors.lastname: Santiago-Recuerda
authors.affiliation: La Paz Hospital, Madrid, Spain.
authors.forename: M A
authors.initials: MA
authors.lastname: Gómez-Mendieta
authors.affiliation: Universitario Lucus Augusti Hospital, Lugo, Spain.
authors.forename: Lidia
authors.initials: L
authors.lastname: Méndez
authors.affiliation: Costa del Sol Hospital, Málaga, Spain.
authors.forename: José J
authors.initials: JJ
authors.lastname: Cebrian
authors.affiliation: Costa del Sol Hospital, Málaga, Spain.
authors.forename: Juan A
authors.initials: JA
authors.lastname: Piña
authors.affiliation: La Princesa Hospital, Madrid, Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Zamora
authors.affiliation: La Princesa Hospital, Madrid, Spain.
authors.forename: Gonzalo
authors.initials: G
authors.lastname: Segrelles
mesh_terms: D000142:Acidosis, Respiratory / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D001784:Blood Gas Analysis; D005260:Female; D006801:Humans; D006935:Hypercapnia / Q000150:complications*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D063087:Noninvasive Ventilation; D010845:Obesity Hypoventilation Syndrome / Q000150:complications*; D057285:Precision Medicine; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications*; D011654:Pulmonary Edema / Q000150:complications; D012124:Respiratory Care Units; D012131:Respiratory Insufficiency / Q000628:therapy*; D012720:Severity of Illness Index; D013030:Spain; D017211:Treatment Failure
keywords: Acute hypercapnic respiratory failure; Acute pulmonary edema; COPD; Noninvasive ventilation; Obesity hypoventilation syndrome; Respiratory intermediate care unit