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Hospitals’ Patterns of Noninvasive Ventilation in Asthma: Evidence or Deep Recommendations Needed? FREE TO VIEW

Huriye Berk Takir, MD; Antonio Esquinas, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aSureyyapasa Chest Disease and Research Hospital—Intensive Care Unit, Istanbul, Turkey

bHospital Morales Meseguer—Intensive Care Unit, Murcia, Spain

CORRESPONDENCE TO: Berk Takir, MD, Zumrutevler Mah, Handegul Sok, Adatepe Sitesi A1 Blok Kat:4 Daire:20 No:104, Maltepe/Istanbul, 34852, Turkey.


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(2):468-469. doi:10.1016/j.chest.2016.04.037
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Respiratory failure is a frequent cause of death that is increased in the absence of ventilatory support. Noninvasive ventilation (NIV) is succesfully used to improve gas exchange, avoid endotracheal intubation, and reduce mortality in respiratory failure., There is good evidence to support NIV use as the first-line treatment in respiratory failure due to COPD exacerbations, but the evidence for use in acute asthma attacks is less compelling.

We read with great pleasure the recent paper by Stefan et al entitled “Hospitals' Patterns of Use of Noninvasive Ventilation in Patients With Asthma Exacerbation” published in CHEST (March 2016). This study, which had a cross-sectional design, used an electronic medical record data set collected from 58 hospitals over a 3-year period. They investigated patterns of NIV use in patients with asthma exacerbations and its association with mortality. They found clear differences between hospitals according to NIV use. This study is valuable, as it illustrates the lack of clear recommendations regarding NIV use in acute asthma. However, we believe that there are some issues worthy of further comment.

First, besides arterial blood gas measurement, FEV1 and peak expiratory flow rate are important predictors of severity and response to initial treatment in asthma attacks. However, there are no data provided by the authors about pulmonary function tests. The severity of the attack and time to initiate mechanical ventilation are also not clear. These factors are very important considerations in the management of acute asthma, and greater clarification would help to guide recommendations.

Second, the low rate of NIV use in some hospitals may be due to the lack of strong evidence for NIV use in patients with respiratory failure resulting from asthma exacerbations. However, we believe that the small sample sizes of the currently available studies do not allow proper conclusions to be formed in this area, and as such this may affect clinicians' confidence in the therapy, knowledge, and experience in this group of patients. Factors known to influence NIV success are varied and often depend on patient characteristics, equipment, and skills of the team applying NIV. The location of NIV application is also an important factor in the success of treatment, as there may be great variation in monitoring and response to therapy between the emergency department, general ward, and intensive care unit. The current study by Stefan et al concluded that NIV use did not reduce progression to invasive mechanical ventilation in asthma exacerbations. However, we believe that assessment of NIV use skills and familiarity with therapy would be useful for improving confidence in NIV use among different hospitals. Further studies are needed to establish critical factors that influence hospitals’ patterns of use of NIV in patients with asthma exacerbations.

References

Mehta S. .Hill N.S. . Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163:540-577 [PubMed]journal. [CrossRef] [PubMed]
 
Peter J.V. .Moran J.L. .Phillips-Hughes J. .Warn D. . Noninvasive ventilation in acute respiratory failure—a meta-analysis update. Crit Care Med. 2002;30:555-562 [PubMed]journal. [CrossRef] [PubMed]
 
Nava S. . Behind a mask: tricks, pitfalls, and prejudices for noninvasive ventilation. Respir Care. 2013;58:1367-1376 [PubMed]journal. [CrossRef] [PubMed]
 
Stefan M.S. .Nathanson B.H. .Priya A. .et al Hospitals' patterns of use of noninvasive ventilation in patients with asthma exacerbation. Chest. 2016;149:729-736 [PubMed]journal. [CrossRef] [PubMed]
 
Rodrigo G.J. . Predicting response to therapy in acute asthma. Curr Opin Pulm Med. 2009;15:35-38 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Mehta S. .Hill N.S. . Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163:540-577 [PubMed]journal. [CrossRef] [PubMed]
 
Peter J.V. .Moran J.L. .Phillips-Hughes J. .Warn D. . Noninvasive ventilation in acute respiratory failure—a meta-analysis update. Crit Care Med. 2002;30:555-562 [PubMed]journal. [CrossRef] [PubMed]
 
Nava S. . Behind a mask: tricks, pitfalls, and prejudices for noninvasive ventilation. Respir Care. 2013;58:1367-1376 [PubMed]journal. [CrossRef] [PubMed]
 
Stefan M.S. .Nathanson B.H. .Priya A. .et al Hospitals' patterns of use of noninvasive ventilation in patients with asthma exacerbation. Chest. 2016;149:729-736 [PubMed]journal. [CrossRef] [PubMed]
 
Rodrigo G.J. . Predicting response to therapy in acute asthma. Curr Opin Pulm Med. 2009;15:35-38 [PubMed]journal. [CrossRef] [PubMed]
 
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