by Wilson, Michael E.;
Majzoub, Abdul M.; Dobler, Claudia C.; Curtis, J. Randall; Nayfeh, Tarek;
Thorsteinsdottir, Bjorg; Barwise, Amelia K.; Tilburt, Jon C.; Gajic, Ognjen;
Montori, Victor M.; Murad, M. Hassan
Objectives: To assess
the effectiveness of noninvasive ventilation in patients with acute respiratory
failure and do-not-intubate or comfort-measures-only orders. Data Sources:
MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science from inception to January
1, 2017. Study Selection: Studies of all design types that enrolled patients in
the ICU or hospital ward who received noninvasive ventilation and had preset
do-not-intubate or comfort-measures-only orders. Data Extraction: Data
abstraction followed Meta-analysis of Observational Studies in Epidemiology
guidelines. Data quality was assessed using a modified Newcastle-Ottawa Scale.
Data Synthesis: Twenty-seven studies evaluating 2,020 patients with
do-not-intubate orders and three studies evaluating 200 patients with
comfort-measures-only orders were included. In patients with do-not-intubate
orders, the pooled survival was 56% (95% CI, 49–64%) at hospital discharge and
32% (95% CI, 21–45%) at 1 year. Hospital survival was 68% for chronic
obstructive pulmonary disease, 68% for pulmonary edema, 41% for pneumonia, and
37% for patients with malignancy. Survival was comparable for patients treated
in a hospital ward versus an ICU. Quality of life of survivors was not reduced
compared with baseline, although few studies evaluated this. No studies
evaluated quality of dying in nonsurvivors. In patients with
comfort-measures-only orders, a single study showed that noninvasive
ventilation was associated with mild reductions in dyspnea and opioid
requirements. Conclusions: A large proportion of patients with do-not-intubate
orders who received noninvasive ventilation survived to hospital discharge and
at 1 year, with limited data showing no decrease in quality of life in
survivors. Provision of noninvasive ventilation in a well-equipped hospital
ward may be a viable alternative to the ICU for selected patients. Crucial
questions regarding quality of life in survivors, quality of death in
nonsurvivors, and the impact of noninvasive ventilation in patients with
comfort-measures-only orders remain largely unanswered.
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