TY - JOUR
T1 - Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure
T2 - a target trial emulation in two cohorts
AU - Yarnell, Christopher J.
AU - Angriman, Federico
AU - Ferreyro, Bruno L.
AU - Liu, Kuan
AU - de Grooth, Harm Jan
AU - Burry, Lisa
AU - Munshi, Laveena
AU - Mehta, Sangeeta
AU - Celi, Leo
AU - Elbers, Paul
AU - Thoral, Patrick
AU - Brochard, Laurent
AU - Wunsch, Hannah
AU - Fowler, Robert A.
AU - Sung, Lillian
AU - Tomlinson, George
N1 - Funding Information:
Dr Brochard’s laboratory received grants from Medtronic, Draeger, equipment from Philips, Sentec, Fisher Paykel and Air Liquide and lecture fees from Fisher Paykel. No other authors have competing interests to declare.
Funding Information:
Dr Yarnell was funded by the Canadian Institutes for Health Research Vanier Scholar program, the Eliot Phillipson Clinician Scientist Training Program, and the Clinician Investigator Program of the University of Toronto. Dr Sung is supported by the Canada Research Chair in Pediatric Oncology Supportive Care. Dr Fowler is the H. Barrie Fairley Professor of Critical Care at the University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto. Funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; nor in the decision to submit the manuscript for publication. The opinions, results, and conclusions reported in this paper are those of the authors and are independent of the funding sources. No endorsement by any of the funding agencies is intended or should be inferred.
Funding Information:
We thank the following for helpful comments: Mathieu Komorowski, Mireille Schnitzer. Computations were performed on the Niagara supercomputer at the SciNet HPC Consortium. SciNet is funded by: the Canada Foundation for Innovation; the Government of Ontario; Ontario Research Fund—Research Excellence; and the University of Toronto.
Publisher Copyright:
© 2023, The Author(s).
PY - 2023/12/1
Y1 - 2023/12/1
N2 - Background: The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation. Methods: This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008–2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003–2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation. Results: We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8). Conclusion: Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.
AB - Background: The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation. Methods: This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008–2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003–2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation. Results: We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8). Conclusion: Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.
KW - Bayesian analysis
KW - Hypoxemic respiratory failure
KW - Intensive care medicine
KW - Mechanical ventilation
KW - Noninvasive ventilation
KW - Statistical methods
KW - Target trial emulation
KW - Thresholds for invasive ventilation
UR - https://www.scopus.com/pages/publications/85148726990
U2 - 10.1186/s13054-023-04307-x
DO - 10.1186/s13054-023-04307-x
M3 - Article
C2 - 36814287
SN - 1364-8535
VL - 27
JO - Critical Care
JF - Critical Care
IS - 1
M1 - 67
ER -