Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis

Michael E Wilson, Aniket Mittal, Bibek Karki, Claudia C Dobler, Abdul Wahab, J Randall Curtis, Patricia J Erwin, Abdul M Majzoub, Victor M Montori, Ognjen Gajic, M Hassan Murad

Research output: Contribution to journalArticleResearchpeer-review

Abstract

PURPOSE: To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.

METHODS: We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019.

RESULTS: Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate.

CONCLUSIONS: One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.

Original languageEnglish
JournalIntensive Care Medicine
DOIs
Publication statusE-pub ahead of print - 28 Oct 2019

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Respiratory Insufficiency
Meta-Analysis
Noninvasive Ventilation
Decision Making
Oxygen
North America
Heart Arrest
Observational Studies
Comorbidity
Mortality
Neoplasms

Cite this

Wilson, Michael E ; Mittal, Aniket ; Karki, Bibek ; Dobler, Claudia C ; Wahab, Abdul ; Curtis, J Randall ; Erwin, Patricia J ; Majzoub, Abdul M ; Montori, Victor M ; Gajic, Ognjen ; Murad, M Hassan. / Do-not-intubate orders in patients with acute respiratory failure : a systematic review and meta-analysis. In: Intensive Care Medicine. 2019.
@article{7366b630a45f43729686e01ab08bce00,
title = "Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis",
abstract = "PURPOSE: To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.METHODS: We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019.RESULTS: Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27{\%}. The pooled rate of do-not-intubate orders in studies from North America was 14{\%} (range 9-22{\%}), from Europe was 28{\%} (range 13-58{\%}), and from Asia was 38{\%} (range 9-83{\%}), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9{\%} in 2000-2004 to 32{\%} in 2015-2019. Only 12 studies (46{\%}) reported information about do-not-intubate decision-making processes. Only 4 studies (15{\%}) also reported rates of do-not-resuscitate.CONCLUSIONS: One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.",
author = "Wilson, {Michael E} and Aniket Mittal and Bibek Karki and Dobler, {Claudia C} and Abdul Wahab and Curtis, {J Randall} and Erwin, {Patricia J} and Majzoub, {Abdul M} and Montori, {Victor M} and Ognjen Gajic and Murad, {M Hassan}",
year = "2019",
month = "10",
day = "28",
doi = "10.1007/s00134-019-05828-2",
language = "English",
journal = "European Journal of Intensive Care Medicine",
issn = "0342-4642",
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Wilson, ME, Mittal, A, Karki, B, Dobler, CC, Wahab, A, Curtis, JR, Erwin, PJ, Majzoub, AM, Montori, VM, Gajic, O & Murad, MH 2019, 'Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis' Intensive Care Medicine. https://doi.org/10.1007/s00134-019-05828-2

Do-not-intubate orders in patients with acute respiratory failure : a systematic review and meta-analysis. / Wilson, Michael E; Mittal, Aniket; Karki, Bibek; Dobler, Claudia C; Wahab, Abdul; Curtis, J Randall; Erwin, Patricia J; Majzoub, Abdul M; Montori, Victor M; Gajic, Ognjen; Murad, M Hassan.

In: Intensive Care Medicine, 28.10.2019.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Do-not-intubate orders in patients with acute respiratory failure

T2 - a systematic review and meta-analysis

AU - Wilson, Michael E

AU - Mittal, Aniket

AU - Karki, Bibek

AU - Dobler, Claudia C

AU - Wahab, Abdul

AU - Curtis, J Randall

AU - Erwin, Patricia J

AU - Majzoub, Abdul M

AU - Montori, Victor M

AU - Gajic, Ognjen

AU - Murad, M Hassan

PY - 2019/10/28

Y1 - 2019/10/28

N2 - PURPOSE: To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.METHODS: We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019.RESULTS: Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate.CONCLUSIONS: One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.

AB - PURPOSE: To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.METHODS: We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019.RESULTS: Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate.CONCLUSIONS: One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.

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U2 - 10.1007/s00134-019-05828-2

DO - 10.1007/s00134-019-05828-2

M3 - Article

JO - European Journal of Intensive Care Medicine

JF - European Journal of Intensive Care Medicine

SN - 0342-4642

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