Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders: A systematic review and meta-analysis

Michael E. Wilson, Abdul M. Majzoub, Claudia C. Dobler, J. Randall Curtis, Tarek Nayfeh, Bjorg Thorsteinsdottir, Amelia K. Barwise, Jon C. Tilburt, Ognjen Gajic, Victor M. Montori, M. Hassan Murad

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Abstract

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.

Original languageEnglish
Pages (from-to)1209-1216
Number of pages8
JournalCritical Care Medicine
Volume46
Issue number8
DOIs
Publication statusPublished - 1 Jan 2018
Externally publishedYes

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Noninvasive Ventilation
Meta-Analysis
Survivors
Quality of Life
Survival
Information Storage and Retrieval
Pulmonary Edema
MEDLINE
Respiratory Insufficiency
Dyspnea
Chronic Obstructive Pulmonary Disease
Opioid Analgesics
Observational Studies
Pneumonia
Epidemiology
Guidelines

Cite this

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. / Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders : A systematic review and meta-analysis. In: Critical Care Medicine. 2018 ; Vol. 46, No. 8. pp. 1209-1216.
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title = "Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders: A systematic review and meta-analysis",
abstract = "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.",
author = "Wilson, {Michael E.} and Majzoub, {Abdul M.} and Dobler, {Claudia C.} and Curtis, {J. Randall} and Tarek Nayfeh and Bjorg Thorsteinsdottir and Barwise, {Amelia K.} and Tilburt, {Jon C.} and Ognjen Gajic and Montori, {Victor M.} and Murad, {M. Hassan}",
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Wilson, ME, Majzoub, AM, Dobler, CC, Curtis, JR, Nayfeh, T, Thorsteinsdottir, B, Barwise, AK, Tilburt, JC, Gajic, O, Montori, VM & Murad, MH 2018, 'Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders: A systematic review and meta-analysis' Critical Care Medicine, vol. 46, no. 8, pp. 1209-1216. https://doi.org/10.1097/CCM.0000000000003082

Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders : A systematic review and meta-analysis. / 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.

In: Critical Care Medicine, Vol. 46, No. 8, 01.01.2018, p. 1209-1216.

Research output: Contribution to journalArticleResearchpeer-review

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T1 - Noninvasive ventilation in patients with do-not-intubate and comfort-measures-only orders

T2 - A systematic review and meta-analysis

AU - Wilson, Michael E.

AU - Majzoub, Abdul M.

AU - Dobler, Claudia C.

AU - Curtis, J. Randall

AU - Nayfeh, Tarek

AU - Thorsteinsdottir, Bjorg

AU - Barwise, Amelia K.

AU - Tilburt, Jon C.

AU - Gajic, Ognjen

AU - Montori, Victor M.

AU - Murad, M. Hassan

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N2 - 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.

AB - 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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JF - Critical Care Medicine

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