Enhancing Utilization of Non-Invasive Positive Pressure Ventilation in Critical Care

Project Focus The focus of this project is to improve the ventilatory management of patients with acute respiratory failure in the critical care setting by enhancing the use of non-invasive ventilation, a goal that should lead to improved outcomes and efficiency of care. Within the framework of the funding agency, the Chest Foundation, this proposal aims to promote the use of alternative therapies in treating patients with critical illness, educate practitioners, and disseminate new knowledge regarding the therapy.

Background Non-invasive positive pressure ventilation (NPPV) provides mechanical ventilation without the need for airway invasion through the use of either nasal or oronasal masks (covering both the nose and mouth) attached to positive pressure ventilators. Published evidence from randomized control trials has demonstrated the effectiveness of the technique in avoiding intubation, reducing complications associated with intubation, shortening ICU and hospital lengths of stay, and reducing mortality rates in selected patients with acute respiratory failure. Randomized trials have demonstrated effectiveness in patients with acute exacerbations of COPD (1-3), cardiogenic pulmonary edema (4), immunocompromised patients with hypoxemic respiratory failure (5,6), facilitating the weaning process in patients ventilated invasively (7), and in patients who develop respiratory insufficiency after lung resection (8). In addition, evidence that is not quite as strong supports the use of NPPV in patients with acute asthma (9), cystic fibrosis (10), community-acquired pneumonia if there is underlying COPD (11), and patients with a do-not-intubate status (12).

Based on this evidence, consensus groups have recommended the use of NPPV in treating patients with COPD exacerbations and for selected patients with other diagnoses (13). However, NPPV is still underutilized at many medical centers throughout the world (14) and it is fair to presume that many patients are being deprived of NPPV's advantages and that ICU resources are being wasted. Similar surveys have not been performed in the US, and my firm impression from polling audiences when I speak on this subject is that a similar proportion of US centers are not using NPPV. The purposes of this project are to acquire this information in a US setting, to identify reasons for underutilization, to implement interventions that encourage more appropriate use of NPPV, and then to evaluate the effectiveness of the intervention.

The successful implementation of this project may have a major impact on the practice of critical care medicine. Reliable information on utilization of NPPV as well as analysis of reasons for underutilization will provide insight into ways of enhancing utilization. Educational programs designed to enhance practitioners' skills in implementing NPPV should lead to greater utilization and improved success rates. Optimal utilization of NPPV should lead to improved outcomes for patients with respiratory failure, more rational use of resources, and lower ICU costs for our health care system.

Project A. Major Hypothesis: An educational intervention will increase utilization and success rates of NPPV in hospitals that currently underutilizing it.