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Multicenter Study
. 2022 Jul 1;50(7):1127-1137.
doi: 10.1097/CCM.0000000000005535. Epub 2022 Mar 14.

The Use and Duration of Preintubation Respiratory Support Is Associated With Increased Mortality in Immunocompromised Children With Acute Respiratory Failure

Robert B Lindell  1 , Julie C Fitzgerald  1 , Courtney M Rowan  2 , Heidi R Flori  3 , Matteo Di Nardo  4 , Natalie Napolitano  5 , Danielle M Traynor  1 , Kyle B Lenz  1 , Guillaume Emeriaud  6 , Asumthia Jeyapalan  7 , Akira Nishisaki  1 ; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
Affiliations
Multicenter Study

The Use and Duration of Preintubation Respiratory Support Is Associated With Increased Mortality in Immunocompromised Children With Acute Respiratory Failure

Robert B Lindell et al. Crit Care Med. .

Abstract

Objectives: To determine the association between preintubation respiratory support and outcomes in patients with acute respiratory failure and to determine the impact of immunocompromised (IC) diagnoses on outcomes after adjustment for illness severity.

Design: Retrospective multicenter cohort study.

Setting: Eighty-two centers in the Virtual Pediatric Systems database.

Patients: Children 1 month to 17 years old intubated in the PICU who received invasive mechanical ventilation (IMV) for greater than or equal to 24 hours.

Interventions: None.

Measurements and main results: High-flow nasal cannula (HFNC) or noninvasive positive-pressure ventilation (NIPPV) or both were used prior to intubation in 1,825 (34%) of 5,348 PICU intubations across 82 centers. When stratified by IC status, 50% of patients had no IC diagnosis, whereas 41% were IC without prior hematopoietic cell transplant (HCT) and 9% had prior HCT. Compared with patients intubated without prior support, preintubation exposure to HFNC (adjusted odds ratio [aOR], 1.33; 95% CI, 1.10-1.62) or NIPPV (aOR, 1.44; 95% CI, 1.20-1.74) was associated with increased odds of PICU mortality. Within subgroups of IC status, preintubation respiratory support was associated with increased odds of PICU mortality in IC patients (HFNC: aOR, 1.50; 95% CI, 1.11-2.03; NIPPV: aOR, 1.76; 95% CI, 1.31-2.35) and HCT patients (HFNC: aOR, 1.75; 95% CI, 1.07-2.86; NIPPV: aOR, 1.85; 95% CI, 1.12-3.02) compared with IC/HCT patients intubated without prior respiratory support. Preintubation exposure to HFNC/NIPPV was not associated with mortality in patients without an IC diagnosis. Duration of HFNC/NIPPV greater than 6 hours was associated with increased mortality in IC HCT patients (HFNC: aOR, 2.41; 95% CI, 1.05-5.55; NIPPV: aOR, 2.53; 95% CI, 1.04-6.15) and patients compared HCT patients with less than 6-hour HFNC/NIPPV exposure. After adjustment for patient and center characteristics, both preintubation HFNC/NIPPV use (median, 15%; range, 0-63%) and PICU mortality varied by center.

Conclusions: In IC pediatric patients, preintubation exposure to HFNC and/or NIPPV is associated with increased odds of PICU mortality, independent of illness severity. Longer duration of exposure to HFNC/NIPPV prior to IMV is associated with increased mortality in HCT patients.

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Conflict of interest statement

Dr. Lindell is supported by the Thrasher Research Fund. Dr. Fitzgerald is supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) K23DK119463. Dr. Rowan is supported by the National Heart, Lung and Blood Institute (NHLBI) K23HL150244. Dr. Flori is supported by NHLBI R01HL149910 and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) R21HD097387. Dr. Napolitano is supported by Agency for Healthcare Research and Quality (AHRQ) R18HS024511 and has research or consulting relationships with Drager, Smiths Medical, Philips/Respironics, Actuated Medical, and VERO-Biotech. Dr. Nishisaki is supported by the AHRQ R18 HS024511. Drs. Fitzgerald, Rowan, and Flori received support for article research from the National Institutes of Health (NIH). Dr. Rowan’s institution received funding from the NHLBI (K23HL150244). Dr. Flori’s institution received funding from the Society of Critical Care Medicine; she disclosed that she is an unpaid advisor to Aerogen Pharma, an unpaid member of Executive Board for Michigan Medical Society, and an unpaid member of Executive Committee for Pediatric Acute Lung Injury and Sepsis Investigators Network. Dr. Nishisaki’s institution received funding from the AHRQ (R18HS024511 and R03HS026939); he received support for article research from the AHRQ. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
PICU mortality by quintiles of HFNC (Panel A) and NIPPV (Panel B) duration, stratified by IC diagnoses. For each quintile, the center circle represents the quintile mortality rate, and the bars represent the 95% confidence interval around this mortality rate. The Cuzick test of trend was used to assess the ordinal trend in mortality within each IC subgroup.
Figure 2.
Figure 2.
Center-level variation in adjusted PICU mortality for patients with pre-intubation exposure to HFNC (Panel A) or NIPPV (Panel B). For both panels, the graphs show adjusted mortality in the base model (top figure), the base model + patient factors (middle figure), and the base model + patient factors + center volume (bottom figure). The size of the point estimate corresponds to the volume of patients from each participating hospital. Error bars indicate the 95% confidence interval. The adjusted mortality rate for the entire cohort is indicated by a broken line on each graph, and the median odds ratio is indicated at the lower right corner.
See this image and copyright information in PMC

Comment in

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