Noninvasive Positive Pressure Ventilation at Respiratory Failure
Noninvasive Positive Pressure Ventilation at Respiratory Failure
Objective: To determine physicians' stated practices regarding the use of bilevel noninvasive ventilation (NIV) for acute respiratory failure and the predictors of practice variation.
Design: Cross-sectional postal survey.
Setting: Province of Ontario, Canada.
Participants: Attending physicians and residents in four specialties at 15 teaching hospitals.
Interventions: We used literature searches and focus groups to design questions related to NIV utilization with respect to frequency, location of and indications for use, awareness of supporting literature, and perceived efficacy. We assessed the survey's clinical sensibility and reliability. We used regression analyses to evaluate practice variation among hospitals and specialties and to determine predictors of more frequent NIV use, initiation of and continued use in nonmonitored settings, and use for specific indications.
Measurements and Main Results: Three hundred eighty-five (48%) of 808 physicians responded; 242 used NIV. The two most common indications for NIV use were chronic obstructive pulmonary disease and congestive heart failure. NIV guidelines, protocols, or policies were available in 12 of 15 hospitals. We found variation in NIV utilization among specialties but not hospitals. Specialty (critical care and respirology versus internal and emergency medicine), fewer years of postgraduate experience, and a greater number of noninvasive ventilators were predictors of more frequent NIV use (all p = .001). Only 6% of respondents reported initiation of use and continued use most frequently in nonmonitored settings, which increased with the number of noninvasive ventilators (p = .02). Physician characteristics such as awareness of the literature were predictive of NIV use for exacerbations of chronic obstructive pulmonary disease, whereas perceived NIV efficacy was predictive of use for many indications, including congestive heart failure.
Conclusions: Self-reported practice variation for bilevel NIV exists among specialties but not hospitals and differs with respect to frequency, location of use, and use for specific indications. Some factors associated with variation in NIV use may be suitable targets for utilization improvement interventions.
Bilevel noninvasive ventilation (NIV) can be lifesaving for patients with acute respiratory failure (ARF). Randomized controlled trials (RCTs) and meta-analyses have established the benefit of NIV for exacerbations of chronic obstructive pulmonary disease (COPD). Other RCTs support its use in weaning from mechanical ventilation, in thoracic and cardiac surgery, and among immunocompromised patients with ARF. However, its use for acute asthma, cystic fibrosis, community-acquired pneumonia, and congestive heart failure (CHF) remains controversial; continuous positive airway pressure is an alternative for CHF. NIV appears harmful in postextubation respiratory failure. In summary, limited evidence guides the use of NIV for ARF unrelated to COPD exacerbations. In the absence of strong evidence for most indications, variability in NIV utilization may reflect the characteristics of treating physicians or their practice setting.
The primary objective of this physician survey was to characterize the extent and predictors of practice variation in NIV utilization among patients with ARF in teaching hospitals in Ontario, Canada. We hypothesized that a) utilization would vary with respect to frequency of use, use in nonmonitored settings, and indications; b) practice variation among specialties would be greater than among hospitals; and c) predictors of practice variation would include physician factors (specialty, clinical experience, perceived efficacy, and awareness of the NIV literature) and hospital factors (presence of a hospital guideline, policy, or protocol; availability and number of noninvasive ventilators [specifically designed for NIV]; and extent of respiratory therapist [RT] involvement in NIV application). We also sought to describe practical aspects of NIV delivery and physicians' educational needs.
Objective: To determine physicians' stated practices regarding the use of bilevel noninvasive ventilation (NIV) for acute respiratory failure and the predictors of practice variation.
Design: Cross-sectional postal survey.
Setting: Province of Ontario, Canada.
Participants: Attending physicians and residents in four specialties at 15 teaching hospitals.
Interventions: We used literature searches and focus groups to design questions related to NIV utilization with respect to frequency, location of and indications for use, awareness of supporting literature, and perceived efficacy. We assessed the survey's clinical sensibility and reliability. We used regression analyses to evaluate practice variation among hospitals and specialties and to determine predictors of more frequent NIV use, initiation of and continued use in nonmonitored settings, and use for specific indications.
Measurements and Main Results: Three hundred eighty-five (48%) of 808 physicians responded; 242 used NIV. The two most common indications for NIV use were chronic obstructive pulmonary disease and congestive heart failure. NIV guidelines, protocols, or policies were available in 12 of 15 hospitals. We found variation in NIV utilization among specialties but not hospitals. Specialty (critical care and respirology versus internal and emergency medicine), fewer years of postgraduate experience, and a greater number of noninvasive ventilators were predictors of more frequent NIV use (all p = .001). Only 6% of respondents reported initiation of use and continued use most frequently in nonmonitored settings, which increased with the number of noninvasive ventilators (p = .02). Physician characteristics such as awareness of the literature were predictive of NIV use for exacerbations of chronic obstructive pulmonary disease, whereas perceived NIV efficacy was predictive of use for many indications, including congestive heart failure.
Conclusions: Self-reported practice variation for bilevel NIV exists among specialties but not hospitals and differs with respect to frequency, location of use, and use for specific indications. Some factors associated with variation in NIV use may be suitable targets for utilization improvement interventions.
Bilevel noninvasive ventilation (NIV) can be lifesaving for patients with acute respiratory failure (ARF). Randomized controlled trials (RCTs) and meta-analyses have established the benefit of NIV for exacerbations of chronic obstructive pulmonary disease (COPD). Other RCTs support its use in weaning from mechanical ventilation, in thoracic and cardiac surgery, and among immunocompromised patients with ARF. However, its use for acute asthma, cystic fibrosis, community-acquired pneumonia, and congestive heart failure (CHF) remains controversial; continuous positive airway pressure is an alternative for CHF. NIV appears harmful in postextubation respiratory failure. In summary, limited evidence guides the use of NIV for ARF unrelated to COPD exacerbations. In the absence of strong evidence for most indications, variability in NIV utilization may reflect the characteristics of treating physicians or their practice setting.
The primary objective of this physician survey was to characterize the extent and predictors of practice variation in NIV utilization among patients with ARF in teaching hospitals in Ontario, Canada. We hypothesized that a) utilization would vary with respect to frequency of use, use in nonmonitored settings, and indications; b) practice variation among specialties would be greater than among hospitals; and c) predictors of practice variation would include physician factors (specialty, clinical experience, perceived efficacy, and awareness of the NIV literature) and hospital factors (presence of a hospital guideline, policy, or protocol; availability and number of noninvasive ventilators [specifically designed for NIV]; and extent of respiratory therapist [RT] involvement in NIV application). We also sought to describe practical aspects of NIV delivery and physicians' educational needs.
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