Predictors of non‑invasive ventilation failure for community acquired pneumonia: a retrospective cohort study

Introduction: the use of non-invasive ventilation (NIV) for community acquired pneumonia (CAP) is not routinely recommended. NIV failure is associated with increased mortality, highlighting the need for careful patient selection. We aimed to identify predictors of NIV failure for severe CAP in our ICU. Methods: in this single-center retrospective cohort study, we included consecutive adults with CAP who received NIV as their initial respiratory support on our ICU. The study data was collected for the period between 1st February 2016 and 30th April 2017. We categorized patients as either NIV success (defined as discharged alive from ICU) or NIV failure (defined as requirement for mechanical ventilation or death). Sequential Organ Failure Assessment (SOFA) score, Heart Rate, Acidosis, Consciousness, Oxygenation, and Respiratory Rate (HACOR) score and ratio of oxygen saturations (ROX) index at various timepoints are reported. Results: we included 106 patients (median age 63 years, 56% male). Median PaO2/FiO2 ratio and SOFA score on ICU admission were 155 mmHg and 5 respectively. Overall, our NIV success rate was 59% and in patients with NIV success, 28-day mortality was lower than for patients who failed NIV (13 vs 35%, p = 0.0085). In univariate analysis, NIV failure was associated with SOFA score (OR 1.33), HACOR score (OR 1.14) and presence of septic shock (OR 3.99). SOFA score has an AUC of 0.75 for NIV failure on ICU admission, whilst HACOR has an AUC of 0.76 after 2 h of NIV. A threshold of HACOR ≤ 5 after 2 h of NIV predicts success with sensitivity and specificity of 53% and 85%, whereas SOFA ≤ 4 has a sensitivity and specificity of 61% and 72%. There were no differences in pH, PaO2/FiO2 ratio, PaCO2 or ROX index between NIV success or failure at any timepoint. Conclusions: our results suggest that SOFA ≤ 4 and HACOR ≤ 5 are reasonable thresholds to identify patients with severe CAP likely to benefit from NIV

Non-invasive ventilation for community-acquired pneumonia: outcomes and predictors of failure from an ICU cohort

Background and Objectives: the use of non-invasive ventilation (NIV) for community-acquired pneumonia (CAP) remains controversial. NIV failure in the setting of acute hypoxemic respiratory failure is associated with increased mortality, highlighting the need for careful patient selection. Methods and methods: this is a retrospective observational cohort study. We included 140 patients with severe CAP, treated with either NIV or invasive mechanical ventilation (IMV) as their primary oxygenation strategy. Results: the median PaO2/FiO2 ratio and SOFA score upon ICU admission were 151 mmHg and 6, respectively. We managed 76% of patients with NIV initially and report an NIV success rate of 59%. Overall, the 28-day mortality was 25%, whilst for patients with NIV success, the mortality was significantly lower at 13%. In the univariate analysis, NIV failure was associated with the SOFA score (OR 1.33), the HACOR score (OR 1.14) and the presence of septic shock (OR 3.99). The SOFA score has an AUC of 0.75 for NIV failure upon ICU admission, whilst HACOR has an AUC of 0.76 after 2 h of NIV. Conclusions: our results suggest that a SOFA ≤ 4 and an HACOR ≤ 5 are reasonable thresholds to identify patients with severe CAP likely to benefit from NIV.</p

Nutritional supplementation for nonalcohol-related fatty liver disease: a network meta-analysis (Review)

BackgroundThe prevalence of non-alcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases risks of liver cirrhosis, hepatocellular carcinoma, and the requirement for liver transplantation. Uncertainty surrounds relative benefits and harms of various nutritional supplements in NAFLD. Currently no nutritional supplement is recommended for people with NAFLD. Objectives • To assess the benefits and harms of different nutritional supplements for treatment of NAFLD through a network meta-analysis • To generate rankings of different nutritional supplements according to their safety and efficacy Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, the World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD. Selection criteria We included only randomised clinical trials (irrespective of language, blinding, or status) for people with NAFLD, irrespective of method of diagnosis, age and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation.Data collection and analysisWe performed a network meta‐analysis with OpenBUGS using Bayesian methods whenever possible and calculated differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios with 95% credible intervals (CrIs) based on an available‐case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.Main resultsWe included in the review a total of 202 randomised clinical trials (14,200 participants). Nineteen trials were at low risk of bias. A total of 32 different interventions were compared in these trials. A total of 115 trials (7732 participants) were included in one or more comparisons. The remaining trials did not report any of the outcomes of interest for this review.Follow‐up ranged from 1 month to 28 months. The follow‐up period in trials that reported clinical outcomes was 2 months to 28 months. During this follow‐up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver‐related mortality were sparse.We did not calculate effect estimates for mortality because of sparse data (zero events for at least one of the groups in the trial). None of the trials reported that they measured overall health‐related quality of life using a validated scale. The evidence is very uncertain about effects of interventions on serious adverse events (number of people or number of events).We are very uncertain about effects on adverse events of most of the supplements that we investigated, as the evidence is of very low certainty. However, people taking PUFA (polyunsaturated fatty acid) may be more likely to experience an adverse event than those not receiving an active intervention (network meta‐analysis results: OR 4.44, 95% CrI 2.40 to 8.48; low‐certainty evidence; 4 trials, 203 participants; direct evidence: OR 4.43, 95% CrI 2.43 to 8.42). People who take other supplements (a category that includes nutritional supplements other than vitamins, fatty acids, phospholipids, and antioxidants) had higher numbers of adverse events than those not receiving an active intervention (network meta‐analysis: rate ratio 1.73, 95% CrI 1.26 to 2.41; 6 trials, 291 participants; direct evidence: rate ratio 1.72, 95% CrI 1.25 to 2.40; low‐certainty evidence).Data were sparse (zero events in all groups in the trial) for liver transplantation, liver decompensation, and hepatocellular carcinoma. So, we did not perform formal analysis for these outcomes. The evidence is very uncertain about effects of other antioxidants (antioxidants other than vitamins) compared to no active intervention on liver cirrhosis (HR 1.68, 95% CrI 0.23 to 15.10; 1 trial, 99 participants; very low‐certainty evidence).The evidence is very uncertain about effects of interventions in any of the remaining comparisons, or data were sparse (with zero events in at least one of the groups), precluding formal calculations of effect estimates.Data were probably because of the very short follow‐up period (2 months to 28 months). It takes follow‐up of 8 to 28 years to detect differences in mortality between people with NAFLD and the general population. Therefore, it is unlikely that differences in clinical outcomes are noted in trials providing less than 5 to 10 years of follow‐up.Authors' conclusionsThe evidence indicates considerable uncertainty about effects of nutritional supplementation compared to no additional intervention on all clinical outcomes for people with non‐alcohol‐related fatty liver disease.Accordingly, high‐quality randomised comparative clinical trials with adequate follow‐up are needed. We propose registry‐based randomised clinical trials or cohort multiple randomised clinical trials (study design in which multiple interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice) comparing interventions such as vitamin E, prebiotics/probiotics/synbiotics, PUFAs, and no nutritional supplementation. The reason for the choice of interventions is the impact of these interventions on indirect outcomes, which may translate to clinical benefit. Outcomes in such trials should be mortality, health‐related quality of life, decompensated liver cirrhosis, liver transplantation, and resource utilisation measures including costs of intervention and decreased healthcare utilisation after minimum follow‐up of 8 years (to find meaningful differences in clinically important outcomes).</div