Analysis of Noninvasive Ventilation in Subjects With Sepsis and Acute Respiratory Failure.

Background: Acute respiratory failure is among the sequelae of complications that can develop in response to severe sepsis. Research into sepsis-related respiratory failure has focused on ARDS and invasive mechanical ventilation. We studied the factors associated with success and failure of noninvasive ventilation (NIV) in the treatment of sepsis-related acute respiratory failure.

Methods: This retrospective study included 136 subjects with a diagnosis of acute respiratory failure and intrapulmonary or extrapulmonary sepsis who were placed on NIV. Subjects were divided into 2 groups based on the need for intubation from NIV: NIV failure ( = 70) and NIV success ( = 66). Demographic, clinical, and outcome data were collected and compared between groups, with the development of multivariate models to predict NIV failure and mortality.

Results: The overall NIV failure rate in subjects with a diagnosis of sepsis was 51%. There were no between-group differences in demographic or baseline characteristics. However, there were significant differences in clinical variables, with higher SOFA scores (NIV failure: 6.4 [± 3.0] vs NIV success: 4.9 [± 2.1]; = .002), 2nd lactate levels (NIV failure: 2.6 [1.7 - 4.3] vs NIV success: 1.9 [1.4 - 2.6] mmol/L; = .007), and initial NIV [Formula: see text] settings (NIV failure: 0.50 [0.40 - 0.70] vs NIV failure: 0.40 [0.35 - 0.50]; = .003) in subjects who failed NIV. There were also more subjects in the NIV failure group who had a lactate ≥ 4 mmol/L prior to NIV start compared to those who succeeded on NIV (33% vs 15%, = .02). At NIV start, subjects in the NIV failure group had lower mean arterial pressure (85 mm Hg [IQR 74-96] vs 91.7 mm Hg [IQR 78-108], = .042) and Glasgow coma scale scores (14 [IQR 13-15] vs 15 [IQR 14-15], < .002), while fewer subjects in the NIV failure group received a fluid bolus in the 24 h prior to NIV start (33% vs 53%, = .02) or had signs of volume overload (36% vs 64%, < .001). Multivariate analysis indicated that age (odds ratio 1.05 [95% CI 1.01-1.09], = .02), SOFA score (odds ratio 1.49 [95% CI 1.15-1.94], = .002), first systolic blood pressure (odds ratio 0.97 [95% CI 0.95-0.99], = .02), signs of volume overload (odds ratio 0.23 [95% CI 0.07-0.68], = .008], fluids prior to NIV (odds ratio 0.08 [95% CI 0.02-0.31], < .001), and initial [Formula: see text] on NIV (odds ratio 1.04 [95% CI 1.01-1.08, = .002) independently predicted NIV failure with an area under the curve of 0.88. Only NIV failure independently predicted death in multivariate analysis (area under the curve = 0.70).

Conclusions: NIV failure in sepsis-related acute respiratory failure was independently predicted by patient acuity, first systolic blood pressure after sepsis alert, initial [Formula: see text] settings on NIV, fluid resuscitation, and signs of volume overload. However, only NIV failure independently predicted death in this cohort of subjects.