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.

中文翻译：

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插管前呼吸支持的使用和持续时间与患有急性呼吸衰竭的免疫功能低下儿童的死亡率增加有关*

目标： 

确定插管前呼吸支持与急性呼吸衰竭患者结局之间的关联，并确定免疫功能低下 (IC) 诊断在调整疾病严重程度后对结局的影响。

设计： 

回顾性多中心队列研究。

环境： 

虚拟儿科系统数据库中有 82 个中心。

患者： 

在 PICU 接受有创机械通气 (IMV) 时间大于或等于 24 小时的 1 个月至 17 岁儿童。

干预措施： 

没有任何。

测量和主要结果： 

在 82 个中心的 5,348 例 PICU 插管中，有 1,825 例 (34%) 在插管前使用了高流量鼻插管 (HFNC) 或无创正压通气 (NIPPV)。按 IC 状态分层时，50% 的患者没有诊断出 IC，而 41% 的患者既往没有接受过造血细胞移植 (HCT)，患有 IC，9% 的患者既往有 HCT。与未经事先支持插管的患者相比，插管前接触 HFNC（调整后比值比 [aOR]，1.33；95% CI，1.10–1.62）或 NIPPV（aOR，1.44；95% CI，1.20–1.74）与比值增加相关PICU 死亡率。在 IC 状态亚组中，插管前呼吸支持与 IC 患者 PICU 死亡率增加相关（HFNC：aOR，1.50；95% CI，1.11–2.03；NIPPV：aOR，1.76；95% CI，1.31–2.35） HCT 患者（HFNC：aOR，1.75；95% CI，1.07–2.86；NIPPV：aOR，1.85；95% CI，1.12–3.02）与没有事先呼吸支持的插管的 IC/HCT 患者相比。对于没有 IC 诊断的患者，插管前暴露于 HFNC/NIPPV 与死亡率无关。HFNC/NIPPV 持续时间超过 6 小时与 IC HCT 患者死亡率增加相关（HFNC：aOR，2.41；95% CI，1.05–5.55；NIPPV：aOR，2.53；95% CI，1.04–6.15） HFNC/NIPPV 暴露时间少于 6 小时的 HCT 患者。根据患者和中心特征进行调整后，插管前 HFNC/NIPPV 使用（中位数，15%；范围，0-63%）和 PICU 死亡率因中心而异。

结论： 

在 IC 儿科患者中，插管前暴露于 HFNC 和/或 NIPPV 与 PICU 死亡率增加相关，与疾病严重程度无关。IMV 之前暴露于 HFNC/NIPPV 的时间较长与 HCT 患者死亡率增加相关。