Failure of Noninvasive Ventilation for De Novo Acute Hypoxemic Respiratory Failure

Objectives: A low or moderate expired tidal volume can be difficult to achieve during noninvasive ventilation for de novo acute hypoxemic respiratory failure (i.e., not due to exacerbation of chronic lung disease or cardiac failure). We assessed expired tidal volume and its association with noninvasive ventilation outcome. Design: Prospective observational study. Setting: Twenty-four bed university medical ICU. Patients: Consecutive patients receiving noninvasive ventilation for acute hypoxemic respiratory failure between August 2010 and February 2013. Interventions: Noninvasive ventilation was uniformly delivered using a simple algorithm targeting the expired tidal volume between 6 and 8 mL/kg of predicted body weight. Measurements: Expired tidal volume was averaged and respiratory and hemodynamic variables were systematically recorded at each noninvasive ventilation session. Main Results: Sixty-two patients were enrolled, including 47 meeting criteria for acute respiratory distress syndrome, and 32 failed noninvasive ventilation (51%). Pneumonia (n = 51, 82%) was the main etiology of acute hypoxemic respiratory failure. The median (interquartile range) expired tidal volume averaged over all noninvasive ventilation sessions (mean expired tidal volume) was 9.8 mL/kg predicted body weight (8.1–11.1 mL/kg predicted body weight). The mean expired tidal volume was significantly higher in patients who failed noninvasive ventilation as compared with those who succeeded (10.6 mL/kg predicted body weight [9.6–12.0] vs 8.5 mL/kg predicted body weight [7.6–10.2]; p = 0.001), and expired tidal volume was independently associated with noninvasive ventilation failure in multivariate analysis. This effect was mainly driven by patients with PaO2/FIO2 up to 200 mm Hg. In these patients, the expired tidal volume above 9.5 mL/kg predicted body weight predicted noninvasive ventilation failure with a sensitivity of 82% and a specificity of 87%. Conclusions: A low expired tidal volume is almost impossible to achieve in the majority of patients receiving noninvasive ventilation for de novo acute hypoxemic respiratory failure, and a high expired tidal volume is independently associated with noninvasive ventilation failure. In patients with moderate-to-severe hypoxemia, the expired tidal volume above 9.5 mL/kg predicted body weight accurately predicts noninvasive ventilation failure.