Timing of invasive mechanical ventilation in patients with sepsis: the impact of excluding non-intubated patients,Critical Care

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Timing of invasive mechanical ventilation in patients with sepsis: the impact of excluding non-intubated patients
Critical Care ( IF 8.8 ) Pub Date : 2024-12-18 , DOI: 10.1186/s13054-024-05208-3
Yun Ji, Libin Li

Dear Editor,

Early initiation of invasive mechanical ventilation (IMV) may represent a potentially beneficial approach for sepsis patients [1]. A recent study by Kim et al. [2], published in Critical Care, provides evidence supporting this approach, reporting that earlier IMV initiation (on the first day of ICU admission) may be associated with lower mortality.

However, in their study, 2,363 patients who never required IMV during their ICU stay were excluded from the analysis. While this approach focuses on patients who received IMV, it may inadvertently select a population with more severe illness for comparison, potentially introducing bias into the results. In clinical practice, a subset of sepsis patients may benefit from a wait-and-see strategy, where intubation is avoided through the use of non-invasive ventilation or other supportive measures, potentially reducing the risks associated with IMV. Excluding these patients from the analysis may have influenced the reported outcomes and the perceived benefits of early IMV.

To better illustrate this issue, we conducted an analysis of sepsis patients using the Medical Information Mart for Intensive Care (MIMIC)-IV database [3] (refer to Additional file 1: Supplemental methods). Among 24,518 ICU patients with sepsis, 12,654 received IMV on the first day of ICU admission (early IMV group). Of the remaining 11,864 patients (non-early IMV group), 1,217 eventually required IMV later during their ICU stay (delayed IMV group), while the rest did not receive IMV during their ICU stay (Additional file 1: Fig. S1).

First, we compared the early IMV group and the non-early IMV group. Propensity score matching (PSM) improved the balance of baseline characteristics between the two groups, achieving an absolute standardized mean difference (SMD) < 0.10 (Additional file 1: Table S1). After matching, the 90-day mortality rate was 23.3% (1,413/6,067) in the early IMV group and 28.5% (1,731/6,067) in the non-early IMV group. The Kaplan–Meier curve for 90-day mortality in the matched cohort is shown in Fig. 1A. Early IMV was associated with lower 90-day mortality in both univariable analysis (hazard ratio [HR], 0.79; 95% confidence interval (CI), 0.74–0.85; P < 0.001) and multivariable analysis (HR, 0.77; 95% CI, 0.72–0.83; P < 0.001).

Next, we compared the early IMV group and the delayed IMV group. Similarly, PSM improved the balance of baseline characteristics between the two groups (absolute SMD < 0.10; Additional file 1: Table S2). After matching, the 90-day mortality rate was 27.1% (302/1,116) in the early IMV group and 45.3% (505/1,116) in the delayed IMV group. The Kaplan–Meier curve for 90-day mortality in the matched cohort is shown in Fig. 1B. Early IMV was associated with significantly lower 90-day mortality in both univariable analysis (HR, 0.53; 95% CI, 0.46–0.61; P < 0.001) and multivariable analysis (HR, 0.52; 95% CI, 0.45–0.60; P < 0.001).

Our findings demonstrate that early IMV is associated with lower mortality, aligning with the results reported by Kim et al. [2]. However, as shown in Fig. 1, the exclusion of patients who never received IMV during their ICU stay may lead to an overestimation of the mortality benefits associated with early IMV. Thus, we believe that including the 2,363 patients who did not receive IMV during their ICU stay could provide a more comprehensive understanding of the mortality benefits associated with early IMV and potentially refine the findings of Kim et al.’s study [2].

The datasets presented in the current study are available in the MIMIC-IV database (https://mimic.mit.edu/).

CI:: Confidence interval
HR:: Hazard ratio
ICU:: Intensive care unit
MIMIC:: Medical information mart for intensive care
IMV:: Invasive mechanical ventilation
PSM:: Propensity score matching
SMD:: Standardized mean difference

Lee KG, Roca O, Casey JD, Semler MW, Roman-Sarita G, Yarnell CJ, Goligher EC. When to intubate in acute hypoxaemic respiratory failure? Options and opportunities for evidence-informed decision making in the intensive care unit. Lancet Respir Med. 2024;12(8):642–54.
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This work was supported by Natural Science Foundation of Zhejiang Province (grant No. LQ22H150001).

Authors and Affiliations

Department of Surgical Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
Yun Ji & Libin Li

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Yun JiView author publications
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Contributions

YJ extracted the data and performed the statistical analyses. YJ and LL participated in the discussion and wrote the manuscript.

Corresponding author

Correspondence to Yun Ji.

Ethics approval and consent to participate

The establishment of this database was approved by the Massachusetts Institute of Technology (Cambridge, MA) and Beth Israel Deaconess Medical Center (Boston, MA) and consent was obtained for the original data collection. Therefore, the ethical approval statement and the need for informed consent were waived for this manuscript.

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Not applicable.

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The authors declare no competing interests.

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Ji, Y., Li, L. Timing of invasive mechanical ventilation in patients with sepsis: the impact of excluding non-intubated patients. Crit Care 28, 415 (2024). https://doi.org/10.1186/s13054-024-05208-3

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Received: 01 December 2024
Accepted: 06 December 2024
Published: 18 December 2024
DOI: https://doi.org/10.1186/s13054-024-05208-3

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中文翻译：

脓毒症患者有创机械通气的时机：排除非插管患者的影响

尊敬的编辑：

早期开始有创机械通气（IMV）可能对脓毒症患者有益 [1]。Kim 等人 [2] 最近发表在《重症监护》上的一项研究提供了支持这种方法的证据，报告称较早开始 IMV（入住 ICU 的第一天）可能与较低的死亡率相关。

然而，在他们的研究中，2,363 名在 ICU 住院期间从未需要 IMV 的患者被排除在分析之外。虽然这种方法侧重于接受 IMV 的患者，但它可能会无意中选择病情更严重的人群进行比较，从而可能在结果中引入偏倚。在临床实践中，一部分脓毒症患者可能受益于观望策略，即通过使用无创通气或其他支持措施来避免插管，从而可能降低与 IMV 相关的风险。将这些患者排除在分析之外可能影响了报告的结果和早期 IMV 的感知益处。

为了更好地说明这个问题，我们使用重症监护医学信息市场（MIMIC）-IV 数据库 [3] 对脓毒症患者进行了分析（参见附加文件 1：补充方法）。在 24,518 例脓毒症 ICU 患者中，12,654 例在入住 ICU 的第一天接受了 IMV（早期 IMV 组）。在其余 11,864 名患者（非早期 IMV 组）中，1,217 名患者最终在 ICU 住院期间晚些时候需要 IMV（延迟 IMV 组），而其余患者在 ICU 住院期间未接受 IMV（附加文件 1：图 S1）。

首先，我们比较了早期 IMV 组和非早期 IMV 组。倾向得分匹配（PSM）改善了两组之间基线特征的平衡，实现了绝对标准化平均差（SMD） < 0.10 （附加文件 1：表 S1）。匹配后，早期 IMV 组的 90 天死亡率为 23.3% （1,413/6,067），非早期 IMV 组为 28.5% （1,731/6,067）。匹配队列中 90 天死亡率的 Kaplan-Meier 曲线如图 1A 所示。在单变量分析中，早期 IMV 与较低的 90 天死亡率相关（风险比 [HR]，0.79;95% 置信区间（CI），0.74-0.85;P < 0.001）和多变量分析（HR， 0.77;95% CI， 0.72–0.83;P < 0.001）。

接下来，我们比较了早期 IMV 组和延迟 IMV 组。同样，PSM 改善了两组之间基线特征的平衡（绝对 SMD < 0.10;附加文件 1：表 S2）。匹配后，早期 IMV 组 90 天死亡率为 27.1% （302/1,116），延迟 IMV 组为 45.3% （505/1,116）。匹配队列中 90 天死亡率的 Kaplan-Meier 曲线如图 1B 所示。在两种单变量分析中，早期 IMV 与显著降低的 90 天死亡率相关（HR，0.53;95% CI，0.46-0.61;P < 0.001）和多变量分析（HR， 0.52;95% CI， 0.45–0.60;P < 0.001）。

我们的研究结果表明，早期 IMV 与较低的死亡率相关，这与 Kim 等人报告的结果一致 [2]。然而，如图 1 所示，排除在 ICU 住院期间从未接受过 IMV 的患者可能会导致高估与早期 IMV 相关的死亡率获益。因此，我们相信，包括 2,363 名在 ICU 住院期间未接受 IMV 的患者可以更全面地了解与早期 IMV 相关的死亡率获益，并可能完善 Kim 等人的研究结果 [2]。

当前研究中介绍的数据集可在 MIMIC-IV 数据库（https://mimic.mit.edu/）中找到。

词：: 置信区间
人力资源：: 风险比
重症监护室：: 重症监护病房
模仿：: 重症监护医疗信息市场
IMV：: 有创机械通气
PSM：: 倾向得分匹配
贴片式（SMD）：: 标准化平均差

Lee KG、Roca O、Casey JD、Semler MW、Roman-Sarita G、Yarnell CJ、Goligher EC。急性低氧血症性呼吸衰竭何时插管？在重症监护病房做出循证决策的选择和机会。柳叶刀呼吸医学 2024;12(8):642–54.

文章 PubMed 谷歌学术
Kim G， Oh DK， Lee SY， Park MH， Lim CM. 有创机械通气时间对脓毒症患者的影响：一项多中心队列研究。暴击护理。2024;28(1):297.

文章： PubMed PubMed Central Google Scholar
Johnson AEW， Bulgarelli L， Shen L， Gayles A， Shammout A， Horng S， Pollard TJ， Hao S， Moody B， Gow B， et al. MIMIC-IV，一个可免费访问的电子健康记录数据集。科学数据。2023;10(1):1.

论文： CAS PubMed， PubMed， Central Google Scholar

下载参考资料

不適用。

这项工作得到了浙江省自然科学基金（Grant No.LQ22H150001）。

作者和单位

浙江大学医学院第二附属医院外科重症监护室， 88 Jiefang Road， Hangzhou， Zhejiang， China
Yun Ji & Libin Li

作者

云吉查看作者出版物

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李利宾查看作者出版物

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贡献

YJ 提取数据并进行统计分析。YJ 和 LL 参与了讨论并撰写了手稿。

通讯作者

与云吉的通信。

道德批准和参与同意

该数据库的建立得到了麻省理工学院（马萨诸塞州剑桥）和 Beth Israel Deaconess Medical Center（马萨诸塞州波士顿）的批准，并获得了原始数据收集的同意。因此，该手稿免除了伦理批准声明和知情同意的需要。

同意发布

不適用。

利益争夺

作者声明没有利益冲突。

出版商注

施普林格·自然（Springer Nature）对已发布的地图和机构隶属关系中的管辖权主张保持中立。

附加文件1 （DOCX 192 KB）

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