One important decision that some hospitalized patients face is whether to pursue a trial of mechanical ventilation should it become necessary.
“The outcomes of patients with respiratory failure who require mechanical ventilation can be quite varied,” says Michael E. Wilson, MD, who works in the Mayo Clinic’s Division of Pulmonary and Critical Care Medicine.
Outcomes range from full recovery to prolonged hospital illness and recovery to death. Mechanical ventilation and the use of an ICU bed may be a valuable (but sometimes limited) resource, Wilson notes. In addition, decisions about life support usage for hospitalized patients often primarily focus on whether to pursue CPR in the event of cardiac arrest. “This is a separate medical situation and decision, compared to whether or not to pursue a trial of mechanical ventilation for patients with respiratory failure,” Wilson explains.
The likelihood of experiencing in-hospital cardiac arrest, and the likelihood of recovery following in-hospital cardiac arrest, are vastly different than the likelihood of experiencing and recovering from respiratory failure, Wilson offers.
The rate of do not intubate orders in patients with acute respiratory failure has increased over time, according to the authors of a recent review.1 “Our goal of this study was to shine a light on decision-making for mechanical ventilation and to better understand reasons for variability in decision-making,” says Wilson, the study’s lead author.
Wilson and colleagues analyzed 26 studies that included 10,755 patients. They found an overall rate of do not intubate orders of 27%. Rates increased over time (from about one in 10 patients 20 years ago to about one in three patients in the past five years). “The exact reasons for this increase over time remain unclear,” Wilson says. “It is possible that patient preferences have changed over time.”
The researchers were surprised to find that factors such as illness severity appeared to not significantly affect rates of do not intubate decisions. “This suggests that other factors may play a larger role in how such decisions are made,” Wilson says.
Decisions about pursuing mechanical ventilation often are matters of life and death. “If there is suboptimal decision-making, then there can be devastating consequences for patients,” Wilson warns.
- Wilson ME, Mittal A, Karki B, et al. Do-not-intubate orders in patients with acute respiratory failure: A systematic review and meta-analysis. Intensive Care Med 2020;46:36-45.