Noninvasive ventilation in patients with "do-not-intubate" orders: medium-term efficacy depends critically on patient selection

Intensive Care Med. 2007 Feb;33(2):350-4. doi: 10.1007/s00134-006-0437-6. Epub 2006 Nov 9.


Objective: Randomized clinical trials demonstrating benefits of noninvasive ventilation (NIV) systematically exclude patients with "do-not-intubate" (DNI) orders, but in daily clinical practice these patients are frequently treated with NIV. A recent North American study found a 43% hospital survival rate in patients with DNI orders. Our hypothesis was that, due to the very different social and cultural setting, written DNI orders in a southern European country would be restricted to a population with a poor outcome, independently of whether they receive NIV, and we analyzed hospital survival in patients receiving NIV and the impact of DNI orders on survival.

Design and setting: Retrospective cohort study in a general ICU in a university-affiliated hospital.

Patients and methods: All 233 patients treated with NIV during 2002-2004. We recorded clinical characteristics on admission, mortality risk by APACHE II and ICU and hospital outcome, and 6-month outcome.

Results: Hospital survival was 66%. Survival was better in the 199 patients without DNI orders than in the 36 with DNI orders both during hospitalization (74% vs. 26%, OR 7.9) and after 6 months (64% vs. 15%, OR 10.2). In both groups the presence of COPD was associated with better prognosis during hospitalization, but not in the medium-term.

Conclusion: Our study suggests that NIV offers low expectations for medium-term survival in DNI patients.

MeSH terms

  • Aged
  • Cross Infection / complications*
  • Cross Infection / mortality
  • Female
  • Hospital Mortality
  • Humans
  • Intensive Care Units / statistics & numerical data*
  • Length of Stay
  • Logistic Models
  • Male
  • Positive-Pressure Respiration / methods*
  • Pulmonary Disease, Chronic Obstructive / complications
  • Pulmonary Disease, Chronic Obstructive / mortality
  • Pulmonary Disease, Chronic Obstructive / therapy*
  • Resuscitation Orders*
  • Retrospective Studies
  • Survival Analysis