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Failure of Noninvasive Ventilation for De Novo Acute Hypoxemic Respiratory Failure: Role of Tidal Volume*

Carteaux, Guillaume MD1,2,3; Millán-Guilarte, Teresa MD4; De Prost, Nicolas MD, PhD1,2,3; Razazi, Keyvan MD1,2,3; Abid, Shariq MD, PhD3; Thille, Arnaud W. MD, PhD5; Schortgen, Frédérique MD, PhD1,3; Brochard, Laurent MD3,6,7; Brun-Buisson, Christian MD1,2,8; Mekontso Dessap, Armand MD, PhD1,2,3

doi: 10.1097/CCM.0000000000001379
Clinical Investigations

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.

Supplemental Digital Content is available in the text.

1Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, DHU A-TVB, Service de Réanimation Médicale, Créteil, France.

2Université Paris Est Créteil, Faculté de Médecine de Créteil, Groupe de recherche clinique CARMAS, Créteil, France.

3INSERM, Unité U955, IMRB, Créteil, France.

4Unidad de Cuidados Intensivos, Hospital Universitario Son Espases, Palma de Mallorca, Spain.

5CHU de Poitiers, Service de Réanimation médicale et CIC-P 1402 (ALIVE group), CHU de Poitiers, Poitiers, France.

6Keenan Research Centre and Critical Care Department, St. Michael’s Hospital, Toronto, ON, Canada.

7Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.

8Inserm U657, Institut Pasteur, Pharmaco-épidémiologie et Maladies Infectieuses, Paris, France.

*See also p. 444.

This work was performed at Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Thille received payment for lecture by Covidien (not in relation with the current study). Dr. Brochard’s institution received funding from General Electric Educational grant; Covidien, research on proportional assist ventilation and consultancy; and Fisher Paykel, research on high flow. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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