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Association Between Noninvasive Ventilation and Mortality Among Older Patients With Pneumonia

Valley, Thomas S., MD, MSc1,2,3; Walkey, Allan J., MD, MSc4; Lindenauer, Peter K., MD, MSc5,6; Wiener, Renda Soylemez, MD, MPH4,7; Cooke, Colin R., MD, MSc, MS1,2,3,8

doi: 10.1097/CCM.0000000000002076
Online Clinical Investigations

Objective: Despite increasing use, evidence is mixed as to the appropriate use of noninvasive ventilation in patients with pneumonia. We aimed to determine the relationship between receipt of noninvasive ventilation and outcomes for patients with pneumonia in a real-world setting.

Design, Setting, Patients: We performed a retrospective cohort study of Medicare beneficiaries (aged > 64 yr) admitted to 2,757 acute-care hospitals in the United States with pneumonia, who received mechanical ventilation from 2010 to 2011.

Exposures: Noninvasive ventilation versus invasive mechanical ventilation.

Measurement and Main Results: The primary outcome was 30-day mortality with Medicare reimbursement as a secondary outcome. To account for unmeasured confounding associated with noninvasive ventilation use, an instrumental variable was used—the differential distance to a high noninvasive ventilation use hospital. All models were adjusted for patient and hospital characteristics to account for measured differences between groups. Among 65,747 Medicare beneficiaries with pneumonia who required mechanical ventilation, 12,480 (19%) received noninvasive ventilation. Patients receiving noninvasive ventilation were more likely to be older, male, white, rural-dwelling, have fewer comorbidities, and were less likely to be acutely ill as measured by organ failures. Results of the instrumental variable analysis suggested that, among marginal patients, receipt of noninvasive ventilation was not significantly associated with differences in 30-day mortality when compared with invasive mechanical ventilation (54% vs 55%; p = 0.92; 95% CI of absolute difference, –13.8 to 12.4) but was associated with significantly lower Medicare spending ($18,433 vs $27,051; p = 0.02).

Conclusions: Among Medicare beneficiaries hospitalized with pneumonia who received mechanical ventilation, noninvasive ventilation use was not associated with a real-world mortality benefit. Given the wide CIs, however, substantial harm associated with noninvasive ventilation could not be excluded. The use of noninvasive ventilation for patients with pneumonia should be cautioned, but targeted enrollment of marginal patients with pneumonia could enrich future randomized trials.

1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

2Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI.

3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.

4The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Center for Implementation and Improvement Sciences, Boston, MA.

5Center for Quality of Care Research and Division of General Medicine and Community Health, Baystate Medical Center, Springfield, MA.

6Tufts Clinical and Translational Science Institute, Tufts University School of Medicine, Boston, MA.

7Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA.

8Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI.

This article does not necessarily represent the view of the U.S. Government or the Department of Veterans Affairs.

Dr. Valley had full access to all of the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Valley and Cooke helped in study concept and design, acquisition of data, drafting of the article, and statistical analysis. Drs. Valley, Walkey, Lindenauer, Wiener, and Cooke helped in analysis and interpretation of data. Valley, Cooke. Drs. Valley, Walkey, Lindenauer, Wiener, and Cooke helped in critical revision of the article for important intellectual content. Dr. Cooke obtained funding.

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 (

Supported by National Institutes of Health T32HL007749 (Dr. Valley), AHRQ K08HS020672 (Dr. Cooke), and by resources from the Edith Nourse Rogers Memorial Hospital, Bedford, MA (Dr. Wiener).

Dr. Valley received support for article research from the National Institutes of Health (NIH). His institution received funding from the NIH. Dr. Walkey received support for article research from the NIH and received funding from UpToDate regarding weaning from mechanical ventilation. His institution received funding from the NIH. Dr. Cooke received funding from the Agency for Healthcare Research and Quality. His institution received funding from the Agency for Healthcare Research and Quality and the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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