Critical Care (Sep 2019)

Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure

  • Guillaume Dumas,
  • Alexandre Demoule,
  • Djamel Mokart,
  • Virginie Lemiale,
  • Saad Nseir,
  • Laurent Argaud,
  • Frédéric Pène,
  • Loay Kontar,
  • Fabrice Bruneel,
  • Kada Klouche,
  • François Barbier,
  • Jean Reignier,
  • Annabelle Stoclin,
  • Guillaume Louis,
  • Jean-Michel Constantin,
  • Florent Wallet,
  • Achille Kouatchet,
  • Vincent Peigne,
  • Pierre Perez,
  • Christophe Girault,
  • Samir Jaber,
  • Yves Cohen,
  • Martine Nyunga,
  • Nicolas Terzi,
  • Lila Bouadma,
  • Christine Lebert,
  • Alexandre Lautrette,
  • Naike Bigé,
  • Jean-Herlé Raphalen,
  • Laurent Papazian,
  • Dominique Benoit,
  • Michael Darmon,
  • Sylvie Chevret,
  • Elie Azoulay

DOI
https://doi.org/10.1186/s13054-019-2590-7
Journal volume & issue
Vol. 23, no. 1
pp. 1 – 10

Abstract

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Abstract Background Acute respiratory failure is the leading reason for intensive care unit (ICU) admission in immunocompromised patients, and the need for invasive mechanical ventilation has become a major clinical endpoint in randomized controlled trials (RCTs). However, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. This study explores how this outcome varies across ICUs. Methods Hierarchical models and permutation procedures for testing multiple random effects were applied on both data from an observational cohort (the TRIAL-OH study: 703 patients, 17 ICUs) and a randomized controlled trial (the HIGH trial: 776 patients, 31 ICUs) to characterize ICU variation in intubation risk across centers. Results The crude intubation rate varied across ICUs from 29 to 80% in the observational cohort and from 0 to 86% in the RCT. This center effect on the mean ICU intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p value = 0.013, median OR 1.48 [1.30–1.72]; RCT: p value 0.004, median OR 1.51 [1.36–1.68]). Two ICU-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to ICU admission) and could partly explain this center effect. In the RCT that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation. Conclusion Intubation rates varied considerably among ICUs, even after adjustment on individual characteristics.

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