Outcomes of Noninvasive Positive Pressure Ventilation in Acute Respiratory Distress Syndrome and Their Predictors: A National Cohort.

RATIONALE: Although noninvasive positive pressure ventilation (NIPPV) is increasingly used in acute respiratory distress syndrome (ARDS) to avoid invasive mechanical ventilation (IMV), the data supporting its benefit for this indication are lacking. OBJECTIVES: To analyze the all-cause in-hospital mortality rate and length of stay (LOS) for ARDS patients who received NIPPV in the United States (US) compared to those who were initially intubated. Our secondary outcome of interest was to determine the predicting factors for NIPPV failure. METHODS: We used the 2016 National Inpatient Sample database to identify 4,277 adult records with ARDS who required positive pressure ventilation. We divided the cohort into initial treatment with IMV or NIPPV. Then, the NIPPV group was further subdivided into NIPPV failure or success. We defined NIPPV failure as same-patient use of NIPPV and IMV either on the same day or using IMV at a later date. We analyzed the in-hospital mortality, LOS, and NIPPV failure rate. Linear regression of log-transformed LOS and logistic regression of binary outcomes were used to test for associations. RESULTS: The NIPPV success group had the lowest mortality rate (4.9% [3.8, 6.4]) and the shortest LOS (7 days [6.6, 7.5]). The NIPPV failure rate was 21%. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure (adjusted OR: 4.47, 2.65, and 2.23, respectively). There was no significant difference between NIPPV failure and IMV groups in-hospital mortality (26.9% [21.8, 32.8] vs. 25.1% [23.5, 26.9], p=0.885) or LOS (16 [14, 18] vs. 15.6 [15, 16.3], p=0.926). CONCLUSIONS: NIPPV success in ARDS exhibits significantly lower hospital mortality rates and shorter LOS compared with IMV, and NIPPV failure exhibits no significant difference in hospital mortality or LOS compared with patients who were initially intubated. Therefore, an initial trial of NIPPV may be considered in ARDS. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure; these factors should be used to stratify patients to the most suitable ventilation modality.

Kidney disease in the obese patient.

Obesity constitutes a strong risk factor for the development of chronic kidney disease. This review examines the epidemiology, clinicopathologic presentation, and proposed mechanisms for chronic kidney disease in the obese patient. Obesity-associated nephropathy displays a continuum that evolves from glomerulomegaly to glomerulosclerosis and from mild to severe proteinuria in the absence of significant edema and hypoalbuminemia. The disease may well progress into end-stage renal disease unless weight management strategies are used. The renal effects of different obesity treatments are reviewed. Interestingly, the reversibility of the disease throughout most of its stages highlights the benefit of weight loss strategies in this population. Nephrolithiasis as it relates to obesity also is examined in addition to other pertinent comorbidities in obesity such as incontinence, calciphylaxis, and the renal complications of bariatric procedures.

Combined false hyperkalemia and hypocalcemia due to specimen contamination during routine phlebotomy.

Combined pseudohyperkalemia and pseudohypocalcemia have not been previously reported in the clinical setting. We report 2 cases in which specimen contamination during routine phlebotomy with ethylenediaminetetraacetic acid (EDTA) caused alteration in serum levels of potassium and calcium. This alteration could be misleading when making clinical decisions and could produce adverse patient outcomes.