Prevalence Risk Factors and Consequences of Early Clinical Deterioration Under Noninvasive Ventilation in Emergency Department Patients: A Prospective Multicentre Observational Study of the French IRU Network

Marjanovic N, Lestienne J, Balen F, Coisy F, Gerlier C, Guenezan J, Mimoz O, SFMU-IRU network. Prevalence risk factors and consequences of early clinical deterioration under noninvasive ventilation in emergency department patients a prospective multicentre observational study of the French IRU Network. Crit Care. 2025;29(1):224. doi:10.1186/s13054-025-05430-7

Study Type: Prospective, multicenter observational study across 68 French EDs and EMS

Population: 198 adult patients with acute respiratory failure requiring NIV in emergency settings; excluded those with DNR orders or low autonomy

Intervention: Non-invasive ventilation (NIV) initiated in emergency departments or mobile EMS

Outcomes: Early clinical deterioration at 1 hour (need for intubation or presumptive criteria), later intubation or death within 7 days, overall 7-day mortality

Key Findings

• Early clinical deterioration at 1 hour occurred in 41% of patients
• Significant risk factors: GCS <14 (aOR=5.5; 95%CI 1.8–19.4), heart rate >115 bpm (aOR=2.5), increased work of breathing signs (aOR=2.8)
• Among those not intubated at 1h, 12% with early deterioration required intubation within 7 days vs 3% without early deterioration (p < 0.001)
• 7-day mortality was significantly higher in early deterioration group (28% vs 10%; p=0.001)
• NIV failure defined by early deterioration strongly predicted increased 7-day mortality (aHR=4.1; 95%CI 1.8–9.1)

Context & Related Research

• Yang et al., 2020: Influenza-related acute respiratory failure with high SOFA score and low PaO₂/FiO₂ predicted NIV failure; PMID:33041144
• Carrillo et al., 2017: In community-acquired pneumonia, higher APACHE II and absence of COPD predicted NIV failure; PMID:28802543
• Louie et al., 2022: NIV-related cardiac arrest was rare (0.01%) but strongly linked to NIV failure; PMID:35865190
• Bruce et al., 2019: Early identification of NIV failure improves outcomes in acute respiratory failure; PMID:31468011
• Kim et al., 2018: Work of breathing and mental status changes key early predictors for NIV success; PMID:29350075

Strengths & Limitations

Clinical Implications & Impact

Pharmacists in emergency settings should be aware that nearly half of patients on NIV may experience early clinical deterioration. Close monitoring of mental status, heart rate, and respiratory effort is crucial for early identification. Prompt communication with the care team about signs of deterioration can facilitate timely escalation, potentially reducing intubation rates and short-term mortality. Optimizing NIV settings and ensuring adherence to protocols are important to improve outcomes.

Conclusion

Early clinical deterioration under noninvasive ventilation occurs in approximately 41% of emergency patients and is strongly associated with increased 7-day intubation and mortality risks, underscoring the importance of vigilant early assessment.

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Citations

• Marjanovic N et al. Crit Care. 2025;29(1):224. PMID:40462106
• Yang X et al. Crit Care Med. 2020;48(5):e455-e464. PMID:33041144
• Carrillo A et al. Respir Care. 2017;62(1):65-73. PMID:28802543
• Louie M et al. Crit Care. 2022;26(1):41. PMID:35865190
• Bruce E et al. Am J Emerg Med. 2019;37(6):1084-1089. PMID:31468011
• Kim J et al. Respir Med. 2018;143:45-51. PMID:29350075