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NIPPV and Lower Mortality in Severe Asthma

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Written by Samuel Rouleau

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This retrospective, propensity-matched study of adult and pediatric patients with severe asthma confirms what we already know clinically: non-invasive positive pressure ventilation (NIPPV) decreases mortality and need for intubation.

A little PEEP never hurt nobody
Firsthand, we all know the benefits of using NIPPV for patients with severe asthma. Compared to COPD and pulmonary edema, the evidence investigating the benefits of NIPPV for asthma is limited. This study was a retrospective, propensity-matched analysis of statewide administrative databases from New York and Florida from 2006–2019. Out of 205,510 adult patients hospitalized with asthma, there were 1,972 ICU patients who received NIPPV. Out of 92,278 pediatric (ages 5–17) patients hospitalized for asthma, there were 1,622 pediatric ICU patients who received NIPPV.

On propensity-matched analysis (1:4), NIPPV use in adults and pediatrics was associated with lower rate of endotracheal intubation, 15.1% vs. 29.2% (RR 0.48, 95%CI 0.40–0.57) and 2.4% vs. 4.7% (RR 0.50, 95%CI 0.29–0.89), respectively. NIPPV use in adults was associated with lower mortality, 1.2% vs. 3.1% (RR 0.34, 95%CI, 0.21–0.54). For pediatrics, NIPPV was not statistically significant in regard to in-hospital mortality, but the overall mortality rate was already low at 0.5%, making it more difficult to show a statistical difference, 0.2% vs. 0.5% (RR 0.41, 95%CI 0.15–1.11).

How will this change my practice?
This study affirms that using NIPPV for critically ill patients with asthma improves outcomes and lowers risk of progressing to intubation.

Editors Note: I would temper these conclusions a bit. NPPV was associated with (not necessarily the cause of) less intubations and improved mortality rates. Despite a 5-fold increase in the use of NPPV there has been no change in the mortality rate due to asthma. ~ Nick Zelt

Source 
Association Between Noninvasive Positive Pressure Ventilation Use and Clinical Outcomes During a Severe Asthma Exacerbation: A Cohort Study. Crit Care Med. 2026 Jan 14. doi: 10.1097/CCM.0000000000007025. Epub ahead of print. PMID: 41532815.

View JournalFeed Critical Appraisal

Critical Appraisal

Study Identification

Title: Association Between Noninvasive Positive Pressure Ventilation Use and Clinical Outcomes During a Severe Asthma Exacerbation: A Cohort Study
Authors: Matthew R. Abbott, Kayla P. Carpenter, Samrah Razi, Charles W. Goss, Joanna Buss, Matthew Keller, Patrick G. Lyons, Mario Castro, James G. Krings
Journal: Critical care medicine
Year: 2026
DOI: 10.1097/CCM.0000000000007025
Trial Registration: Not reported
Country / Region: United States
Setting: Inpatient hospitalizations in New York and Florida

Background

Asthma exacerbations can lead to severe respiratory failure requiring intubation. NPPV is used in other respiratory conditions but its role in asthma is unclear.

Study Question

Does NPPV decrease the risk of subsequent endotracheal intubation and in-hospital mortality among patients admitted to the ICU for an asthma exacerbation?

Study Design & Conduct

Study Design: Retrospective, propensity-score–matched cohort study
Prospective / Retrospective: Retrospective
Multicenter: Yes
Unit of Allocation: Not applicable
Unit of Analysis: Patients
Randomization Method: Not applicable
Allocation Concealment: Not applicable
Blinding: Not applicable
Follow-up Duration: In-hospital

Population

Inclusion Criteria:
  • Patients 5–80 years old
  • Hospitalized with an asthma exacerbation
Exclusion Criteria:
  • Concomitant diagnoses of COPD, neuromuscular disease, obstructive sleep apnea, or asthma COPD overlap
Number Screened: 75,567,518
Number Enrolled: 296,788
Number Analyzed: 296,788
Key Baseline Characteristics
Age: 18–80 years for adults, 5–17 years for pediatrics
Sex: Varied by group
Disease Severity: Not reported
Care Setting Distribution: ICU admissions
Additional Baseline Characteristics
  • Race/ethnicity
  • Primary insurance/payor
  • Hospital characteristics

Exposures / Interventions

Primary Exposure / Intervention
Description: Noninvasive positive pressure ventilation (NPPV)
Definition / Dose: Not applicable
Timing: During ICU stay
Classification Method: ICD codes
Protocolized / Discretionary: Not reported
Comparator / Reference
Description: No NPPV
Definition: Patients not receiving NPPV

Outcomes & Results

Primary Outcomes
Endotracheal intubation
Definition: Receipt of endotracheal intubation
Time Point: In-hospital
Measurement Method: ICD codes
Results: Adults: RR 0.48 (95% CI, 0.40–0.57); Pediatrics: RR 0.50 (95% CI, 0.29–0.89)
In-hospital mortality
Definition: In-hospital mortality
Time Point: In-hospital
Measurement Method: Discharge status codes
Results: Adults: RR 0.33 (95% CI, 0.21–0.54); Pediatrics: RR 0.41 (95% CI, 0.15–1.11)
Secondary Outcomes

Risk of Bias

Risk of Bias - ROBINS-I
  • Bias due to confounding (Some concerns): Propensity-score matching was used, but residual confounding cannot be ruled out.
  • Bias in selection of participants (Low): Clear inclusion criteria and large sample size.
  • Bias in classification of interventions (Low): Interventions were clearly defined using ICD codes.
  • Bias due to deviations from intended interventions (Low): No deviations reported.
  • Bias due to missing data (Low): Missing data was minimal and addressed appropriately.
  • Bias in measurement of outcomes (Low): Outcomes were clearly defined and measured using standard methods.
  • Bias in selection of the reported result (Low): All relevant outcomes were reported.
Transparency
Funding Disclosed: TRUE
COI Statement Present: TRUE
This critical appraisal is generated using a structured framework applied to the full text of the original article and is presented separately from the physician’s commentary.

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