Thresholds for Initiating Invasive Ventilation in Hypoxemic Respiratory Failure
Bibliographic record
Abstract
Background: Invasive ventilation is a potentially life-saving intervention for people with severe hypoxemic respiratory failure, however the optimal thresholds for its initiation are unknown. Objectives: In people with hypoxemic respiratory failure, (1) measure the probability of invasive ventilation after meeting physiologic thresholds, (2) compare 28-day survival associated with lower versus higher hypoxemia severity thresholds for initiating invasive ventilation, and (3) estimate costs, quality-adjusted life-years, and the value of a randomized controlled trial for different thresholds used to initiate invasive ventilation. Methods: We studied people from the Medical Information Mart for Intensive Care version IV (MIMIC-IV) and Amsterdam University Medical Centres databases who were receiving an inspired oxygen fraction of 0.4 or more via non-rebreather mask, high flow nasal cannula, or noninvasive ventilation. We used thresholds based on prior research, Gaussian processes for imputation, G-computation for causal inference, and Monte Carlo simulation for health economic modelling. Results: We studied 4,726 patients. Invasive ventilation occurred in 28% (1,320). The probability of invasive ventilation within 3 hours of meeting physiologic thresholds was consistently 25% or less, even for severe thresholds such as a saturation-to-inspired oxygen fraction ratio (SF) of less than 90. In the MIMIC-IV cohort, for invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%), compared to SF < 98 (absolute riskincrease 1.6%) or SF < 88 (absolute risk increase 3.5%). A threshold of SF < 110, compared to usual care, resulted in more quality-adjusted life years (8.48 vs 8.34) and lifetime costs (86,700 Canadian dollars (CAD) vs 75,600 CAD). The expected value to Canadian society over the next 10 years of a 400-person randomized trial was at least 2.64 billion CAD. Conclusion: For people with hypoxemic respiratory failure, there is variation in the physiologic states that prompt invasive ventilation and the predicted mortality that results from different initiation thresholds. The estimated value to society of a corresponding randomized trial is large.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.010 | 0.052 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".