Invasive ventilation used less among Asian, Black, Hispanic patients

David Hill, MD

The findings of this study are significant. This is a large retrospective review of more than 38,000 critically ill patients revealing that Asian, Black and Hispanic patients received lower rates of invasive mechanical ventilation than white patients. However, short-term outcomes, most notably 28-day mortality, were not impacted by this difference. This could be due to harmful effects of invasive ventilation, so one outstanding question is, do the differences in invasive ventilation rates equate to undertreatment of non-white patients or overtreatment of white patients?

The reasons for the varying rates of mechanical ventilation between these patient groups need further exploration. Prior literature suggests that non-white populations are less likely to have advanced care directives (do not resuscitate and do not intubate orders) and are more likely to receive aggressive end-of-life care than white patients, so lower rates of invasive mechanical ventilation are a surprising finding in the non-white population. Systemic racism and implicit bias are an embedded feature in our society and the health care system is not immune to the effects of racism, so further investigation regarding whether the disparity in care illustrated in this study results from racism or implicit bias is of importance.

It is difficult to relate the findings in this study to my own personal experience. My own ICU patient population is predominantly white and Hispanic with a lower proportion of Black patients and very few Asian or South Asian patients. Identifying variation in intubation rates in my own patients would require statistical analysis and would be a much smaller sample size than that in this study. The decision to intubate a patient and provide mechanical ventilation is dependent on both patient/guardian desires and clinical judgment of the care team. There is a great deal of this decision process that remains an art form even in 2024.

The findings of this study can be utilized to help identify sources of bias or differing care that may be based on racial or socioeconomic bias along with cultural differences in approach to care that might be amenable to interventions that could improve outcomes. Awareness of implicit bias and its impact on decision-making is important for all health care providers.

Further study of disparate care of critically ill patients based on race or socioeconomic status is needed. Some of our standard measurements, such as pulse oximetry, are designed for white populations and errors based on misreading or misinterpretation of data could affect care and outcomes. Additional studies designed to evaluate disparities in care based on race or other socio-economic factors are an ongoing need. The field of critical care is constantly changing. This study, which looked at patient populations in the mid-2010s, predates the widespread use of high-flow nasal cannula and the COVID-19 pandemic, which have led to various changes in the delivery of critical care, oxygen supplementation and use of mechanical ventilation.