Factors Associated With Mechanical Ventilation in Patients Hospitalized With Hepatic Encephalopathy: A Nationwide Inpatient Sample Analysis.

Background Hepatic encephalopathy (HE) is a debilitating and potentially fatal complication of advanced liver disease. While most patients with HE improve with medical therapy, a significant subset requires mechanical ventilation, an escalation of care associated with higher mortality, prolonged hospitalization, and greater financial burden. Despite this clinical and economic burden, factors associated with mechanical ventilation and the outcomes of intubated HE patients remain poorly defined at a national level. We aimed to characterize both the risk factors for mechanical ventilation and the associated clinical outcomes among hospitalized patients with HE using a large, representative cohort. Methods We performed a retrospective cohort study using the National Inpatient Sample (NIS) from 2016 to 2020. Adult patients (≥18 years) hospitalized with HE were included and identified using International Classification of Diseases, 10th Revision (ICD-10) codes for cirrhosis with HE. Elective admissions and transfers from acute-care hospitals were excluded. Baseline characteristics and clinical outcomes were compared between patients requiring mechanical ventilation and those not intubated. Multivariable logistic regression was used to identify factors associated with mechanical ventilation. Results From 2016 to 2020, 572,600 HE hospitalizations were identified, with 9.1% (52,295) requiring mechanical ventilation. Ventilated patients were younger (57.9 vs. 60.3 years, p<0.001), more often male (61% vs. 58%) and Black (11% vs. 8.6%), and had higher rates of sepsis (50% vs. 12%), acute kidney injury (AKI) (64% vs. 35%), and gastrointestinal (GI) bleeding (28% vs. 16%) (p<0.001 for all). Mechanical ventilation was associated with higher mortality (43% vs. 4.7%; adjusted OR, 8.32; 95% CI, 7.84-8.83), longer length of stay (11.5 vs. 6.0 days; adjusted RR, 1.43; 95% CI, 1.40-1.47), and increased costs ($48,511 vs. $15,731; adjusted RR, 2.23; 95% CI, 2.18-2.28), all p<0.001. On multivariable analysis, the strongest factors associated with mechanical ventilation included sepsis (OR, 5.42; 95% CI, 5.17-5.67), AKI (OR, 2.35; 95% CI, 2.24-2.46), and GI bleeding (OR, 1.84; 95% CI, 1.75-1.94). Conclusion Nearly 1 in 10 hospitalized patients with HE required mechanical ventilation, which was associated with substantially higher in-hospital mortality and increased hospitalization costs. Sepsis, renal failure, and GI bleeding were the strongest factors associated with intubation. These findings suggest that mechanical ventilation likely reflects underlying disease severity rather than serving as an independent driver of mortality. These clinical features are associated with mechanical ventilation and may aid risk stratification in hospitalized patients with HE.