Noninvasive mechanical ventilation for very old patients with limitations of care: is the ICU the most appropriate setting?
- SourceAvailable from: Marco Confalonieri[show abstract] [hide abstract]
ABSTRACT: The imbalance between the increasing prevalence of acutely decompensated respiratory diseases and the shortage of intensive care unit beds has stimulated the growth of respiratory high-dependence care units (RHDCUs). We conducted a national survey to analyze the changes, in the past 10 years, in the number, structures, staff, procedures, diagnoses, and outcomes in Italian RHDCUs that satisfy the European Respiratory Society's criteria (modified according to the Italian Association of Hospital Pneumologists) for high level (respiratory intensive care unit), intermediate level (respiratory intermediate intensive care unit), and low level (respiratory monitoring unit) RHDCU care. The number of RHDCUs increased from 26 to 44. The relative prevalence among all the RHDCUs increased only for the low-level units (P = .03). Compared to 1997, in 2007 a higher percentage of Italian RHDCUs were located within respiratory wards than located outside of respiratory wards (P = .03), and the physician-to-patient mean ratio and the nurse-to-patient mean ratio per shift were lower (P = .001 and P = .002, respectively). Admissions for only monitoring decreased (P < .001), and admissions for active interventions increased: noninvasive ventilation (P = .002), invasive ventilation (P < .001), weaning from invasive ventilation (P < .001), and tracheal decannulation (P < .001). The complexity of RHDCU patients' conditions increased: there was a reduction in the percentage of COPD patients (P < .001) and an increase in the percentage of patients with neuromyopathies (P < .001) and de novo hypoxemia (P = .006). Between 1997 and 2007 there was an increase in the number and expertise of Italian RHDCUs, with a shift toward less expensive care, and greater complexity of interventions and patient dysfunctions. These findings support the crucial role of RHDCUs in the management of respiratory critical patients.Respiratory care 04/2011; 56(8):1100-7. · 2.03 Impact Factor
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ABSTRACT: Noninvasive ventilation (NIV) is frequently used for the management of acute respiratory failure (ARF) in very old patients (≥ 80 years), often in the context of a do-not-intubate order (DNI). We aimed to determine its efficacy and long-term outcome. Prospective cohort of all patients admitted to the medical ICU of a tertiary hospital during a 2-year period and managed using NIV. Characteristics of patients, context of NIV, and treatment intensity were compared for very old and younger patients. Six-month survival and functional status were assessed in very old patients. During the study period, 1,019 patients needed ventilatory support and 376 (37%) received NIV. Among them, 163 (16%) very old patients received ventilatory support with 60% of them managed using NIV compared with 32% of younger patients (p < 0.0001). Very old patients received NIV more frequently with DNI than in younger patients (40% vs. 8%). Such cases were associated with high mortality for both very old and younger patients. Hospital mortality was higher in very old than in younger patients but did not differ when NIV was used for cardiogenic pulmonary edema or acute-on-chronic respiratory failure (20% vs. 15%) and in postextubation (15% vs. 17%) out of a context of DNI. Six-month mortality was 51% in very old patients, 67% for DNI patients, and 77% in case of NIV failure and endotracheal intubation. Of the 30 hospital survivors, 22 lived at home and 13 remained independent for activities of daily living. Very old patients managed using NIV have an overall satisfactory 6-month survival and functional status, except for endotracheal intubation after NIV failure.Annals of intensive care. 02/2012; 2(1):5.
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ABSTRACT: For patients with acute respiratory failure who have declined intubation and resuscitation or have chosen comfort measures only, noninvasive ventilation (NIV) may help them achieve important health or personal goals, or merely prolong the dying process. To determine clinicians' attitudes to and stated use of NIV for these patients. We developed an instrument to assess the attitudes of intensivists, pulmonologists, and respiratory therapists (RTs) toward the use of NIV for patients with acute respiratory failure near or at the end of life. After assessing its psychometric properties, we mailed the survey to these clinicians at 18 Canadian and two U.S. hospitals. We analyzed factors associated with stated use of NIV for do-not-resuscitate and comfort-measures-only patients. Overall, 104 of 183 (57%) physicians and 290 of 473 (61%) RTs participated. Two thirds of physicians include NIV during life support discussions with do-not-resuscitate patients at least sometimes, and 87% of RTs stated that NIV should be included in such discussions. For patients choosing comfort measures only, almost half of physicians reported including NIV as an option in their discussions at least sometimes, while fewer than half of RTs stated that these discussions should be conducted. Most (>80%) physicians use NIV and most (>80%) RTs are asked to initiate NIV for do-not-resuscitate patients with chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Fewer clinicians report using NIV for do-not-resuscitate patients with underlying malignancy (59% of physicians, 69% of RTs) or for patients choosing comfort measures only (40% of physicians, 51% of RTs; p < .001). For patients with do-not-resuscitate orders, many physicians use NIV, and many RTs are asked to initiate NIV, most often to treat chronic obstructive pulmonary disease and cardiogenic pulmonary edema. Further study is needed on the goals of NIV near the end of life, whether these goals are understood by all stakeholders, and how well they are achieved in practice.Critical care medicine 04/2008; 36(3):789-94. · 6.37 Impact Factor
We read with interest the recent article by Schortgen and
colleagues , who emphasized the role of noninvasive
ventilation (NIV) as a ‘ceiling’ ventilatory treatment
within the ‘do-not-intubate (DNI) context’, which turns
out to be the largest indication in octogenarians given
their high risk of developing life-threatening compli-
cations during invasive ventilation. As underlined by the
authors, NIV may be considered a valid option in a wide
range of ‘DNI-linked’ clinical scenarios, ranging from life
support to a purely palliative tool .
Bearing this scenario in mind, we wonder whether the
intensive care unit (ICU) is the best setting for NIV in
‘older elderly DNI patients’ [2,3]. While the use of NIV in
patients with acute respiratory failure without preset
limitations on life-sustaining treatment may be
implemented in diff erent settings (ICUs, respiratory
ICUs (RICUs), and emergency rooms), depending on the
typology of acute syndrome and the likelihood of success,
the ideal care for ‘DNI patients’ is likely to be more
appropriate outside the ICU . In fact, for these patients
for whom endotracheal intubation is question able or care
is centered largely on symptom palliation or both, NIV
failure requires the intensifi cation of comfort measures
only, adequately performed in totally or partially ‘open’
environments [2,3]. Th e option of NIV in end-of-life
decisions is emerging in European RICUs, where a large
majority of DNI patients are treated by pulmonologists
. Th is is not surprising, as RICUs diff er substantially
from ICUs in terms of patient population, staffi ng,
monitor ing, and use of NIV as the preferred ventilatory
approach . Furthermore, a recent American survey
showed that the stated use of NIV and the confi dence in
its utility in end-of-life patients were greater for pulmo-
nologists than for intensivists . A pulmonologist’s
point of view may be infl uenced by caring for end-stage
respiratory patients over the entire spectrum of their
illness as opposed to the greater focus on acute care
In conclusion, the assignment of ‘older elderly DNI
patients’ to an environment, such as the ICU, that was
originally designed to treat patients without preset
limitations of care (that is, invasive mechanical
ventilation) raises fi nancial and ethical concerns, namely
(a) the questionable cost-utility ratio of allocating the
precious limited ICU resources for patients whose needs
may be met by lower levels of care (that is, nurse work-
load) and (b) the inappropriateness of a ‘close environ-
ment’ for managing respiratory patients who would like
to spend the end of their lives near their friends and family.
Hospital administrators should identify, in expert pulmo-
nology units, the optimal setting for implementing NIV
within the ‘DNI and end-of-life context’ to achieve econo-
mic and ethical benefi ts that surpass those of the ICU.
DNI, do-not-intubate; ICU, intensive care unit; NIV, noninvasive ventilation;
RICU, respiratory intensive care unit.
The authors declare that they have no competing interests.
1Respiratory Ward and Respiratory Intensive Care Unit, S. Donato Hospital,
ASL 8 Arezzo, Via Nenni 20, 52100 Arezzo, Italy. 2Intensive Care Unit, Hospital
Morales Meseguer, Avenida Marqués de Los Velez s/n, 30500, Murcia, Spain.
Published: 7 June 2012
1. Schortgen F, Follin A, Piccari L, Roche-Campo F, Carteaux G, Taillandier-
Heriche E, Krypciak S, Thille AW, Paillaud E, Brochard L: Results of noninvasive
ventilation in very old patients. Ann Intensive Care 2012, 2:5.
2. Scala R, Nava S: NIV and palliative care. Eur Respir Mon 2008, 41:287-306.
3. Nava S, Sturani C, Hartl S, Magni G, Ciontu M, Corrado A, Simonds A;
European Respiratory Society Task Force on Ethics and decision-making in
end stage lung disease: End-of-life decision-making in respiratory
intermediate care units: a European survey. Eur Respir J 2007, 30:156-164.
4. Scala R, Corrado A, Confalonieri, Marchese S, Ambrosino N: Increased
number and expertise of Italian Respiratory High-Dependency Care Units:
the second national survey. Respir Care 2011, 56:1100-1107.
5. Sinuff T, Cook DJ, Keenan SP, Burns KE, Adhikari NK, Rocker GM, Mehta S,
Kacmarek R, Eva K, Hill NS: Noninvasive ventilation for acute respiratory
failure near the end of life. Crit Care Med 2008, 36:789-794.
© 2010 BioMed Central Ltd
Noninvasive mechanical ventilation for very old
patients with limitations of care: is the ICU the
most appropriate setting?
Raff aele Scala*1 and Antonio Esquinas2
*Correspondence: raff firstname.lastname@example.org
1Respiratory Ward and Respiratory Intensive Care Unit, S. Donato Hospital, ASL 8
Arezzo, Via Nenni 20, 52100 Arezzo, Italy
Full list of author information is available at the end of the article
Cite this article as: Scala R, Esquinas A: Noninvasive mechanical ventilation
for very old patients with limitations of care: is the ICU the most
appropriate setting? Critical Care 2012, 16:429.
Scala and Esquinas Critical Care 2012, 16:429
© 2012 BioMed Central Ltd