We read with interest the recent article by Schortgen and Download full-text
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