Non-invasive ventilation for respiratory failure in elderly patients
SIR—We have read with great interest the article by Balami et al. [1] and the related editorial by Connolly [2] recently published in Age and Ageing on the efficacy of non-invasive ventilation (NIV) for respiratory failure in elderly patients. Published data are very important because they support the possibility to transfer the results till now obtained in younger respiratory patients also in the larger segment of population needing hospitalisation due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD), i.e. elderly patients.
We like to contribute to this topic with observational data obtained in a recently developed medical sub-intensive care unit (SICU) for elderly patients. In a 24-bed geriatric ward following the acute care for elders (ACE) model of care [3], we have dedicated four beds to a SICU [4]. Our model is developed to meet the needs of critically ill elderly medical patients who do not require global intensive care but a higher level of care than that provided in a general ward. The technological equipment of the SICU (monitors for cardiac and respiratory function, non-invasive mechanical ventilators, peristaltic and volumetric pumps for i.v. therapy and enteral nutrition, etc.) allows non-invasive monitoring of vital signs and/or intensive interventions. From February 2003 to June 2005, 852 patients aged 
60 years were admitted to SICU. Non-invasive mechanical ventilation was commenced in 174 patients (20.4%). A decision to commence or exclude NIV treatment was taken by the intensivist physician in charge at our hospital emergency room according to British Thoracic Society criteria [5]. Of NIV patients, those with a hypercapnic respiratory failure due to AECOPD were 127.
The NIV was used as much as possible in the first 48 h after admission, and patients were subsequently weaned off according to clinical improvement and arterial blood gas results. Arterial blood gas tension and respiratory rate were measured before NIV and at 1 and every 4 h after NIV. Pulse rate, respiratory rate, blood pressure and oximetry were continuously monitored.
Bi-level pressure support ventilators (Respironics) were used with full-face masks. Initial ventilator pressure support was 10 cmH2O. Inspiratory pulmonary alveolar pressure (IPAP) was increased by 2 cmH2O increments during the first hour according to patient’s tolerance up to a maximum of 20 cmH2O and then subsequently according to clinical response, measurements of arterial blood gas and the patient’s ability to tolerate the NIV.
Characteristics of patients are described in Table 1. One hundred and fifteen patients (90.6%) were successfully initiated on and tolerated NIV because 12 patients (9.4%) failed to be initiated on NIV due to inability to tolerate the mask. No patient developed any severe complications from NIV except facial skin lesions (n = 14). Of the 115 patients who were initiated, NIV was successful in 90 patients (78.3%) as defined by clinical improvement (4 h after NIV pH was 7.39 + 0.1; PaCO2: 52 + 21 mmHg). The other 25 patients (21.7%) failed to meet the above criteria of improvement; of these, four (3.4%) were transferred to the ICU for endotracheal intubation and mechanical ventilation, and 21 (18.3%) were considered end stage. All 25 patients died in hospital. In particular, in elderly patients without disability and dementia (n = 24), mortality was 8.3% (n = 2), in those with disability but without dementia (n = 59), mortality was 25.9% (n = 15) and in those with disability and dementia (n = 32), mortality was 25% (n = 8).
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Our data support the Balami’s indications that NIV can be used in elderly patients admitted with hypercapnic respiratory failure secondary to AECOPD. The study reports a high treatment efficacy showing that NIV can be used as an alternative to endotracheal intubation and mechanical ventilation in an ICU in selected elderly patients with acute hypercapnic respiratory failure due to AECOPD. Even if mortality was higher in the more severe patients, we found that NIV is effective also in disabled as well as in disabled and demented patients, indicating that barriers generally considered for these procedures may be overwhelmed in a dedicated geriatric setting. Its tolerability, success rate and associated global mortality are comparable with those of younger patients [6]. As all patients transferred to the ICU died, we can infer that NIV may be used as a ceiling of treatment in severe old patients with hypercapnic respiratory failure due to AECOPD. In conclusion, on the basis of our data, we completely agree with the Connolly’s comment to Balami et al.’s article that we ‘should be considering and where appropriate pressing for NIV in our elderly acidotic patients hospitalised with AECOPD; that we should no longer be accepting that the evidence base is against us in our advocacy for these patients; that elderly patients generally tolerate NIV well; and that mortality, though high, is probably little or no worse than that in younger patients’ [2].
1 Medical Unit for the Acute Care of the Elderly, Poliambulanza Hospital, Via Bissolati 57, 25124 Brescia, Italy Fax: (+39) 030 48508; Email: renzo.rozzini{at}iol.it
2 Geriatric Research Group, Via Romanino 1, 25122 Brescia, Italy
* To whom correspondence should be addressed
References
- Balami JS, Packham SM, Gosney MA. Non-invasive ventilation (NIV) for respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease (COPD) in older patients. Age Ageing 2006; 35: 75–8.
[Free Full Text] - Connolly MJ. Non-invasive ventilation in elderly patients with acute exacerbations of COPD: bringing pressure to bear. Age Ageing 2006; 35: 1–2.
[Free Full Text] - Landefeld CS, Palmer RM, Kresevic DM et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995; 332: 1338–44.
[Abstract/Free Full Text] - Rozzini R, Sabatini T, Trabucchi M. A silent ageism in access to critical care. Age Ageing 2004; 33: 517.
- British Thoracic Society Standards of Care Committee. Noninvasive ventilation in acute respiratory failure. Thorax 2002; 57: 192–211.
[Free Full Text] - Lightowler JV, Wedzicha JA, Elliott MW, Ram FSF. Noninvasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systemic review and meta-analysis. BMJ 2003; 326: 185.
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