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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2023. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Schönhofer B, Barchfeld T, Geiseler J, Heppner HJ. [Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age]. Pneumologie 2021; 75:142-155. [PMID: 33578435 DOI: 10.1055/a-1201-9007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.
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Heili-Frades S, Minguez P, Mahillo Fernández I, Jiménez Hiscock L, Santos A, Heili Frades D, Carballosa de Miguel MDP, Fernández Ormaechea I, Álvarez Suárez L, Naya Prieto A, González Mangado N, Peces-Barba Romero G. Patient Management Assisted by a Neural Network Reduces Mortality in an Intermediate Care Unit. Arch Bronconeumol 2020; 56:564-570. [DOI: 10.1016/j.arbres.2019.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/24/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
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Pulliam KE, Pritts TA. Non-Invasive Ventilatory Support In the Elderly. CURRENT GERIATRICS REPORTS 2019; 8:153-159. [PMID: 32509503 PMCID: PMC7274080 DOI: 10.1007/s13670-019-00287-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The first description of non-invasive ventilation use began in the 1920s. Since then, its role in patient care has evolved through increased clinical knowledge and scientific advancements. The utilization of non-invasive ventilation has broadened from initial application in acute in-hospital ICU settings to now include the outpatient settings. This review discusses the history of non-invasive ventilation and its role in acute in-hospital chronic obstructive pulmonary disease (COPD) exacerbations, cardiogenic pulmonary edema, and weaning from mechanical ventilation in the elderly. The elderly population represents a significant portion of patients hospitalized for the aforementioned conditions. These groups often have more limitations related to the use of invasive mechanical ventilation (IMV), therefore, it is essential to understand the impact of non-invasive ventilation on hospital outcomes. RECENT FINDINGS There is strong clinical evidence supporting the use of non-invasive ventilation in patients with respiratory failure secondary to acute COPD exacerbations and cardiogenic pulmonary edema. When compared to standard medical management of these conditions, there is a consistent and significant reduction in the rate of endotracheal intubation and in-hospital mortality. SUMMARY The basis of noninvasive ventilation applicability has been determined by significant reduction in mortality and intubation rates. Although survival benefits have been observed, there still remain limitations to the clinical applicability of non-invasive ventilation in certain patient populations and conditions that require further investigation.
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Affiliation(s)
- Kasiemobi E Pulliam
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, Ohio 45267-0558
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, Ohio 45267-0558
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Diaz de Teran T, Barbagelata E, Cilloniz C, Nicolini A, Perazzo T, Perren A, Ocak Serin S, Scharffenberg M, Fiorentino G, Zaccagnini M, Khatib MI, Papadakos P, Rezaul Karim HM, Solidoro P, Esquinas A. Non-invasive ventilation in palliative care: a systematic review. Minerva Med 2019; 110:555-563. [PMID: 31359741 DOI: 10.23736/s0026-4806.19.06273-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION An ageing population and steady increase in the rates of neoplasms and chronic degenerative diseases poses a challenge for societies and their healthcare systems. Because of the recent and continued advances in therapies, such as the development and widespread use of non-invasive ventilation (NIV), survival rates have increased for these pathologies. For patients with end-stage chronic respiratory diseases, the use of NIV following the onset of acute or severe chronic respiratory failure is a valid option when intubation has been excluded. EVIDENCE ACQUISITION The following electronic databases were searched from their inception to January 2000 to December 2017: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), the Cochrane Database of Systematic Reviews, ACP Journal Club database. EVIDENCE SYNTHESIS The available evidence strongly supports the use of NIV in patients presenting with an exacerbation of chronic obstructive pulmonary disease, as well end-stage neuromuscular disease. Few studies support the use of NIV in end-stage interstitial lung disease and in morbid obesity patients. In patients with cancer has been recommend offering NIV as palliative care to improve dyspnea. CONCLUSIONS The decision regarding the treatment should be made by the patient, ideally before reaching the terminal stage and after having a frank dialogue with healthcare professionals and family members.
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Affiliation(s)
- Teresa Diaz de Teran
- Unit of Sleep and Non-Invasive Ventilation, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Elena Barbagelata
- Department of Internal Medicine, General Hospital of Sestri Levante, Sestri Levante, Genoa, Italy
| | - Catia Cilloniz
- Department of Pneumology, Clinical Institute of Thoracic Surgery, August Pi i Sunyer Institute of Biomedical Research (IDIBAPS), Hospital Clínic, Barcelona, University of Barcelona (UB), Barcelona, Spain.,Unit SGR 911, Center for Biomedical Network Research for Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antonello Nicolini
- Department of Respiratory Diseases, General Hospital of Sestri Levante, Sestri Levante, Genoa, Italy -
| | - Tommaso Perazzo
- Department of Respiratory Diseases, General Hospital of Sestri Levante, Sestri Levante, Genoa, Italy
| | - Andreas Perren
- Department of Intensive Care, Regional Hospital of Bellinzona, Bellinzona, Switzerland
| | - Sibel Ocak Serin
- University of Health Science, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Martin Scharffenberg
- Department of Anesthesiology and Critical Care Medicine, Carl Gustav Carus Faculty of Medicine, Technical University of Dresden, Dresden, Germany
| | - Giuseppe Fiorentino
- Unit of Respiratory Pathophysiology, Diseases, and Rehabilitation, Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Marco Zaccagnini
- Department of Anesthesia and Critical Care, McGill University Health Center, Montreal, QC, Canada
| | - Mohamad I Khatib
- Department of Anesthesiology, School of Medicine, American University of Beirut, Beirut, Lebanon
| | - Peter Papadakos
- Department of Anesthesiology, University of Rochester, Rochester, NY, USA
| | - Habib M Rezaul Karim
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, India
| | - Paolo Solidoro
- Unit of Pneumology U, Department of Cardiovascular and Thoracic Surgery, Molinette Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Antonio Esquinas
- Unit of Intensive Care, Morales Meseguer Hospital, Murcia, Spain
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Todd A, Blackley S, Burton JK, Stott DJ, Ely EW, Tieges Z, MacLullich AMJ, Shenkin SD. Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis. BMC Geriatr 2017; 17:283. [PMID: 29216846 PMCID: PMC5721682 DOI: 10.1186/s12877-017-0661-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/09/2017] [Indexed: 12/20/2022] Open
Abstract
Background Reduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality. Methods We conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model. Results From 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias). Conclusions Reduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium. Electronic supplementary material The online version of this article (10.1186/s12877-017-0661-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Todd
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Samantha Blackley
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Jennifer K Burton
- Alzheimer Scotland Dementia Research Centre, Edinburgh, Scotland.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences University of Glasgow, Glasgow, Scotland
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education and Clinical Centre (GRECC), Nashville, TN, USA.,Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Zoë Tieges
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Alasdair M J MacLullich
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Susan D Shenkin
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland. .,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland.
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Vallet H, Riou B, Boddaert J. [Elderly patients and intensive care: Systematic review and geriatrician's point of view]. Rev Med Interne 2017; 38:760-765. [PMID: 28215925 DOI: 10.1016/j.revmed.2017.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 11/29/2022]
Abstract
The global population is aging and intensive care unit admission rate of elderly patients is dramatically increasing. The objective of this review is to provide an overview of the literature about the management of elderly patients in intensive care unit and more specifically about epidemiology, admission criteria, mortality, functional prognosis and ethical aspects. We also discuss the data on cardiorespiratory arrest, shock, acute respiratory failure and delirium. The mortality rate of patients over 80 years old in intensive care unit can reach up to 70% at 1year, but is dependent on many factors, such as comorbidities or frailty. Above all, more than half of elderly patients recover their long-term autonomy. Their quality of life is comparable to that of the same age population. Considering that the first 3months after an intensive care unit stay are the most decisive in terms of vital and functional prognosis, we will discuss strategies to improve care through the creation of dedicated intensive care-geriatrics networks.
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Affiliation(s)
- H Vallet
- Unité périopératoire gériatrique, service de gériatrie, hôpitaux universitaires Pitié-Salpêtrière-Charles-Foix, DHU FAST, AP-HP, Paris, France; UMR Inserm 1135, Sorbonne universités, UPMC université Paris 6, Paris, France.
| | - B Riou
- UMR Inserm 1166, IHU ICAN, Sorbonne universités, UPMC université Paris 6, Paris, France; Service d'accueil des urgences, hôpitaux universitaires Pitié-Salpêtrière-Charles-Foix, DHU FAST, AP-HP, Paris, France
| | - J Boddaert
- Unité périopératoire gériatrique, service de gériatrie, hôpitaux universitaires Pitié-Salpêtrière-Charles-Foix, DHU FAST, AP-HP, Paris, France; UMR Inserm 1166, UMR CNRS 8256, Sorbonne universités, UPMC université Paris 6, Paris, France
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Piroddi IMG, Barlascini C, Esquinas A, Braido F, Banfi P, Nicolini A. Non-invasive mechanical ventilation in elderly patients: A narrative review. Geriatr Gerontol Int 2016; 17:689-696. [PMID: 27215767 DOI: 10.1111/ggi.12810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/17/2016] [Accepted: 03/25/2016] [Indexed: 10/21/2022]
Abstract
The treatment of acute respiratory failure with non-invasive ventilation (NIV) as a first-line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of "do not intubate" orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689-696.
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Affiliation(s)
| | - Cornelius Barlascini
- Hygiene and Health Medicine Unit Hospital of Sestri Levante, Sestri Levante, Italy
| | | | - Fulvio Braido
- Allergy and Respiratory Diseases Unit Department IRCSS AOU San Martino- IST, Genova, Italy
| | - Paolo Banfi
- Pulmonary Rehabilitation Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Antonello Nicolini
- Respiratory Diseases Unit Hospital of Sestri Levante, Sestri Levante, Italy
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Maria Grazia PI, Sofia K, Antonio E, Paolo B, Cornelius B, Antonello N. The outcomes of elderly ED patients intubated because of community acquired pneumonia: Why not give noninvasive ventilation a chance? Am J Emerg Med 2015; 33:1106-7. [DOI: 10.1016/j.ajem.2015.04.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 04/27/2015] [Indexed: 11/28/2022] Open
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