American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Letter
The outcomes of elderly ED patients intubated because of community acquired pneumonia: Why not give noninvasive ventilation a chance? To the Editor, We have read the study regarding the impact of age on outcomes of elderly patients admitted to emergency department (ED) because of severe community acquired pneumonia (CAP) and treated with invasive mechanical ventilation (IMV) by Hifumi et al [1] with great interest. The authors investigated patients older than 65 years who were divided in 3 groups (65-74, 75-84, and 85 years or older). No significant differences were observed among the 3 groups on mechanical ventilation (MV), hospital mortality, ventilator-free days, or intensive care unit (ICU) days. The authors conclude that age, in itself, may not be a factor limiting the initiation of MV in the ED in advanced age with CAP. This conclusion, among other contentions, in Hifumi et al demands some perspective. We provide some observations based on our experience with the treatment of CAP in elderly patients. 1. As previously reported, the proportion of elderly persons among hospitalized patients, including ICU admissions, is rapidly increasing in developed countries: very old patients represent 10% to 15% of ICU admissions [2]. In patients with chronic obstructive pulmonary disease with hypercapnia, noninvasive ventilation (NIV) achieved high rate of success in very old patients, and MV was of questionable value [3]. Did the authors consider in less severely ill patients (as measured by objective parameters) the use of NIV before IMV, which can decrease the need of intubation and ICU mortality [4]? 2. Numerous previous studies have suggested that age alone is not a reliable predictor of mortality in the critically ill patients. Other predictors including disease severity using objective criteria, body mass index, functional impairment, or the presence of an underlying fatal disease account for poor outcomes in elderly cohorts [5]. It would be of great interest to know if the authors considered illness severity scores such as APACHE II or SOFA and respiratory criteria (PaO2/FiO2 or A-aDO2) before starting and/or as outcome of the CAP treatment. 3. Regarding patients with “do not intubate order,” there is no mention of them in the exclusion criteria: we would ask if these patients were not admitted in the study. Moreover, were these patients treated? If treated, what was the treatment (eg, empiric antibiotics and a venturi mask)? Moreover, to use a euphemism, was nature allowed to take its course? We are aware that NIV is less effective in the treatment of severe CAP than severe acute chronic obstructive pulmonary disease exacerbations [6], but its usefulness in elderly patients is increasing. We think that further studies should compare appropriate indications and usefulness of NIV and IMV in old and very old patients.
The authors have no conflicts of interest to communicate. Piroddi Ines Maria Grazia, MD Respiratory Diseases Unit, Hospital of Sestri Levante, Italy Karamichali Sofia, MD Allergy and Respiratory Diseases Department, IRCSS AOU San Martino-IST Genoa, Italy Esquinaz Antonio, MD Intensive Care Unit, Hospital Morales Mesegue, Murcia, Spain Banfi Paolo, MD Don Gnocchi Foundation, IRCSS, Milan, Italy Barlascini Cornelius, MD Hygiene and Health Medicine, Hospital of Sestri Levante, Italy Nicolini Antonello, MD E-mail address: [email protected] Respiratory Diseases Unit, Hospital of Sestri Levante, Italy Corresponding author. Respiratory Diseases Unit, via Terzi 43 16039 Sestri Levante, Italy. Tel.:+39 0185329145 fax: +39 0185329121, +39 3495952294 (mobile)
http://dx.doi.org/10.1016/j.ajem.2015.04.056 References [1] Hifumi T, Jinbo T, Okada I, Kiriu N, Kato H, Koido Y, et al. The impact of age on outcomes of elderly ED patients ventilated due to community acquired pneumonia. Am J Emerg Med 2015;33:277–81. [2] Schortgen F, Follin A, Piccari L, Roche Campo F, Carteaux G, Taillandier-Heriche E, et al. Results of noninvasive ventilation in very old patients. Anaesth Intensive Care 2012;2:5. [3] Nicolini A, Santo M, Ferrera L, Ferrari-Bravo M, Barlascini C, Perazzo A. The use of noninvasive ventilation in very old patients with hypercapnic acute respiratory failure because of COPD exacerbation. Int J Clin Pract 2014;68(2):1523–9. [4] Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilationin severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003;168:1438–44. [5] Sligl WI, Eurich DT, Marrie TJ, Majumdar SR. Age still matters: prognostic short and long term mortality for critically ill patients with pneumonia. Crit Care Med 2010; 38:2126–32. [6] Risom MB, Kjaer BN, Risom E, Guldager H. Non-invasive ventilation is less effective in pneumonia than in chronic obstructive pulmonary disease exacerbation. Dan Med J 2014;61(3):A4799.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Maria Grazia PI, et al, The outcomes of elderly ED patients intubated because of community acquired pneumonia: Why not give noninvasive ventilation a chance?, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.056
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Letter
The outcomes of elderly ED patients intubated because of community acquired pneumonia: Why not give noninvasive ventilation a chance? To the Editor, We have read the study regarding the impact of age on outcomes of elderly patients admitted to emergency department (ED) because of severe community acquired pneumonia (CAP) and treated with invasive mechanical ventilation (IMV) by Hifumi et al [1] with great interest. The authors investigated patients older than 65 years who were divided in 3 groups (65-74, 75-84, and 85 years or older). No significant differences were observed among the 3 groups on mechanical ventilation (MV), hospital mortality, ventilator-free days, or intensive care unit (ICU) days. The authors conclude that age, in itself, may not be a factor limiting the initiation of MV in the ED in advanced age with CAP. This conclusion, among other contentions, in Hifumi et al demands some perspective. We provide some observations based on our experience with the treatment of CAP in elderly patients. 1. As previously reported, the proportion of elderly persons among hospitalized patients, including ICU admissions, is rapidly increasing in developed countries: very old patients represent 10% to 15% of ICU admissions [2]. In patients with chronic obstructive pulmonary disease with hypercapnia, noninvasive ventilation (NIV) achieved high rate of success in very old patients, and MV was of questionable value [3]. Did the authors consider in less severely ill patients (as measured by objective parameters) the use of NIV before IMV, which can decrease the need of intubation and ICU mortality [4]? 2. Numerous previous studies have suggested that age alone is not a reliable predictor of mortality in the critically ill patients. Other predictors including disease severity using objective criteria, body mass index, functional impairment, or the presence of an underlying fatal disease account for poor outcomes in elderly cohorts [5]. It would be of great interest to know if the authors considered illness severity scores such as APACHE II or SOFA and respiratory criteria (PaO2/FiO2 or A-aDO2) before starting and/or as outcome of the CAP treatment. 3. Regarding patients with “do not intubate order,” there is no mention of them in the exclusion criteria: we would ask if these patients were not admitted in the study. Moreover, were these patients treated? If treated, what was the treatment (eg, empiric antibiotics and a venturi mask)? Moreover, to use a euphemism, was nature allowed to take its course? We are aware that NIV is less effective in the treatment of severe CAP than severe acute chronic obstructive pulmonary disease exacerbations [6], but its usefulness in elderly patients is increasing. We think that further studies should compare appropriate indications and usefulness of NIV and IMV in old and very old patients.
The authors have no conflicts of interest to communicate. Piroddi Ines Maria Grazia, MD Respiratory Diseases Unit, Hospital of Sestri Levante, Italy Karamichali Sofia, MD Allergy and Respiratory Diseases Department, IRCSS AOU San Martino-IST Genoa, Italy Esquinaz Antonio, MD Intensive Care Unit, Hospital Morales Mesegue, Murcia, Spain Banfi Paolo, MD Don Gnocchi Foundation, IRCSS, Milan, Italy Barlascini Cornelius, MD Hygiene and Health Medicine, Hospital of Sestri Levante, Italy Nicolini Antonello, MD E-mail address: [email protected] Respiratory Diseases Unit, Hospital of Sestri Levante, Italy Corresponding author. Respiratory Diseases Unit, via Terzi 43 16039 Sestri Levante, Italy. Tel.:+39 0185329145 fax: +39 0185329121, +39 3495952294 (mobile)
http://dx.doi.org/10.1016/j.ajem.2015.04.056 References [1] Hifumi T, Jinbo T, Okada I, Kiriu N, Kato H, Koido Y, et al. The impact of age on outcomes of elderly ED patients ventilated due to community acquired pneumonia. Am J Emerg Med 2015;33:277–81. [2] Schortgen F, Follin A, Piccari L, Roche Campo F, Carteaux G, Taillandier-Heriche E, et al. Results of noninvasive ventilation in very old patients. Anaesth Intensive Care 2012;2:5. [3] Nicolini A, Santo M, Ferrera L, Ferrari-Bravo M, Barlascini C, Perazzo A. The use of noninvasive ventilation in very old patients with hypercapnic acute respiratory failure because of COPD exacerbation. Int J Clin Pract 2014;68(2):1523–9. [4] Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilationin severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003;168:1438–44. [5] Sligl WI, Eurich DT, Marrie TJ, Majumdar SR. Age still matters: prognostic short and long term mortality for critically ill patients with pneumonia. Crit Care Med 2010; 38:2126–32. [6] Risom MB, Kjaer BN, Risom E, Guldager H. Non-invasive ventilation is less effective in pneumonia than in chronic obstructive pulmonary disease exacerbation. Dan Med J 2014;61(3):A4799.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Maria Grazia PI, et al, The outcomes of elderly ED patients intubated because of community acquired pneumonia: Why not give noninvasive ventilation a chance?, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.056
