Abstract
In this chapter the reader will learn the physiological effects and the commonly accepted indications for noninvasive respiratory support (high flow nasal cannulae [HFNC], noninvasive mechanical ventilation [NIMV]) and invasive mechanical ventilation (IMV), with special consideration to the elderly patient, whenever there is specific information in the literature regarding this age group.
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Keywords
FormalPara Learning ObjectivesIn this chapter the reader will learn the physiological effects and the commonly accepted indications for noninvasive respiratory support (high flow nasal cannulae [HFNC], noninvasive mechanical ventilation [NIMV]) and invasive mechanical ventilation (IMV), with special consideration to the elderly patient, whenever there is specific information in the literature regarding this age group.
Practical Implications
HFNC are increasingly used for the treatment of acute hypoxemic respiratory failure (AHRF), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and other conditions associated with risk of hypoxemia.
Unlike standard oxygen therapy (SOT), HFNC provide a higher airflow rate, higher fraction of inspired oxygen (FiO2), and effectively heated and humidified air.
Physiological effects include provision of some level of positive end expiratory pressure, improved oxygenation, reduced anatomical dead space, better patient comfort, and less dryness.
When compared to SOT, HFNC decreases the need for intubation and escalation of respiratory support in AHRF.
Patients with AHRF being treated with HFNC should be closely monitored to identify signs of failure and the need for intubation. There are studies supporting the use of the ROX index ([SpO2/FiO2]/RR) to predict the likelihood of intubation in patients requiring HFNC.
NIMV is used for the treatment of AECOPD. In elderly patients it has been shown that NIMV, as compared to standard medical treatment, is associated with a significant decrease in the proportion of patients meeting criteria for tracheal intubation.
NIMV is also used for the treatment of acute cardiogenic pulmonary edema (ACPE) where, as compared to SOT, it is associated with a reduction in hospital mortality, intubation rate and ICU length of stay, and a quicker symptomatic improvement and better tolerance.
In AHRF, NIMV reduces the intubation rate and hospital mortality, as compared to SOT.
In ARDS, success rates of NIMV in mild, moderate, and severe ARDS are 78%, 58%, and 53%, respectively, according to the LUNG SAFE study. The use of NIMV was in that study independently associated with increased ICU (but not hospital) mortality. Using propensity score, ICU mortality was greater in the NIMV versus the IMV group only in patients with PaO2/FiO2 ratio <150. Thus, consideration should be given to the high mortality rate of patients with ARDS failing treatment with NIMV, and to the association between the initial use of NIMV and mortality in ARDS, at least for patients with more impaired oxygenation (e.g., PaO2/FiO2 < 150). The conclusions of the LUNG SAFE study may partly pertain to the elderly, as median age was between 66 and 63 years.
1 Introduction
Different forms of respiratory support can be used to treat oxygenation and ventilation failure of the lungs. We will discuss here the role of HFNC, NIMV, and IMV for the treatment of acute respiratory failure (ARF) in the elderly. We will also address ventilation issues in patients with AHRF and COVID-19 pertaining to elderly patients. Most of the published literature does not deal directly with elderly patients, but often a large proportion of patients included in the different studies are >65 years of age, and conclusions can to some extent be applied to the treatment of the elderly patient population.
2 High Flow Nasal Cannulae
HFNC are increasingly used for the treatment of AHRF and AECOPD and prevention of post-extubation respiratory failure, preintubation oxygenation, sleep apnea, acute heart failure, and hypoxemia in the context of do-not-intubate (DNI) orders [1].
Unlike standard oxygen therapy (SOT), HFNC provide a higher airflow rate, higher fraction of inspired oxygen (FiO2), and effectively heated and humidified air.
Physiological effects include provision of some level of positive end expiratory pressure (PEEP), improved oxygenation, reduced anatomical dead space, better patient comfort, and less dryness [2,3,4]. Due to the higher airflow rate delivered, the FiO2 provided is more predictable than with SOT [5,6,7]. As a result of providing high FiO2 and low level of PEEP, oxygenation increases with HFNC [4, 7,8,9,10,11,12,13,14,15]. HFNC also increases tidal volume (Vt) and decreases respiratory rate (RR) [11], thus decreasing the work of breathing.
3 HFNC in AHRF
A number of studies have shown that HFNC improves oxygenation and enhances patient comfort, but whether its use attains other benefits as compared to SOT or NIMV is less clear. The outcome benefits of treatment with HFNC have been analyzed in different meta-analysis.
Nedel et al. evaluated nine studies that assessed HFNC in critically ill subjects with AHRF or at risk for this complication [16]. They found that HFNC was associated with nonsignificant reduction in the incidence of IMV compared with NIMV (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.57–1.20) or SOT (OR 0.49, 95% CI 0.22–1.08), nor was it associated with reduction in ICU mortality compared with NIMV (OR 0.72, 95% CI 0.23–2.21) or with SOT (OR 0.69, 95% CI 0.33–1.42). There was a trend toward better oxygenation compared with SOT but a worse gas exchange compared with NIMV.
Another meta-analysis of randomized controlled trials that compared HFNC and SOT or nasal continuous positive airway pressure (nCPAP) in children with acute lower respiratory infection reported treatment failure as an outcome [17]. HFNC significantly reduced treatment failure (risk ratio [RR] 0.49, 95% CI 0.40–0.60) in children with mild hypoxemia (arterial pulse oximetry [SpO2] >90% on room air), but in infants of 1–6 months of age with severe hypoxemia (SpO2 < 90% on room air or SpO2 > 90% on supplemental oxygen), HFNC was associated with an increased risk of treatment failure compared with nCPAP (risk ratio [RR] 1.77, 95% CI 1.17–2.67). No significant differences were found in intubation rates or mortality between HFNC and SOT or nCPAP. HFNC had a significantly lower risk of nasal trauma compared with nCPAP (RR 0.35, 95% CI 0.16–0.77).
In a more recent meta-analysis, Lewis et al. [18] included 51 studies in which treatment was initiated either after extubation or before mechanical ventilation in adults admitted to the ICU. The authors concluded that HFNC, versus SOT, may lead to less treatment failure (low-certainty evidence) but probably with little or no difference in mortality (moderate-certainty evidence). HFNC versus NIMV found no evidence of a difference in treatment failure, either being used post-extubation or before IMV (low-certainty evidence), nor was it associated with difference in in-hospital mortality (low-certainty evidence).
Thus, HFNC has been shown to enhance patient comfort and improve oxygenation, and may lead to less treatment failure when compared to SOT, but probably makes little or no difference when compared to NIMV, conclusions supported in general by low or very low certainty. There is not enough evidence to support the use of HFNC to achieve other benefits such as decrease in mortality or decrease in intubation rates.
The recommendation based on the available evidence is that HFNC is preferred to SOT for the treatment of AHRF [18]. When compared to SOT, HFNC decreases the need for intubation and escalation of respiratory support. It also has a greater improvement in oxygenation, but it provides no benefit in mortality, length of stay, dyspnea, or patient comfort [19,20,21,22,23,24]. There is not enough data to compare HFNC with NIMV for treatment of AHRF [18]. Patient comfort is greater with HFNC, but there is not enough evidence to support a benefit in other outcomes such as intubation rate, mortality, or length of stay [25, 26].
4 Other Indications for HFNC
HFNC is used for preoxygenation before and during intubation. However, studies have not shown consistent benefit in clinically relevant outcomes [27,28,29,30], and therefore practice guidelines give no recommendation as to the use of HFNC for the intubation procedure [1].
HFNC is also used in post-extubation respiratory failure. In patients at low risk for extubation failure, SOT often suffices to maintain oxygenation. One clinical trial showed reduction in re-intubation rate as compared to SOT [31], but no difference was reported in another study [32]. Thus, HFNC is not routinely recommended for the prevention of post-extubation respiratory failure in patients with low risk for re-intubation.
In patients at high risk for re-intubation, clinical trials show that HFNC is superior to SOT for the prevention of post-extubation respiratory failure [4, 33,34,35,36]. However, no differences are shown when HFNC is compared to NIMV [36,37,38]. Current guidelines thus indicate a conditional recommendation for the use of HFNC (versus SOT) in patients at high risk for re-intubation. NIMV should be used instead according to routine practice of the particular institution [1].
In the postoperative setting, HFNC can be used for the treatment or prevention of respiratory failure. Some patients, but not all, should receive HFNC in the postoperative period, such as obese and high-risk patients following cardiothoracic surgery [1, 11, 18, 32, 39,40,41,42,43,44,45,46,47,48].
Other common uses of HFNC include oxygenation during bronchoscopy, in patients with tracheostomy being weaned off the ventilator, and in combination with NIMV for oxygenation support.
5 Failure of HFNC in AHRF
Patients with AHRF being treated with HFNC should be closely monitored to identify signs of failure and the need for intubation. There are studies supporting the use of the ROX index to predict the likelihood of intubation in patients requiring HFNC [15]. The acronym ROX stands for respiratory rate and oxygenation. It is calculated as the ratio of (SpO2/FiO2) to respiratory rate (RR): ([SpO2/FiO2]/RR). The ROX index remains to be validated and is not currently routinely used to guide the clinical decision of intubation.
Roca et al. studied 157 patients with severe pneumonia treated with HFNC, of whom 44 (28.0%) required MV [49]. The ROX index measured at 12 hours after initiation of HFNC had the best accuracy (area under the receiver operating characteristic curve [AUC] 0.74) for the prediction of the need for MV, with the best cut-off value of 4.88. In a more recent multicenter prospective observational cohort study of patients with pneumonia treated with HFNC [50], among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time. ROX index ≥4.88 measured at 2 (hazard ratio [HR] 0.434; 95% CI 0.264–0.715), 6 (HR 0.304; 95% CI 0.182–0.509), or 12 hours (HR 0.291; 95% CI 0.161–0.524) after HFNC initiation was consistently associated with a lower risk for intubation. ROX indices <2.85, < 3.47, and <3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among the components of the index, SpO2/FiO2 was more predictive than RR. In a retrospective analysis of patients with COVID-19 pneumonia, the ROX index was tested in 120 patients receiving HFNC [51], of whom 35 patients (29%) failed HFNC and required intubation. ROX index at 12 h was the best predictor of intubation, with an AUC of 0.792 and a cut-off value of 5.99, with specificity 96% and sensitivity 62%. The ROX index has also been tested in other conditions. For instance, in 171 chest trauma patients receiving SOT, 49 (28.6%) of whom required endotracheal intubation, a threshold value of 12.85 (sensitivity 82, specificity 89) over the first 24 h predicted endotracheal intubation [52]. According to these data, the ROX index may be useful in assessing treatment failure in patients with different conditions, but different threshold values may be optimal in different conditions.
6 Development of NIMV
First used as the iron lung in the polio epidemics [53], NIMV later evolved when delivering intermittent positive pressure ventilation, and continuous positive airway pressure via a rubber face mask to treat different respiratory conditions became feasible [54, 55]. In 1981 Sullivan et al. described the successful use of continuous positive airway pressure (CPAP) via nasal mask in the management of obstructive sleep apnea [56] that was later used to treat respiratory failure from neuromuscular disease and nocturnal hypoventilation [57]. Subsequently, a Consensus Conference agreed on the role of NIMV in the management of patients with ARF [58,59,60,61]. NIMV is currently recommended for the treatment of various forms of ARF as detailed below. Specific indications for the elderly, when available, will be commented.
7 NIMV for the Treatment of AECOPD
AECOPD is one of the leading causes of hospitalizations. Pathophysiological changes during AECOPD include increased airflow resistance resulting in incomplete expiration, dynamic hyperinflation, and subsequent reduced diaphragm strength and respiratory muscle fatigue [62,63,64]. Reduced respiratory reserve in the elderly aggravates these physiological changes. NIMV is not the first line of treatment in AECOPD, but it is rather used in severe cases to prevent progression of the respiratory failure [65]. NIMV unloads the respiratory muscles and improves oxygenation and ventilation [25].
A trial of NIMV is recommended for AECOPD since it has shown a significant decrease in mortality, length of stay, intubation rate, and improvement in gas exchange [18, 59, 60, 66,67,68,69,70,71,72,73,74,75,76]. The recommended modality in this setting is bilevel positive airway pressure (BPAP). The benefit of BPAP in AECOPD extends from mild to severe COPD exacerbation and therefore should be used in all range of severities [69].
A national audit by Roberts et al. [77] of 10,000 COPD admissions showed that in patients with acidosis, mortality was higher if they received NIMV versus those who did not. However, this could be due to the late use of NIMV in patients already deteriorated or to the use of NIMV in cases of non-respiratory acidosis.
Whereas NIMV is recommended in the management of AECOPD, little evidence existed at the time of those recommendations [78, 79] to advocate its use in the elderly, and the guidelines had little evidence for the use of NIMV in the elderly with AECOPD [80].
Later studies proved the safety and efficacy of NIMV for the treatment of AECOPD in elderly patients. In a clinical trial on the treatment of AECOPD with NIMV, 82 patients aged >75 years [81] were randomized to receive NIMV or standard medical treatment (SMT). Treatment was associated with a significant decrease in the proportion of patients meeting criteria for tracheal intubation (7.3 versus 63.4%, in the treated and control groups, respectively), and a reduction in mortality rate (OR 0.40; 95% CI 0.19–0.83). Interestingly, 22 of 41 patients in the SMT group and DNI orders received NIMV as a rescue therapy. The mortality rate in this subgroup was comparable to the group receiving NIMV (OR 0.60, 95% CI 0.18–1.92), and significantly lower when compared with patients receiving intubation (OR 4.03, 95% CI 2.35–6.94). Balami et al. conducted a prospective study of 36 patients >65 years of age with AECOPD [82]. Mean age was 77.4 years. Only 2 patients (6%) could not be started on NIMV because of lack of tolerance, and treatment was successful in 27 of 34 patients treated (79%), whereas it did not succeed in 21%. Another indirect evidence that NIMV is effective in elderly patients is the finding that when patients ≥75 years of age are compared to younger patients, there are no differences in intubation or mortality rates [83], suggesting that NIMV is also safe and effective in the elderly population.
It is important to underline the clinical impact of a specialized NIMV team to optimize treatment success. A lower risk of death and intubation and a shorter ICU and hospital stay have been shown in patients treated with a dedicated NIMV team compared to management by ICU doctors and nurses working independently [84].
8 NIMV for the Treatment of Acute Cardiogenic Pulmonary Edema
Acute cardiogenic pulmonary edema (ACPE) is a leading cause of hospitalization for the elderly [85] and is associated with a high mortality rate. Reported in-hospital and 1-year mortality rates are 12% and 40%, respectively [86, 87]. In ACPE, the increase in extravascular lung fluid results in reduced lung volume and respiratory system compliance, increased airway resistance, and increased work of breathing. Noninvasive ventilation in ACPE prevents alveolar collapse, reduces alveolar edema, improves lung compliance [87], and decreases preload and afterload, thus reducing the work of breathing, increasing cardiac output, and improving oxygenation [65, 87, 88].
Systematic reviews and meta-analysis demonstrated a reduction in the rate of intubation and mortality in patients that received NIM [89]. Although a non-inferiority study questioned the role of NIMV in the management of ACPE, showing no difference in short-term mortality or need for intubation between the NIMV and standard therapy groups, several subsequent studies concluded that the use of NIMV in treating ACPE decreased the rate of intubation and in-hospital mortality [90,91,92,93,94]. However, results regarding mortality have not been entirely consistent between clinical trials [89, 90, 95,96,97,98,99,100,101].
There are few studies focused specifically on the elderly population, but given that the mean age of patients admitted for acute heart failure is greater than 70 years, many of the previous studies are thought to be applicable to this population. A study designed to investigate the clinical efficacy of NIMV in ACPE in patients greater than 75 years of age demonstrated early clinical improvement with a reduction in the rate of intubation and 48-hour mortality without sustained benefit during their hospital stay [101].
9 NIMV for the Treatment of AHRF
There is conflicting evidence about whether NIMV is beneficial to patients with AHRF not due to ACPE [102,103,104,105,106,107,108,109,110]. A prospective observational study on the use of NIMV in patients with AHRF reported a failure rate of 61% in patients with septic shock and 23% in patients without sepsis [111]. A meta-analysis of 11 studies (excluding patients with AECOPD or ACPE) showed that NIMV reduced the intubation rate (RR 0.59, 95% CI 0.44–0.79) and hospital mortality (RR 0.46; 95% CI 0.24–0.87) compared with SOT [109]. The wide confidence intervals reported suggest variable benefit among patients. A network meta-analysis studied 25 clinical trials comparing noninvasive treatments (NIMV or HFNC) with SOT in patients with AHRF [25]. Mortality was lower in patients treated with helmet or face mask NIMV compared with SOT. All three noninvasive modalities (helmet NIMV, face mask NIMV, HFNC) reduced intubation rates. High heterogeneity and risk of bias suggest caution when interpreting the results of this meta-analysis. In addition, a mortality benefit was not observed in patients with more severe impairment of oxygenation (PaO2/FiO2 < 200 mm Hg). In another meta-analysis of 29 randomized trials of mixed population of patients with AHRF comparing NIMV versus HFNC [112], it was found that HFNC resulted in lower mortality (RR 0.44, 95% CI 0.24–0.79), intubation rate (RR 0.71, 95% CI 0.53–0.95), and possibly hospital-acquired pneumonia (RR 0.46, 95% CI 0.15–1.45) and improved patient comfort.
The LUNG SAFE study provided important insights into the effects of treatment with NIMV in patients with ARDS [113]. Of 2813 patients with ARDS, 436 (15.5%) were managed with NIMV on days 1 and 2 following fulfillment of diagnostic criteria. The use of NIMV in moderate and severe forms of ARDS was surprising as the recommendations for NIMV in ARDS suggest that its use be restricted to mild ARDS [114]. However, success rates of NIMV in mild, moderate, and severe ARDS were not low (78%, 58%, and 53%, respectively). Hospital mortality in patients with NIMV success and failure was 16.1% and 45.4%, respectively. Importantly, the use of NIMV was independently associated with increased ICU (HR 1.446, 95% CI, 1.159–1.805), but not hospital, mortality. However, using propensity score, ICU mortality was greater in the NIMV versus the IMV group only in patients with PaO2/FiO2 ratio <150 (36.2% with NIMV compared with 24.7% with IMV). Thus, consideration should be given to the high mortality rate of patients with ARDS failing treatment with NIMV, and to the association between the initial use of NIMV and mortality in ARDS, at least for patients with more impaired oxygenation (e.g., PaO2/FiO2 < 150). The conclusions of the LUNG SAFE study do not pertain necessarily to the elderly patient population. However the median (IQR) age of patients with NIMV success or failure was, respectively, 66.5 [52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77] and 63.0 [53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73] years, indicating that elderly patients were notably represented in this study.
In immunocompromised patients, NIMV is suggested as first option for treatment of patients with mild or moderate AHRF [115,116,117]. Several studies [118,119,120,121,122], but not all [123], have suggested improved mortality by using NIMV in these patients.
10 Noninvasive Mechanical Ventilation for Weaning from Mechanical Ventilation
Different clinical trials and a meta-analysis have shown that patients weaned with NIMV after extubation demonstrate reduced mortality, less ventilator-associated pneumonia, and shorter ICU and hospital stay, without increasing the risk of weaning failure or re-intubation [124,125,126,127,128,129,130,131].
In a Cochrane systematic review, 16 trials comparing extubation and immediate application of NIMV with continued invasive weaning in adults on mechanical ventilation were studied, involving 994 participants, most of them with COPD [132]. The use of NIMV was associated with reduced mortality (RR 0.53, 95% CI 0.36–0.80), weaning failure (RR 0.63, 95% CI 0.42–0.96), ventilator-associated pneumonia (RR 0.25, 95% CI 0.15–0.43), length of stay in the ICU (mean difference [MD] −5.59 days, 95% CI −7.90 to −3.28) and in hospital (MD -6.04 days, 95% CI −9.22 to −2.87), and total duration of mechanical ventilation (MD −5.64 days, 95% CI −9.50 to −1.77). This indication for NIMV mainly applies to hypercapnic respiratory failure, and patients included in the studies are generally old. For instance, in the study by Ferrer et al. [126], mean age was 70 years.
11 NIMV for Post-extubation Support
NIMV can be used after extubation in patients at low risk for post-extubation respiratory failure. In this scenario, NIMV provides no benefit compared to SOT. In patients at high risk for post-extubation respiratory failure, some studies do not show reduction in re-intubation rate or mortality [133,134,135,136], whereas others suggest a decrease in the re-intubation rate [131, 132, 136,137,138,139,140].
12 NIMV in the Postoperative Setting
Changes in respiratory function in the postoperative period, including depressed respiratory drive, decreased Vt because of postoperative pain, recumbent atelectasis, etc., place the patient at increased risk of ARF. The elderly is at increased risk for these changes, as muscle function may already be deteriorated.
NIMV is not recommended in all postoperative patients for the prevention of ARF. The general indication of NIMV in the postoperative period is for the treatment of patients who develop AHRF and fail to respond to HFNC [141,142,143].
13 Invasive Mechanical Ventilation
ARDS represents a high proportion of patients receiving mechanical ventilation in the ICU. Among 29,144 ICU patients, 10.4% fulfilled the criteria for the diagnosis of ARDS, and ARDS represented 23.4% of patients requiring mechanical ventilation [144]. In line with those results [144], in a large prospective study, among 7944 patients requiring mechanical ventilation for >24 hours, 986 (12.3%) had hypoxemic respiratory failure (PaO2/FiO2 < 300), and 731 (9.1%) met criteria for ARDS [145].
Mortality of AHRF and ARDS is high. In the LUNG SAFE study, hospital mortality was 34.9%, 40.3%, and 46.1% for patients with mild, moderate, and severe ARDS, respectively [144]. Parhar et al. reported that hospital mortality for mild, moderate, and severe ARDS was, respectively, 26.5%, 31.8%, and 60.0%, whereas 3-year mortality was 43.5%, 46.9%, and 71.1% [145].
How ARDS is diagnosed and managed seems to be suboptimal. First, the syndrome is recognized only in part of the patients fulfilling the diagnostic criteria, ranging from 51.3% in mild to 79% in severe ARDS [144]. Second, modifiable mortality risk factors related with mechanical ventilation settings are not always measured or set according to current recommendations. In 18,302 patients receiving mechanical ventilation for various indications [146], Vt decreased over time from a mean (SD) of 9.3 (2.3) to 8.2 (2.0) mL/kg predicted body weight between 2004 and 2010. However, in the more recent LUNG SAFE study [144], less than two-thirds of 2377 patients with ARDS received a tidal volume ≤8 mL/kg of predicted body weight. Plateau airway pressure was measured only in 40.1% of patients with ARDS, and prone positioning was used in 16.3% of patients with severe ARDS [144]. In addition, it has been shown that mechanical power is associated with increased 28-day hospital and 3-year mortality [145]. This finding is of importance, since modifiable determinants of mechanical power associated with lower survival include plateau pressure and driving pressure.
Description on how mechanical ventilation is used may apply to the elderly population only to some extent. For instance, in a large prospective study of 731 patients with ARDS [145], median (IQR) age was 60 (49–69) years; in 3022 ARDS patients [144], mean (95% CI) age was 61.5 (60.9–62.1). In another study of 18,302 patients [146], mean (SD) age was 59 (17), 59 (17), and 61 (17) years in three different study periods (1998, 2004, and 2010, respectively). However, it seems reasonable to assume that conclusions as to under recognition of ARDS and suboptimal treatment in terms of attaining low plateau and delta pressures, and low tidal volume, and using prone positioning as indicated, will also apply to the elderly patient population.
14 Invasive Versus Noninvasive Ventilation for Patients with COVID-19 and ARF
Clinical experience indicates that many patients can be supported with noninvasive oxygen therapy (either HFNC or NIMV) only to require tracheal intubation and IMV some time later in worse clinical conditions. Whether late intubation worsens prognosis is not known. Mortality of patients with COVID-19 and AHRF seems to be decreasing over time [147, 148], and it has been proposed that the decrease in mortality could be related to less frequency in the use of tracheal intubation as first therapy in patients with COVID-19 and AHRF. Other factors can certainly contribute to the decreased mortality, including routine use of corticosteroids, the use of HFNC, lung-protective ventilation strategies, better sedation, better attention to the treatment of delirium, and avoidance of unproven therapies [149].
In an ancillary analysis of the COVID-ICU study, Dres et al. [150] studied 1199 elderly patients admitted to the ICU, 62% of whom were intubated on day 1 and an additional 16% were intubated during their ICU stay. Those two groups did not differ in their PaO2/FiO2 ratio or other characteristics, suggesting that the decision to intubate was based just on clinical judgment. However, using Inverse Probability Weighting Treatment and propensity score analysis, mortality was higher in patients intubated on day 1 (42% versus 28%).
In a large multicenter cohort of 13,301 patients with the diagnosis of COVID-19 admitted to 126 ICUs in Brazil, younger age, absence of frailty, and the use of noninvasive respiratory support (NIRS) as first support strategy were independently associated with improved outcomes [151]. Among all patients, 18% received some form of NIRS (either NIMV, HFOT, or both), and 13% received IMV. However, there was a time pattern from the first to the last period of time analyzed: some form of NIRS (NIMV or HFOT) increased from 8.3% to 25%, whereas only IMV decreased markedly from 25% to 6.5% of all patients. Among those patients receiving some form of NIRS, there were significant changes: only NIMV from 92% to 79%, only HFOT from 4.4% to 6%, and both NIVM and HFOT from 3.3% to 15.0%. Thus, patients were less often intubated to receive IMV, and among those not intubated, the use of only NIMV decreased, whereas the use of HFOT or a combination of NIMV and HFOT increased over time. In addition, patients who suffered failure of NIRS did not show a greater mortality in comparison to those intubated directly [151]. In conclusion, HFNC has been used during the COVID-19 outbreak [51, 152,153,154]. The use of first some form of NIRS, probably HFNC, rather than quickly deciding IMV in patients with COVID-19 and AHRF, does not seem to be unwarranted, even in elderly patients [150, 151].
If HFNC is chosen, close monitoring is required for the early identification of signs of failure that would indicate the requirement of IMV [152]. Roca et al. [49] identified patients at high risk of HFNC failure if ROX <4.88 at 12 hours. This threshold was confirmed also in COVID-19 patients [155, 156] who showed, however, higher intubation rates than in other studies [153, 154, 157]. Panadero et al. conducted a retrospective, observational single-center study of 196 patients with COVID-19 and bilateral pneumonia, 40 of whom were treated with HFNC [156]. The intubation rate at day 30 was 52.5%, and overall mortality was 22.5%. Patients that required intubation, as compared to patients who did not, presented a significantly lower PaO2/FiO2 (93.7 ± 6.7 vs. 113.4 ± 6.6) and a significantly lower ROX index (4.0 ± 1.0 vs. 5.0 ± 1.6). A ROX index <4.94 measured 2 to 6 h after the start of therapy was associated with increased risk of intubation (HR 4.03, 95% CI 1.18–13.7). In another study, Vega et al. [51] tested whether the ROX index is an accurate predictor of HFNC failure for COVID-19 patients treated outside the ICU. In a multicenter retrospective observational study, 120 patients with confirmed COVID-19 treated with HFNC were included, of whom 35 (29%) failed HFNC and required intubation. The 12-hour ROX index was the best predictor of intubation according to an area under the ROC curve of 0.792 (95% CI 0.691–0.893), with a threshold of 5.99 (specificity 96%, sensitivity 62%). Thus, the ROX index seems useful to predict failure of treatment with HFNC, although the best discriminative value differs from the previously reported for patients with other types of AHRF. Previous small single-center studies in patients with COVID-19, probably with greater disease severity, reported lower values for the ROX index (4.95 and 5.40) during the first 6 hours of treatment [155, 156].
15 Liberation from Mechanical Ventilation in the Elderly
Physiological and anatomical respiratory peculiarities in the elderly make the weaning process different as compared to younger adults. Different studies have investigated factors involved in weaning in patients ≥75 years of age. Decreased elastic recoil of the lung and the chest wall, ventilation-perfusion mismatch, and diminished muscle strength are among the age-related respiratory physiological changes in the elderly. Of interest, studies reviewing weaning in the elderly did not identify age in itself as an independent risk factor for difficult weaning, but severity of acute illness instead influences weaning [158,159,160,161,162,163].
It has been shown that the probability of meeting weaning criteria and successful weaning decreases with age [159], but independent predictors of weaning were comorbidity, severity of illness, rapid shallow breathing (the ratio between the respiratory frequency to the tidal volume), and lung static compliance, not age. Negative fluid balance and lower central venous pressure have also been shown to be related to weaning success [162].
In another study [163], after adjusting for the APACHE II score, patients ≥75 years of age passed a spontaneous breathing trial earlier than younger patients, further indicating that age in itself is not a risk factor for delayed extubation. Same results on the lack of independent relationship between age and weaning were obtained by Hifumi et al. [158] in a retrospective study in patients with community-acquired pneumonia. Another study [160] found that the presence of emphysematous changes in chest CT and low serum albumin concentration, but not age, were associated with difficult weaning.
A number of measures have been proposed to expedite weaning, including less use of benzodiazepines to decrease the risk of delirium [164, 165], and early rehabilitation and prevention of immobility [166]. Daily spontaneous breathing trial to test for readiness for extubation (one the inciting event has resolved) is crucial to shorten the time spent on mechanical ventilation [167]. Daily awakening trials have been associated with fewer days on mechanical ventilation, better cognitive function, and decreased long-term mortality [164, 165]. Cader et al. [161] studied 41 elderly intubated patients who had been mechanically ventilated for at least 48 h and showed that providing inspiratory muscle training resulted in increased maximal inspiratory pressure and reduction in the weaning time by 1.7 days. In addition, physical therapy and occupational therapy during spontaneous awakening trials to patients who had been intubated for more than 48 hours had beneficial effects and found decreased incidence of delirium and shortened time spent in mechanical ventilation [166, 168].
Conclusions
Recommendations for the use of various form of respiratory support (NIMV, HFNC, IMV) exist for different forms of ARF. However, studies in elderly patients are scarce and insufficient to emit recommendations for this specific age group. Patients included in studies on NIMV for the treatment of AECOPD and ACPE represent to some extent the aged group and could reasonably be extrapolated to the elderly. This is less the case for studies on the use of IMV for the treatment of AHRF and ARDS. Thus, studies on respiratory support for the elderly are required, particularly for the treatment of AHRF.
References
Rochwerg B, Einav S, Chaudhuri D, et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 2020;46(12):2226–37.
Roca O, Riera J, Torres F, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respir Care. 2010;55(4):408–13.
Tiruvoipati R, Lewis D, Haji K, Botha J. High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care. 2010;25(3):463–8.
Rittayamai N, Tscheikuna J, Rujiwit P. High-flow nasal cannula versus conventional oxygen therapy after endotracheal extubation: a randomized crossover physiologic study. Respir Care. 2014;59(4):485–90.
Sim MA, Dean P, Kinsella J, et al. Performance of oxygen delivery devices when the breathing pattern of respiratory failure is simulated. Anaesthesia. 2008;63(9):938–40.
Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care. 2011;39(6):1103–10.
Wagstaff TA, Soni N. Performance of six types of oxygen delivery devices at varying respiratory rates. Anaesthesia. 2007;62(5):492–503.
Parke RL, McGuinness SP. Pressures delivered by nasal high flow oxygen during all phases of the respiratory cycle. Respir Care. 2013;58(10):1621–4.
Parke RL, Eccleston ML, McGuinness SP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care. 2011;56(8):1151–5.
Groves N, Tobin A. High flow nasal oxygen generates positive airway pressure in adult volunteers. Aust Crit Care. 2007;20(4):126–31.
Parke R, McGuinness S, Dixon R, Jull A. Open-label, phase II study of routine high-flow nasal oxygen therapy in cardiac surgical patients. Br J Anaesth. 2013;111(6):925–31.
Corley A, Caruana LR, Barnett AG, et al. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in postcardiac surgical patients. Br J Anaesth. 2011;107(6):998–1004.
Frat JP, Brugiere B, Ragot S, et al. Sequential application of oxygen therapy via high-flow nasal cannula and noninvasive ventilation in acute respiratory failure: an observational pilot study. Respir Care. 2015;60(2):170–8.
Schwabbauer N, Berg B, Blumenstock G, et al. Nasal high-flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV). BMC Anesthesiol. 2014;14:66. https://doi.org/10.1186/1471-2253-14-66. eCollection 2014.
Nishimura M. High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects. Respir Care. 2016;61(4):529–41.
Nedel WL, Deutschendorf C, Moraes Rodrigues Filho E. High-flow nasal cannula in critically ill subjects with or at risk for respiratory failure: a systematic review and meta-analysis. Respir Care. 2017;62(1):123–32.
Luo J, Duke T, Chisti MJ, Kepreotes E, Kalinowski V, Li J. Efficacy of high-flow nasal cannula vs standard oxygen therapy or nasal continuous positive airway pressure in children with respiratory distress: a meta-analysis. J Pediatr. 2019;215:199–208.
Lewis SR, Baker PE, Parker R, Smith AF. High-flow nasal cannulae for respiratory support in adult intensive care patients. Cochrane Database Syst Rev. 2021;3(3):CD010172. https://doi.org/10.1002/14651858.CD010172.pub3. PMID: 33661521; PMCID: PMC8094160.
Azoulay E, Lemiale V, Mokart D, et al. Effect of high-flow nasal oxygen vs standard oxygen on 28-day mortality in immunocompromised patients with acute respiratory failure: the HIGH randomized clinical trial. JAMA. 2018;320(20):2099–107.
Bell N, Hutchinson CL, Green TC, Rogan E, Bein KJ, Dinh MM. Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department. Emerg Med Austr EMA. 2015;7(6):537–41.
Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185–96.
Jones PG, Kamona S, Doran O, Sawtell F, Wilsher M. Randomized controlled trial of humidified high-flow nasal oxygen for acute respiratory distress in the emergency department: the HOT-ER study. Respir Care. 2016;61(3):291–9.
Lemiale V, Mokart D, Mayaux J, et al. The effects of a 2-h trial of high-flow oxygen by nasal cannula versus Venturi mask in immunocompromised patients with hypoxemic acute respiratory failure: a multicenter randomized trial. Crit Care. 2015;19:380.
Makdee O, Monsomboon A, Surabenjawong U, et al. High-flow nasal cannula versus conventional oxygen therapy in emergency department patients with cardiogenic pulmonary edema: a randomized controlled trial. Ann Emerg Med. 2017;70(4):465–72.
Ferreyro BL, Angriman F, Munshi L, et al. Association of Noninvasive Oxygenation Noninvasive ventilation in adults with acute respiratory failure: strategies with all-cause mortality in adults with acute hypoxemic respiratory failure: a systematic review and meta-analysis. JAMA. 2020;324(1):57–67.
Grieco DL, Menga LS, Raggi V, Bongiovanni F, Anzellotti GM, Tanzarella ES, Bocci MG, Mercurio G, Dell’Anna AM, Eleuteri D, Bello G, Maviglia R, Conti G, Maggiore SM, Antonelli M. Physiological comparison of high-flow nasal cannula and helmet noninvasive ventilation in acute hypoxemic respiratory failure. Am J Respir Crit Care Med. 2020;201(3):303–12.
Jaber S, Monnin M, Girard M, et al. Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the intensive care unit: the single-Centre, blinded, randomized controlled OPTINIV trial. Intensive Care Med. 2016;42(12):1877–87.
Miguel-Montanes R, Hajage D, Messika J, et al. Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Crit Care Med Crit Care Med. 2015;43(3):574–83.
Vourc'h M, Asfar P, Volteau C, et al. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial. Intensive Care Med. 2015;41:1538.29.
Semler MW, Janz DR, Lentz RJ, et al. Randomized trial of Apneic oxygenation during endotracheal intubation of the critically ill. Am J Respir Crit Care Med. 2016;193(3):273–80.
Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354–61.
Futier E, Paugam-Burtz C, Godet T, et al. Effect of early postextubation high-flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery: a French multicentre randomised controlled trial (OPERA). Intensive Care Med. 2016;42(12):1888–98.
Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190(3):282–8.
Fernandez R, Subira C, Frutos-Vivar F, et al. High-flow nasal cannula to prevent postextubation respiratory failure in high-risk non-hypercapnic patients: a randomized multicenter trial. Ann Intensive Care. 2017;7(1):47. https://doi.org/10.1186/s13613-017-0270-9. Epub 2017 May 2. PMID: 28466461; PMCID: PMC5413462.
Song HZ, Gu JX, Xiu HQ, Cui W, Zhang GS. The value of high-flow nasal cannula oxygen therapy after extubation in patients with acute respiratory failure. Clinics (Sao Paulo). 2017;72(9):562–7.
Hernandez G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial. JAMA. 2016;316(15):1565–74.
Theerawit PN, Sutherasan Y. The efficacy of the Whisperflow CPAP system versus high flow nasal cannula in patients at high risk for postextubation failure. J Crit Care. 2021;63:117–23.
Jing G, Li J, Hao D, et al. Comparison of high flow nasal cannula with noninvasive ventilation in chronic obstructive pulmonary disease patients with hypercapnia in preventing postextubation respiratory failure: a pilot randomized controlled trial. Res Nurs Health. 2019;42(3):217–25.
Stephan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331–9.
Lu Z, Chang W, Meng S, et al. The effect of high-flow nasal oxygen therapy on postoperative pulmonary complications and hospital length of stay in postoperative patients: a systematic review and meta-analysis. J Intensive Care Med. 2020;35:1129–40.
Ansari BM, Hogan MP, Collier TJ, et al. A randomized controlled trial of high-flow nasal oxygen (Optiflow) as part of an enhanced recovery program after lung resection surgery. Ann Thorac Surg. 2016;101(2):459–64.
Brainard J, Scott BK, Sullivan BL, et al. Heated humidified high-flow nasal cannula oxygen after thoracic surgery—a randomized prospective clinical pilot trial. J Crit Care. 2017;40:225–8.
Corley A, Bull T, Spooner AJ, Barnett AG, Fraser JF. Direct extubation onto high-flow nasal cannulae post-cardiac surgery versus standard treatment in patients with a BMI >/=30: a randomised controlled trial. Intensive Care Med. 2015;41(5):887–94.
Pennisi MA, Bello G, Congedo MT, et al. Early nasal high-flow versus Venturi mask oxygen therapy after lung resection: a randomized trial. Crit Care (Lond Engl). 2019;23(1):68. https://doi.org/10.1186/s13054-019-2361-5.
Sahin M, El H, Akkoc I. Comparison of mask oxygen therapy and high-flow oxygen therapy after cardiopulmonary bypass in obese patients. Can Respir J. 2018;2018:1039635. https://doi.org/10.1155/2018/1039635. PMID: 29623135; PMCID: PMC5829344
Tatsuishi W, Sato T, Kataoka G, Sato A, Asano R, Nakano K. High-flow nasal cannula therapy with early extubation for subjects undergoing off-pump coronary artery bypass graft surgery. Respir Care. 2020;65(2):183–90.
Yu Y, Qian X, Liu C, Zhu C. Effect of high-flow nasal cannula versus conventional oxygen therapy for patients with thoracoscopic lobectomy after extubation. Can Respir J. 2017;2017:7894631. https://doi.org/10.1155/2017/7894631. Epub 2017 Feb 19
Zochios V, Collier T, Blaudszun G, et al. The effect of high-flow nasal oxygen on hospital length of stay in cardiac surgical patients at high risk for respiratory complications: a randomised controlled trial. Anaesthesia. 2018;73(12):1478–88.
Roca O, Messika J, Caralt B, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: the utility of the ROX index. J Crit Care. 2016;35:200–5.
Roca O, Caralt B, Messika J, et al. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med. 2019;199(11):1368–76.
Vega ML, Dongilli R, Olaizola G, Colaianni N, Sayat MC, Pisani L, Romagnoli M, Spoladore G, Prediletto I, Montiel G, Nava S. COVID-19 pneumonia and ROX index: time to set a new threshold for patients admitted outside the ICU. Pulmonology. 2021;S2531-0437(21)00092-1 https://doi.org/10.1016/j.pulmoe.2021.04.003.
Cornillon A, Balbo J, Coffinet J, Floch T, Bard M, Giordano-Orsini G, Malinovsky JM, Kanagaratnam L, Michelet D, Legros V. The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma. Scand J Trauma Resusc Emerg Med. 2021;29(1):81. https://doi.org/10.1186/s13049-021-00876-4.
Drinker PA, McKhann CF 3rd. Landmark perspective: the iron lung. First practical means of respiratory support. JAMA. 1986;255(11):1476–80.
Motley HL, Cournand A, et al. Intermittent positive pressure breathing; a means of administering artificial respiration in man. JAMA. 1948;137(4):370–82.
Motley HL, Lang LP, Gordon B. Use of intermittent positive pressure breathing combined with nebulization in pulmonary disease. Am J Med. 1948;5(6):853–6.
Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981;1(8225):862–5.
Kerby GR, Mayer LS, Pingleton SK. Nocturnal positive pressure ventilation via nasal mask. Am Rev Respir Dis. 1987;135(3):738–40.
Bersten AD, Holt AW, Vedig AE, Skowronski GA, Baggoley CJ. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med. 1991;325(26):1825–30.
Bott J, Carroll MP, Conway JH, et al. Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet. 1993;341(8860):1555–7.
Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817–22.
British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax. 2002;57(3):192–211.
Antonelli M, Conti G. Noninvasive positive pressure ventilation as treatment for acute respiratory failure in critically ill patients. Crit Care. 2000;4(1):15–22.
Stevenson NJ, Walker PP, Costello RW, Calverley PM. Lung mechanics and dyspnea during exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(12):1510–6.
O’Donnell DE, Parker CM. COPD exacerbations. 3: pathophysiology. Thorax. 2006;61(4):354–61.
Organized jointly by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Société de Réanimation de Langue Française, and approved by ATS Board of Directors, December 2000. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure. Am J Respir Crit Care Med. 2001;163(1):283–91.
Williams JW Jr, Cox CE, Hargett CW, et al. Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. Report No.: 12-EHC089-EF. PMID: 22876372.
Diaz O, Iglesia R, Ferrer M, et al. Effects of noninvasive ventilation on pulmonary gas exchange and hemodynamics during acute hypercapnic exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1997;156(6):1840–5.
Lindenauer PK, Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Hill NS. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014;174(12):1982–93.
Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017;7(7):CD004104. https://doi.org/10.1002/14651858.CD004104.pub4. PMID: 28702957; PMCID: PMC6483555.
Conti G, Antonelli M, Navalesi P, et al. Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med. 2002;28(12):1701–7.
Kramer N, Meyer TJ, Meharg J, Cece RD, Hill NS. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med. 1995;151(6):1799–806.
Angus RM, Ahmed AA, Fenwick LJ, Peacock AJ. Comparison of the acute effects on gas exchange of nasal ventilation and doxapram in exacerbations of chronic obstructive pulmonary disease. Thorax. 1996;51(10):1048–50.
Celikel T, Sungur M, Ceyhan B, Karakurt S. Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. Chest. 1998;114(6):1636–42.
Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000;355(9219):1931–5.
Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163(2):540–77.
Wedzicha JA Ers Co-Chair, Miravitlles M, Hurst JR, Calverley PM, Albert RK, Anzueto A, Criner GJ, Papi A, Rabe KF, Rigau D, Sliwinski P, Tonia T, Vestbo J, Wilson KC, Krishnan JA Ats Co-Chair. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3):1600791. https://doi.org/10.1183/13993003.00791-2016. PMID: 28298398.
Roberts CM, Stone RA, Buckingham RJ, Pursey NA, Lowe D, National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project Implementation Group. Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations. Thorax. 2011;66(1):43–8.
National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax. 2004;59(Suppl 1):1–232.
National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical Guideline Centre. 2010. Available at: http://guidance.nice.org.uk/CG101/Guidance/pdf/English.
Connolly MJ. Acute non-invasive ventilation in older patients: medical evolution and improvement in survival of the un-fittest. Age Ageing. 2011;40(4):414–6.
Nava S, Grassi M, Fanfulla F, et al. Non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure: a randomised controlled trial. Age Ageing. 2011;40(4):444–50.
Balami JS, Packham SM, Gosney MA. Non-invasive ventilation for respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease in older patients. Age Ageing. 2006;35(1):75–9.
Nicolini A, Santo M, Ferrera L, Ferrari-Bravo M, Barlascini C, Perazzo A. The use of non-invasive ventilation in very old patients with hypercapnic acute respiratory failure because of COPD exacerbation. Int J Clin Pract. 2014;68(12):1523–9.
Vaudan S, Ratano D, Beuret P, Hauptmann J, Contal O, Garin N. Impact of a dedicated noninvasive ventilation team on intubation and mortality rates in severe COPD exacerbations. Respir Care. 2015;60(10):1404–8.
Siirilä-Waris K, Lassus J, Melin J, Peuhkurinen K, Nieminen MS, Harjola VP, FINN-AKVA Study Group. Characteristics, outcomes, and predictors of 1-year mortality in patients hospitalized for acute heart failure. Eur Heart J. 2006;27(24):3011–7.
Girou E, Brun-Buisson C, Taillé S, Lemaire F, Brochard L. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA. 2003;290(22):2985–91.
Nieminen MS, Böhm M, Cowie MR, ESC Committee for Practice Guideline (CPG). Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J. 2005;26(4):384–416.
Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J. 3CPO Trialists. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142–51.
Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito JA. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA. 2005;294(24):3124–30.
Potts JM. Noninvasive positive pressure ventilation: effect on mortality in acute cardiogenic pulmonary edema: a pragmatic meta-analysis. Pol Arch Med Wewn. 2009;119:349–53.
Goodacre SW, Gray A, Newby D. Errors in meta-analysis regarding the 3CPO trial. Ann Intern Med. 2010;153(4):277–8.
Bello G, De Santis P, Antonelli M. Non-invasive ventilation in cardiogenic pulmonary edema. Ann Transl Med. 2018;6(18):355. https://doi.org/10.21037/atm.2018.04.39. PMID: 30370282; PMCID: PMC6186545.
Weng CL, Zhao YT, Liu QH, et al. Meta-analysis: noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010;152(9):590–600.
Mariani J, Macchia A, Belziti C, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema: a meta-analysis of randomized controlled trials. J Card Fail. 2011;17(10):850–9.
Nava S, Carbone G, DiBattista N, Bellone A, Baiardi P, Cosentini R, Marenco M, Giostra F, Borasi G, Groff P. Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. Am J Respir Crit Care Med. 2003;168(12):1432–7.
Nouira S, Boukef R, Bouida W, et al. Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department. Intensive Care Med. 2011;37(2):249–56.
Masip J, Betbesé AJ, Páez J, et al. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial. Lancet. 2000;356(9248):2126–32.
Cabrini L, Landoni G, Oriani A, et al. Noninvasive ventilation and survival in acute care settings: a comprehensive systematic review and metaanalysis of randomized controlled trials. Crit Care Med. 2015;43(4):880–8.
Mehta S, Al-Hashim AH, Keenan SP. Noninvasive ventilation in patients with acute cardiogenic pulmonary edema. Respir Care. 2009;54(2):186–95.
Winck JC, Azevedo LF, Costa-Pereira A, Antonelli M, Wyatt JC. Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema--a systematic review and meta-analysis. Crit Care. 2006;10(2):R69. https://doi.org/10.1186/cc4905. PMID: 16646987; PMCID: PMC1550884.
L’Her E, Duquesne F, Girou E, et al. Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients. Intensive Care Med. 2004;30(5):882–8.
Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med. 2003;168(12):1438–44.
Martin TJ, Hovis JD, Costantino JP, et al. A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure. Am J Respir Crit Care Med. 2000;161:807–13.
Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med. 1998;339(7):429–35.
Delclaux C, L’Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: a randomized controlled trial. JAMA. 2000;284(18):2352–60.
Keenan SP, Sinuff T, Cook DJ, Hill NS. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med. 2004;32(12):2516–23.
Hernandez G, Fernandez R, Lopez-Reina P, et al. Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial. Chest. 2010;137(1):74–80.
Faria DA, da Silva EM, Atallah ÁN, Vital FM. Noninvasive positive pressure ventilation for acute respiratory failure following upper abdominal surgery. Cochrane Database Syst Rev. 2015;2015(10):CD009134. https://doi.org/10.1002/14651858.CD009134.pub2. PMID: 26436599; PMCID: PMC8080101.
Xu XP, Zhang XC, Hu SL, et al. Noninvasive ventilation in acute hypoxemic Nonhypercapnic respiratory failure: a systematic review and meta-analysis. Crit Care Med. 2017;45(7):e727–33. https://doi.org/10.1097/CCM.0000000000002361. PMID: 28441237; PMCID: PMC5470860.
Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive-pressure ventilation in acute respiratory failure outside clinical trials: experience at the Massachusetts General Hospital. Crit Care Med. 2008;36(2):441–7.
Duan J, Chen L, Liang G, et al. Noninvasive ventilation failure in patients with hypoxemic respiratory failure: the role of sepsis and septic shock. Ther Adv Respir Dis. 2019;13:1753466619888124. https://doi.org/10.1177/1753466619888124. PMID: 31722614; PMCID: PMC6856973.
Baldomero AK, Melzer AC, Greer N, et al. Effectiveness and harms of high-flow nasal oxygen for acute respiratory failure: an evidence report for a clinical guideline from the American College of Physicians. Ann Intern Med. 2021;174(7):952–66.
Bellani G, Laffey JG, Pham T, LUNG SAFE Investigators, ESICM Trials Group, et al. Noninvasive ventilation of patients with acute respiratory distress syndrome. Insights from the LUNG SAFE study. Am J Respir Crit Care Med. 2017;195(1):67–77.
Ferguson ND, Fan E, Camporota L, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38(10):1573–82.
Antonelli M, Conti G, Bufi M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 2000;283(2):235–41.
Adda M, Coquet I, Darmon M, Thiery G, Schlemmer B, Azoulay E. Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure. Crit Care Med. 2008;36(10):2766–72.
Squadrone V, Massaia M, Bruno B, et al. Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy. Intensive Care Med. 2010;36(10):1666–74.
Gristina GR, Antonelli M, Conti G, GiViTI (Italian Group for the Evaluation of Interventions in Intensive Care Medicine), et al. Noninvasive versus invasive ventilation for acute respiratory failure in patients with hematologic malignancies: a 5-year multicenter observational survey. Crit Care Med. 2011;39(10):2232–9.
Lemiale V, Resche-Rigon M, Mokart D, et al. Acute respiratory failure in patients with hematological malignancies: outcomes according to initial ventilation strategy. A groupe de recherche respiratoire en réanimation onco-hématologique (Grrr-OH) study. Ann Intensive Care. 2015;5(1):28. https://doi.org/10.1186/s13613-015-0070-z. Epub 2015 Sep 30. PMID: 26429355; PMCID: PMC4883632.
Azoulay E, Mokart D, Pène F, et al. Outcomes of critically ill patients with hematologic malignancies: prospective multicenter data from France and Belgium–a groupe de recherche respiratoire en réanimation onco-hématologique study. J Clin Oncol. 2013;31(22):2810–8.
Conti G, Marino P, Cogliati A, et al. Noninvasive ventilation for the treatment of acute respiratory failure in patients with hematologic malignancies: a pilot study. Intensive Care Med. 1998;24(12):1283–8.
Depuydt PO, Benoit DD, Roosens CD, Offner FC, Noens LA, Decruyenaere JM. The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failure. J Crit Care. 2010;25(1):30–6.
Lemiale V, Mokart D, Resche-Rigon M, Groupe de Recherche en Réanimation Respiratoire du patient d’Onco-Hématologie (GRRR-OH), et al. Effect of noninvasive ventilation vs oxygen therapy on mortality among immunocompromised patients with acute respiratory failure: a randomized clinical trial. JAMA. 2015;314(16):1711–9.
Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998;128(9):721–8.
Girault C, Daudenthun I, Chevron V, Tamion F, Leroy J, Bonmarchand G. Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med. 1999;160(1):86–92.
Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;168(1):70–6.
Vaschetto R, Turucz E, Dellapiazza F, et al. Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-Centre feasibility study. Intensive Care Med. 2012;38(10):1599–606.
Trevisan CE, Vieira SR, Research Group in Mechanical Ventilation Weaning. Noninvasive mechanical ventilation may be useful in treating patients who fail weaning from invasive mechanical ventilation: a randomized clinical trial. Crit Care. 2008;12(2):R51. https://doi.org/10.1186/cc6870. Epub 2008 Apr 17. PMID: 18416851; PMCID: PMC2447605.
Collaborating Research Group for Noninvasive Mechanical Ventilation of Chinese Respiratory, S., Pulmonary infection control window in treatment of severe respiratory failure of chronic obstructive pulmonary diseases: a prospective, randomized controlled, multi-centred study. Chin Med J. 2005;118(19):1589–94.
Prasad SB, Chaudhry D, Khanna R. Role of noninvasive ventilation in weaning from mechanical ventilation in patients of chronic obstructive pulmonary disease: an Indian experience. Indian J Crit Care Med. 2009;13(4):207–12.
Girault C, Bubenheim M, Abroug F, VENISE Trial Group, et al. Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial. Am J Respir Crit Care Med. 2011;184(6):672–9.
Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review. CMAJ. 2014;186(3):E112–22.
Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA. 2002;287(24):3238–44.
Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350(24):2452–60.
Lin C, Yu H, Fan H, Li Z. The efficacy of noninvasive ventilation in managing postextubation respiratory failure: a meta-analysis. Heart Lung. 2014;43(2):99–104.
Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33(11):2465–70.
Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173(2):164–70.
El-Solh AA, Aquilina A, Pineda L, Dhanvantri V, Grant B, Bouquin P. Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients. Eur Respir J. 2006;28(3):588–95.
Ferrer M, Sellarés J, Valencia M, Carrillo A, Gonzalez G, Badia JR, Nicolas JM, Torres A. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 2009;374(9695):1082–8.
Khilnani GC, Galle AD, Hadda V, Sharma SK. Non-invasive ventilation after extubation in patients with chronic obstructive airways disease: a randomised controlled trial. Anaesth Intensive Care. 2011;39(2):217–23.
Jaber S, Lescot T, Futier E, NIVAS Study Group, et al. Effect of noninvasive ventilation on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: a randomized clinical trial. JAMA. 2016;315(13):1345–53.
Jaber S, Chanques G, Jung B. Postoperative noninvasive ventilation. Anesthesiology. 2010;112(2):453–61.
Chiumello D, Chevallard G, Gregoretti C. Non-invasive ventilation in postoperative patients: a systematic review. Intensive Care Med. 2011;37(6):918–29.
Bellani G, Laffey JG, Pham T, LUNG SAFE Investigators, ESICM Trials Group, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800.
Parhar KKS, Zjadewicz K, Soo A, et al. Epidemiology, mechanical power, and 3-year outcomes in acute respiratory distress syndrome patients using standardized screening. An observational cohort study. Ann Am Thorac Soc. 2019;16(10):1263–72. https://doi.org/10.1513/AnnalsATS.201812-910OC. PMID: 31247145; PMCID: PMC6812172.
Esteban A, Frutos-Vivar F, Muriel A, et al. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med. 2013;188(2):220–30.
Dennis JM, McGovern AP, Vollmer SJ, Mateen BA. Improving survival of critical care patients with coronavirus disease 2019 in England: a National Cohort Study, March to June 2020. Crit Care Med. 2021;49(2):209–14.
COVID-ICU Group on behalf of the REVA Network and the COVID-ICU Investigators. Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study. Intensive Care Med. 2021;47:60–73.
Prescott HC, Levy MM. Survival from severe coronavirus disease 2019: is it changing? Crit Care Med. 2021;49(2):351–3.
Dres M, Hajage D, Lebbah S, COVID-ICU Investigators, et al. Characteristics, management, and prognosis of elderly patients with COVID-19 admitted in the ICU during the first wave: insights from the COVID-ICU study: prognosis of COVID-19 elderly critically ill patients in the ICU. Ann Intensive Care. 2021;11(1):77.
Kurtz P, Bastos LSL, Dantas LF, et al. Evolving changes in mortality of 13,301 critically ill adult patients with COVID-19 over 8 months. Intensive Care Med. 2021;47(5):538–48.
Fernández R, González de Molina FJ, Batlle M, Fernández MM, Hernandez S, Villagra A, Grupo Semicríticos Covid. Non-invasive ventilatory support in patients with COVID-19 pneumonia: a Spanish multicenter registry. Med Intensiva (Engl Ed). 2021;45(5):315–7.
Franco C, Facciolongo N, Tonelli R, et al. Feasibility and clinical impact of out-of-ICU noninvasive respiratory support in patients with COVID-19-related pneumonia. Eur Respir J. 2020;56(5):2002130.
Patel M, Gangemi A, Marron R, et al. Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure. BMJ Open Respir Res. 2020;7(1):e000650. https://doi.org/10.1136/bmjresp-2020-000650. PMID: 32847947; PMCID: PMC7451488.
Zucman N, Mullaert J, Roux D, Roca O, Ricard JD, Contributors. Prediction of outcome of nasal high flow use during COVID-19- related acute hypoxemic respiratory failure. Intens Care Med. 2020;46(10):1924–6.
Panadero C, Abad-Fernández A, Rio-Ramirez MT, et al. High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Multidiscip Respir Med. 2020;15(1):693. https://doi.org/10.4081/mrm.2020.693. PMID: 32983456; PMCID: PMC7512942.
Vianello A, Arcaro G, Molena B, et al. High-flow nasal cannula oxygen therapy to treat patients with hypoxemic acute respiratory failure consequent to SARS- CoV-2 infection. Thorax. 2020;75(11):998–1000.
Hifumi T, Jinbo I, Okada I, et al. The impact of age on outcomes of elderly ED patients ventilated due to community acquired pneumonia. Am J Emerg Med. 2015;33(2):277–81.
Frengley JD, Sansone GR, Shakya K, Kaner RJ. J Am Geriatr Soc. 2014;62(1):1–9.
Fujii M, Iwakami S, Takagi H, et al. Factors influencing weaning from mechanical ventilation in elderly patients with severe pneumonia. Geriatr Gerontol Int. 2012;12(2):277–83.
Cader SA, Vale RG, Castro JC, et al. Inspiratory muscle training improves maximal inspiratory pressure and may assist weaning in older intubated patients: a randomised trial. J Physiother. 2010;56(3):171–7.
Epstein CD, Peerless JR. Weaning readiness and fluid balance in older critically ill surgical patients. Am J Crit Care. 2006;15(1):54–64.
Ely EW, Evans GW, Haponik EF. Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit. Ann Int Med. 1999;131(2):96–104.
Kher S, Roberts RJ, Garpestad E, et al. Development, implementation, and evaluation of an institutional daily awakening and spontaneous breathing trial protocol: a quality improvement project. J Intensive Care Med. 2013;28(3):189–97.
Jackson DL, Proudfoot CW, Cann KF, Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 2010;14(2):R59. https://doi.org/10.1186/cc8956. Epub 2010 Apr 9. PMID: 20380720; PMCID: PMC2887180.
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874–82.
MacIntyre NR, Cook DJ, Ely EW, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(6 suppl):375S–95S.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.
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Lorente-Ros, M., Artigas, A., Lorente, J.A. (2022). Ventilation. In: Flaatten, H., Guidet, B., Vallet, H. (eds) The Very Old Critically Ill Patients. Lessons from the ICU. Springer, Cham. https://doi.org/10.1007/978-3-030-94133-8_18
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