Effect of noninvasive mechanical ventilation in elderly patients with hypercapnic acute-on-chronic respiratory failure and a do-not-intubate order

Original Research

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Authors: Paolo Scarpazza, Cristoforo Incorvaia, Giuseppe di Franco, Stefania Raschi, Pierfranco Usai, et al

Published Date October 2008 Volume 2008:3(4) Pages 797 - 801

DOI: http://dx.doi.org/10.2147/COPD.S3976

Paolo Scarpazza¹, Cristoforo Incorvaia², Giuseppe di Franco¹, Stefania Raschi¹, Pierfranco Usai¹, Monica Bernareggi¹, Cristiano Bonacina¹, Chiara Melacini¹, Silvia Vanni¹, Serena Bencini¹, Chiara Pravettoni², Giuseppe Di Cara³, Mona-Rita Yacoub⁴, Gian Galeazzo Riario-Sforza², Enrico Guffanti⁵, Walter Casali¹

¹Divisione di Broncopneumotisiologia, Ospedale Civile, Vimercate, Italy; ²Pulmonary rehabilitation, Istituti Clinici di Perfezionamento, Milan, Italy; ³University Department of Medical and Surgical Specialties and Public Health, Perugia, Italy; ⁴Allergy and Immunology Unit, IRCCS San Raffaele Hospital, Milan, Italy; ⁵Pulmonary rehabilitation, INRCA, Casatenovo, Italy

Abstract: Noninvasive mechanical ventilation (NIMV) is effective in the treatment of patients with acute respiratory failure (ARF). It proved to reduce the need of endotracheal intubation (ETI), the incidence of ETI-associated pneumonia, and mortality compared to nonventilated patients. A particular aspect concerns the outcome of NIMV in patients referring to an emergency room (ER) for ARF, and with a do-not-intubate (DNI) status due to advanced age or critical conditions. The aim of our study is to assess the outcome of NIMV in a group of elderly patients with acute hypercapnic ARF who had a DNI status. An overall number of 62 subjects (30 males, 32 females, mean age 81 ± 4.8 years, range 79–91 years) referred to our semi-intensive respiratory department were enrolled in the study. The underlying diseases were severe chronic obstructive pulmonary disease (COPD) in 50/62 subjects, restrictive thoracic disorders in 7/62 subjects, and multiorgan failure in 5/62 subjects. Fifty-four/62 patients were successfully treated with NIMV while 2/62 did not respond to NIMV and were therefore submitted to ETI (one survived). Among NIMV-treated patients, death occurred in 6 patients after a mean of 9.9 days; the overall rate of NIMV failure was 12.9%. Negative prognostic factors for NIMV response proved to be: an older age, a low Glasgow Coma Score, a high APACHE score at admission, a high PaCO₂ after 12 hours and a low pH both after 1 and 12 hours of NIMV. We conclude that elderly patients with acute hypercapnic ARF with a DNI status can be successfully treated by NIMV.

Keywords: acute respiratory failure, noninvasive mechanical ventilation, endotracheal intubation, do-not-intubate, COPD, oxygen therapy

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