Challenges on non-invasive ventilation to treat acute respiratory failure in the elderly

Abstract

Acute respiratory failure is a frequent complication in elderly patients especially if suffering from chronic cardio-pulmonary diseases. Non-invasive mechanical ventilation constitutes a successful therapeutic tool in the elderly as, like in younger patients, it is able to prevent endotracheal intubation in a wide range of acute conditions; moreover, this ventilator technique is largely applied in the elderly in whom invasive mechanical ventilation is considered not appropriated. Furthermore, the integration of new technological devices, ethical issues and environment of treatment are still largely debated in the treatment of acute respiratory failure in the elderly.This review aims at reporting and critically analyzing the peculiarities in the management of acute respiratory failure in elderly people, the role of noninvasive mechanical ventilation, the potential advantages of applying alternative or integrated therapeutic tools (i.e. high-flow nasal cannula oxygen therapy, non-invasive and invasive cough assist devices and low-flow carbon-dioxide extracorporeal systems), drawbacks in physician’s communication and “end of life” decisions. As several areas of this topic are not supported by evidence-based data, this report takes in account also “real-life” data as well as author’s experience.The choice of the setting and of the timing of non-invasive mechanical ventilation in elderly people with advanced cardiopulmonary disease should be carefully evaluated together with the chance of using integrated or alternative supportive devices. Last but not least, economic and ethical issues may often challenge the behavior of the physicians towards elderly people who are hospitalized for acute respiratory failure at the end stage of their cardiopulmonary and neoplastic diseases.

Highlights in acute respiratory failure

“…In noninvasive ventilation (NIV) a dedicated interface is used, while with invasive mechanical ventilation (IMV) assistance is provided through an endotracheal tube or tracheostomy. New therapeutic options include high-flow nasal cannula [5], noninvasive and invasive cough assist strategies, high-frequency chest wall oscillation, and extracorporeal CO 2 removal (ECCO 2 R) [6]. Finally, refractory hypoxaemia during IMV may require additional integrated strategies such as prone ventilation, neuromuscular blockage, and implementation of "artificial lung" by means of extracorporeal membrane oxygenation [7].…”

High‐flow nasal cannula oxygen therapy for acute respiratory failure in a non‐intensive geriatric setting

“…Nevertheless, further studies should identify less‐severe older ARF patients who might benefit from an early HFNC treatment, even in geriatric wards. Furthermore, HFNC requires less training by hospital staff, is well tolerated and does not compromise communication, normal nutrition and hydration, thereby potentially preventing delirium and the “geriatric cascade.” Consequently, HFNC might significantly improve quality of life, either during hospitalization or in the post‐hospital settings, and might represent an attractive alternative to NIV for geriatric patients still requiring respiratory support after discharge.…”

A study of noninvasive positive-pressure mechanical ventilation in the treatment of acute lung injury with a complex critical care ventilator. Is it the best choice?

“…The correct choice of ventilator is crucial for the success of the technique; inadequate equipment may lead to poor tolerance and excessive leakage and increases the chances of failure. [9][10][11] Declaration of conflicting interest…”