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

Raffaele Scala, Raffaele Scala

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 challenges 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.

Keywords: Acute respiratory failure; Bronchoscopy; CO2-removal; Elderly patient; End-of-life; Endotracheal intubation; High-flow nasal cannula; Non-invasive mechanical ventilation.

Figures

Fig. 1
Fig. 1
Therapeutic options in elderly with acute respiratory failure
Fig. 2
Fig. 2
Characteristics of the different settings where non-invasive ventilation (NIV) may be applied. Green, yellow, red indicates respectively a highly favorable, favorable, unfavorable issue for the different enviroment. ICU: Intensive Care Unit, RICU: Respiratory Intensive Care Unit, ED: Emergency Department, ETI: endotracheal intubation, EOL: end-of-life
Fig. 3
Fig. 3
Reasons for applying non-invasive ventilation in elderly at different stages of acute respiratory failure
Fig. 4
Fig. 4
Flow-chart depicting the potential integrated respiratory therapies in adjunct to NIV in case of risk of failure in cases of elderly patients with DNI status. ARF: acute respiratory failure, ECCO2R: extracorporeal CO2 removal, FOB: flexible bronchoscopy, HES: hypercapnic encephalopathy syndrome, HFCWO: high-frequency chest wall oscillation, HFNC: high-flow nasal cannula, NIV: non-invasive ventilation

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