Correspondence / American Journal of Emergency Medicine 36 (2018) 2307–2335 2321

The reduced use of intubations in elderly patients in the emergency department: Many insights behind a historical trend

Johnson et al. in their article [1] bring to light, albeit the limitations of the study, some important aspects about the reduction of intubations in elderly patients in the emergency department over the past two decades. The authors identified essentially three specific reasons behind this trend: the increased use of noninvasive mechanical ventilation (NIMV), the ad- vancements in the medical management of cardiac heart failure (CHF) and increased use of Advance directives. We agree with the fact that this phenomenon is multifactorial. The first cause is the substantial evidence of the use of NIMV in patients with COPD. In the 1990s there was the con- siderable evidence that the intermittent positive airway pressure deliv- ered by facemask reduced the need for invasive mechanical ventilation in COPD patients with hypercapnic respiratory failure [2]. Since then, this evidence has been strengthened by many systematic reviews and RCTs. Age did not imply a weaker response. The use of NIPPV has in- creased significantly over time among patients (of all classes of age) hos- pitalized for acute Exacerbations of COPD, whereas the need for intubation and in-hospital mortality has declined [3].

However, some important practical aspects need to take into ac- count in this study for a proper clinical extrapolations.

First, the demographic changes determined a significant increase in the percentage of adults who are very elderly and the proportion of their hospital admissions. In this group, the IMV use decreased signifi- cantly even after adjustment for DNR (do not resuscitate) status [4]. The poor prognosis and the subsequent belief that IMV and ICU care could be deleterious are two conditioning factors in daily clinical prac- tice. The IMV may be “a questionable option” in some (do not intubate) DNI related clinical scenarios, for example in an older patient, bedrid- den, who cannot perform ADLs independently, with multimorbidity and acute respiratory failure, in the absence of Advance directives. The NIMV could be a leading mode of comfort care only. The authors in their study did not identify the data about the patients that refused en- dotracheal intubation but accepted the NIMV. We believe that this data could be interesting. We think, in our experience, that the adoption of advance directives influences only marginally the trend of reduced intu- bations. In Europe, many states have not yet adopted advance directives. Frequently, where the law provides this model, the majority of elderly patients with chronic illnesses do not have advance directives in place on admission to hospital [5].

Secondly, we agree with the evidence of the use of NIMV-CPAP in

cardiac pulmonary edema. The first RCT that showed the NIMV CPAP re- duces Intubation rate in cardiac pulmonary edema [6], opened the door to widespread use in clinical practice.

We believe that respiratory failure requiring IMV in very elderly population identifies a population at high risk of death. The traditional goals of ICU of reducing morbidity and mortality, of maintaining Organ functions and restoring health, caring for severely very old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their Life expectancy and the impact of multimorbidity [7]. The majority of in- vestigations are retrospective. The need for extensive prospective study is crucial.

Conflict of interest

Authors declare no conflict of interest.

Abbreviations: CHF, cardiac heart failure, COPD, chronic obstructive pulmonary disease, CPAP, continuous positive airway pressure, CPE, cardiac pulmonary edema, DNR, do not resuscitate, ICU, Intensive Care Unit, IMV, invasive mechanical ventilation, NIMV, noninvasive mechanical ventilation

Nicola Vargas

Geriatric and Intensive Geriatric cares, “San Giuseppe Moscati” Hospital,

Avelllino, Italy Corresponding author at: Geriatric and Intensive Geriatric Care Unit, “San Giuseppe Moscati” Hospital, Avellino, Italy.

E-mail address: [email protected].

Antonio M. Esquinas

Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain

24 March 2018

https://doi.org/10.1016/j.ajem.2018.04.021

References

1. Johnson Timothy, et al. Intubations in elderly patients, have decreased from 1999 through 2014-results of a multi-center cohort study. Am J Emerg Med 2018 Nov;36 (11):1964-6.
2. Brochard L, Isabey D, Piquet J, Amaro P, Mancebo J, Messadi AA, et al. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. N Engl J Med 1990;323:1523-30.
3. Chandra D, Stamm JA, Taylor B, et al. Outcomes of NIV for acute exacerbations of COPD in the United States, 1998-2008. Am J Respir Crit Care Med 2012;185:152-9.
4. Esteban A, Anzueto A, Frutos-Vivar F, et al. Outcome of older patients receiving me- chanical ventilation. Intensive Care Med 2004;30:639-46.
5. Tierney WM, Dexter PR, Gramelspacher GP, Perkins AJ, Zhou X-H, Wolinsky FD. The

   effect of discussions about advance directives on Patients’ satisfaction with primary care. J Gen Intern Med 2001;16(1):32-40.

   Bersten AD, Holt AW, Vedig AE, Skowronski GA, Baggoley CJ. Treatment of severe car- diogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med 1991;325:1825-30.

6. Vargas N, Tibullo L, Landi E, et al. Caring for critically ill oldest old patients: a clinical review. Aging Clin Exp Res 2017;29:833. https://doi.org/10.1007/s40520-016-0638.

   Impact of a CPRMeter Feedback device on chest Compression quality performer by nurses: A randomized crossover study

   To the Editor,

   Firefighters-paramedics who arrive at the incident scene often first provide help to the victims even before the Emergency Medical Service teams arrive. Trauma patients who have impaired awareness often have difficulty maintaining airway patency, therefore firefighters are the ones who must protect the patency and when it is necessary support breathing [1]. Cardiopulmonary resuscitation is the example of another situation when it is required to use devices which maintain the airway patency [2,3]. The American Society of Cardiology guidelines indicate the need to minimize pauses during the chest compressions which is achieved by the use of endotracheal intubation or supraglottic airway devices (SAD) [4]. Various studies indicate that both medical profes- sionals and non-medical personnel, after completing just a short training, are able to secure the airways with SADs achieving high efficiency [3,5-7]. Thanks to SADs, it is possible to perform Continuous chest compressions and monitor respiratory parameters with capnometry [8].

   The aim of the study was to assess the time it takes to Secure airway patency with the use of two different SADs and to assess firefighters’ at- titude towards the usage of SADs in cardiac arrest patients.

   The study included 34 firefighters who work in the State Fire Service. Prior to the study, participants took part in the training of qualified first aid which covered problems regarding both cardiopulmonary resuscita- tion of children and adults and maintaining the airway patency. During the study’s theoretical part, a qualified instructor demonstrated the cor- rect way of using both types of SADs: Laryngeal Mask Airway (LMA; SUMI, Sulejowek, Poland) and King LT-D Supraglottic airways (LTD; AMBU INC., Ballerup, Denmark) to maintain the airway patency. After