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

Published:April 12, 2018DOI:https://doi.org/10.1016/j.ajem.2018.04.021
      Johnson et al. in their article [
      • Johnson Timothy
      • et al.
      Intubations in elderly patients, have decreased from 1999 through 2014–results of a multi-center cohort study.
      ] 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 advancements 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 considerable evidence that the intermittent positive airway pressure delivered by facemask reduced the need for invasive mechanical ventilation in COPD patients with hypercapnic respiratory failure [
      • Brochard L.
      • Isabey D.
      • Piquet J.
      • Amaro P.
      • Mancebo J.
      • Messadi A.A.
      • et al.
      Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask.
      ]. 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 increased significantly over time among patients (of all classes of age) hospitalized for acute exacerbations of COPD, whereas the need for intubation and in-hospital mortality has declined [
      • Chandra D.
      • Stamm J.A.
      • Taylor B.
      • et al.
      Outcomes of NIV for acute exacerbations of COPD in the United States, 1998–2008.
      ].

      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)

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      References

        • 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. 1990; https://doi.org/10.1016/j.ajem.2018.02.022
        • Brochard L.
        • Isabey D.
        • Piquet J.
        • Amaro P.
        • Mancebo J.
        • Messadi A.A.
        • et al.
        Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask.
        N Engl J Med. 1990; 323: 1523-1530
        • Chandra D.
        • Stamm J.A.
        • 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: 152-159
        • Esteban A.
        • Anzueto A.
        • Frutos-Vivar F.
        • et al.
        Outcome of older patients receiving mechanical ventilation.
        Intensive Care Med. 2004; 30: 639-646
        • Tierney W.M.
        • Dexter P.R.
        • Gramelspacher G.P.
        • Perkins A.J.
        • Zhou X.-H.
        • Wolinsky F.D.
        The effect of discussions about advance directives on Patients' satisfaction with primary care.
        J Gen Intern Med. 2001; 16: 32-40
        • Bersten A.D.
        • Holt A.W.
        • Vedig A.E.
        • Skowronski G.A.
        • Baggoley C.J.
        Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask.
        N Engl J Med. 1991; 325: 1825-1830
        • Vargas N.
        • Tibullo L.
        • Landi E.
        • et al.
        Caring for critically ill oldest old patients: a clinical review.
        Aging Clin Exp Res. 2017; 29: 833https://doi.org/10.1007/s40520-016-0638