[Evidence-based medicine: implications from the guideline "non-invasive ventilation" in critically ill elderly patients]

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Intensive care of geriatric patients-a thin line between under- and overtreatment

Demographic developments are leading to an ever-increasing proportion of elderly and aged patients in hospitals at all levels of care, and even more patients from these age groups are to be expected in the future. Based on the projected population development, e.g., in Norway, an increase in intensive care beds of between 26 and 37% is expected by 2025. This poses special challenges for the treatment and management of geriatric intensive care patients. The acute illness is not the only decisive factor, but rather the existing multimorbidity and functional limitations of this vulnerable patient group must likewise be taken into account. Age per se is not the sole determinant of prognosis in critical patients, even though mortality increases with age.

[Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age]

Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.

[Requirements for perioperative intensive care of geriatric patients]

BACKGROUND

Demographic change has also caused changes in perioperative intensive care because the proportion of geriatric patients who must undergo surgical procedures is increasing. With the current preoperative assessment instruments, it is still not possible to identify high-risk patients of this collective or to make a reliable prognosis concerning postoperative course.

MATERIALS AND METHODS

In addition to pain control, important aspects to minimize complications in postoperative intensive care include adequate oxygenation, adequate fluid management, an adequate supply of energy and nutrients, good control of blood sugar levels, and early mobilization of patients.

RESULTS

The perioperative intensive care treatment of geriatric patients requires the readiness to engage in interdisciplinary collaboration because only with this close dialog can the treatment results be sustained.