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Cammarota G, Simonte R, De Robertis E. Treatment of patients with 'do not intubate orders'. Curr Opin Anaesthesiol 2023; 36:183-187. [PMID: 36794875 DOI: 10.1097/aco.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW Do-not-intubate (DNI) orders are more frequently encountered over time. This widespread diffusion of DNI orders make it essential to develop therapeutic strategies matching patient's and his family willingness. The present review sheds light on the therapeutic approaches employed to support respiratory function of patients with DNI orders. RECENT FINDINGS In DNI patients, several approaches have been described to relieve dyspnoea and address acute respiratory failure (ARF). Despite its extensive use, supplemental oxygen is not so useful in assuring dyspnoea relief. Noninvasive respiratory support (NIRS) is frequently employed to treat ARF in DNI patients. Also, to enhance DNI patients comfort during NIRS, it is worthy to point out the role of analgo-sedative medications. Lastly, a particular aspect concerns the first waves of coronavirus disease 2019 pandemic, when DNI orders have been pursued on factors unrelated to patient's wishes, in the total absence of family support due to the lockdown policy. In this setting, NIRS has been extensively employed in DNI patients with a survival rate of around 20%. SUMMARY In dealing with DNI patients, the individualization of treatments is of pivotal importance to respect patient's preferences and improve quality of life at the same time.
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Simpson N, Milnes S, Steinfort D. Don't forget shared decision-making in the COVID-19 crisis. Intern Med J 2020; 50:761-763. [PMID: 32537930 PMCID: PMC7322986 DOI: 10.1111/imj.14862] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 01/08/2023]
Abstract
Mechanical ventilation as a resource is limited and may lead to poor outcomes in at‐risk populations. Critical care supports may not be preferred by those at risk of deterioration in the COVID‐19 setting. Patient‐centred communication and shared decision‐making should continue to remain central to clinical practice.
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Affiliation(s)
- Nicholas Simpson
- Intensive Care Unit, Barwon Health, Geelong, Victoria, Australia
| | - Sharyn Milnes
- Clinical Education and Training Unit, Barwon Health, Geelong, Victoria, Australia
| | - Daniel Steinfort
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Vargas N, Tibullo L, Landi E, Carifi G, Pirone A, Pippo A, Alviggi I, Tizzano R, Salsano E, Di Grezia F, Vargas M. Caring for critically ill oldest old patients: a clinical review. Aging Clin Exp Res 2017; 29:833-845. [PMID: 27761759 DOI: 10.1007/s40520-016-0638-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022]
Abstract
Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest 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. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.
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Affiliation(s)
- Nicola Vargas
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy.
| | - Loredana Tibullo
- Medicine Ward, Medicine Department, "San Giuseppe Moscati" Hospital, via Gramsci, 81031, Aversa, CE, Italy
| | - Emanuela Landi
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Giovanni Carifi
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Alfonso Pirone
- Clinical Nutrition and Dietology Unit, Medicine Department, Azienda Ospedaliera di Rilievo Nazionale e di alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Antonio Pippo
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Immacolata Alviggi
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Renato Tizzano
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Elisa Salsano
- Department of Clinical Disease and Internal Medicine, Federico II University of Naples, via Pansini, 80121, Naples, Italy
| | - Francesco Di Grezia
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Maria Vargas
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini, 89121, Naples, Italy
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Piroddi IMG, Barlascini C, Esquinas A, Braido F, Banfi P, Nicolini A. Non-invasive mechanical ventilation in elderly patients: A narrative review. Geriatr Gerontol Int 2016; 17:689-696. [PMID: 27215767 DOI: 10.1111/ggi.12810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/17/2016] [Accepted: 03/25/2016] [Indexed: 10/21/2022]
Abstract
The treatment of acute respiratory failure with non-invasive ventilation (NIV) as a first-line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of "do not intubate" orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689-696.
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Affiliation(s)
| | - Cornelius Barlascini
- Hygiene and Health Medicine Unit Hospital of Sestri Levante, Sestri Levante, Italy
| | | | - Fulvio Braido
- Allergy and Respiratory Diseases Unit Department IRCSS AOU San Martino- IST, Genova, Italy
| | - Paolo Banfi
- Pulmonary Rehabilitation Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Antonello Nicolini
- Respiratory Diseases Unit Hospital of Sestri Levante, Sestri Levante, Italy
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Tabernero Huguet E, Gil Alaña P, Arana-Arri E, Citores Martín L, Alkiza Basañez R, Hernandez Gil A, Gil Molet A. [Non-invasive ventilation in 'do-not-intubate' patients in a chronic disease hospital. One year follow-up study]. Rev Esp Geriatr Gerontol 2016; 51:221-4. [PMID: 26811123 DOI: 10.1016/j.regg.2015.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 11/23/2015] [Accepted: 11/26/2015] [Indexed: 11/30/2022]
Abstract
UNLABELLED Elderly patients with multiple morbidity and do not intubate (DNI) orders frequently present with acute respiratory failure. There are data supporting the effectiveness of non-invasive ventilation (NIV) in this context. Our chronic disease hospital developed an integrated care clinical pathway for the use of NIV in acute respiratory failure in the emergency room and wards in 2010. The aim of this study was to assess the outcome of NIV in patients with acute respiratory failure who had a DNI order in a sub-acute care hospital. METHODS Observational, one year-follow up study. The main variables were in-hospital mortality and one year mortality. Other variables recorded were: demographics, clinical data, functional data, performance of daily life activities, dementia, arterial blood gases and re-admissions. RESULTS The study included a total of 102 patients, of which 22% were in institutions. The mean age 81±7.47% males, with a Charlson index 3.7±1, and Barthel index 54±31. The overall mortality during the admission was 33% (34 patients). Among those patients ventilated outside the protocol indication, the mortality was significantly greater, at 71% (P>.05). Overall one-year survival rate was 46%. This survival rate was statistically higher in patients with obesity hypoventilation syndrome and a Barthel >50. CONCLUSIONS NIV is a useful technique in a hospital for chronic patients in an elderly population with a therapeutic ceiling. Despite their disease severity and comorbidity, acceptable survival rates are achieved. A correct case selection is needed. Obesity hypoventilation syndrome and those with Barthel index >50 have a better prognosis.
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Affiliation(s)
| | - Pilar Gil Alaña
- Servicio de Neumología, Hospital de Santa Marina, Bilbao, España
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Nicolini A, Santo M, Ferrera L, Ferrari-Bravo M, Barlascini C, Perazzo A. The use of non-invasive ventilation in very old patients with hypercapnic acute respiratory failure because of COPD exacerbation. Int J Clin Pract 2014; 68:1523-9. [PMID: 25283150 DOI: 10.1111/ijcp.12484] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
AIMS We prospectively enrolled 207 patients (121 were 75 or older and 86 younger than 75) who were admitted to three Respiratory Monitoring Units. The primary outcomes were intubation and mortality rates; the secondary outcomes were changes in arterial blood gases analysis, non-invasive ventilation (NIV) duration and length of hospital stay. RESULTS Hospital mortality was similar in the two groups, as were intubation rates. The proportion who died in the very old patient group was 19.8% (24/121) vs. 10.4% (9/86) in the younger group. Intubation rate was 10.7% (13/121) in the very old patient group and 11.6% (10/86) in the younger group. The presence of comorbidities, the severity of illness (SAPS II), the level of consciousness, NIV failure (intubation), absolute value of pH prior to NIV, as well as the changes in pH and paCO2 and PaO2 /FiO2 after 2 h of NIV, were the variables associated with higher mortality. Very old patients had significantly higher NIV duration than younger patients (69.0 ± 47.0 vs. 57.0 ± 27.0 h) (p ≤ 0.03) and hospital stays (11.6 ± 3.8 vs. 8.4 ± 1.4) (p ≤ 0.02). CONCLUSIONS The use of NIV in very old patients was effective in many cases. Endotracheal intubation after NIV failure was not efficacious in either group.
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Affiliation(s)
- A Nicolini
- Respiratory Medicine Unit, ASL4 Chiavarese, Sestri Levante, Italy
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Lacroix G, Legodec J, D'Aranda E, Esnault P, Romanat PE, Goutorbe P. Is non-invasive ventilation the best ventilatory support for 'do not intubate' patients? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:442. [PMID: 22871046 PMCID: PMC3580715 DOI: 10.1186/cc11435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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