Search

This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV).NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation.Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done.Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile.Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations.Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938-948.

During the COVID-19 pandemic, the considerable preponderance of deaths is occurring in older persons. The current Italian data, for example, indicate that persons aged 70 years and older contribute to about 85% of the death events [1]. In the scenario of rationing the resources, the differentiation between the causes of death can be difficult. Specifically, to establish if the death of an older patient is due to COVID-19 or the result of treatment limitations can be difficult [2]. The reading of actual pandemic from the geriatric point of view should include different planes: ethical, legal and clinical.

Some criteria and selection tools are, in a general line, useful for recognition of all elderly patients with COVID-19 disease. Furthermore, many organisations may influence this criterion such as WHO, scientific medical society, a single government or health ministers and hospital management systems. In this chapter, we analysed the requirements for admission of the elderly patients in a general ward starting from triage evaluation using the new proposed tool for the selection. The necessity of a comprehensive geriatric assessment with a holistic vision has been not so crucial as in this period.

The management of acute respiratory failure is more complicated in elderly patients. The reasons behind this difficulty are mainly related to the frailty and the comorbidities. In particular, the frailty is characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. In a few words, frailty means diminished organ reserve, including that of the lung. The first step in the management of acute respiratory failure remains to treat hypoxemia with oxygen therapy. The primary rationale of oxygen (O2) therapy is to prevent and correct arterial hypoxaemia (reduction of O2 in the blood) and any resulting hypoxia (the decrease of the O2 in the tissues) in patients with or at risk for impaired pulmonary gas exchange. The hypoxaemia is characterised by the partial pressure of O2 less than 60 mmHg in blood gas analysis or a SaO2 of

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 invasive mechanical ventilation (IMV) use decreased significantly even after adjustment for DNR (do not resuscitate) status. The noninvasive ventilation (NIV) use in the elderly represents a shift in managing acute respiratory failure. The NIV should be used with the correct indications. In choosing the setting, the physicians should take into account the safety of patients.

Elderly patients, frail, and with underlying many chronic comorbidities or severe illness are most at risk from COVID-19 pandemic. Recent data from the Italian Istituto Superiore di Sanita (ISS) showed that COVID-19 is more lethal in older subjects. In Italy, on the date of March 17, 2020, the overall case-fatality rate was 7.2%, and 96.4% of died patients had more than 60 years. When age groups stratified data, individuals aged 70 years or older represent 35.5% of cases, while subjects aged ≥80 years were 52.3% [1]. With respect to the severe context of widespread world mortality, the main aims of the palliative care (quality of life, discernment of patient goals, advance care planning, pain and symptom management, and support for caregivers over protracted trajectories) may appear not essential [2]. The COVID-19 pandemic showed, conversely, the limits of the healthcare system on managing elderly patient’s wishes even and expectations during the dreadful COVID-19 disease. During epidemic such as that of SARS CoV 2, the necessity of intensive care unit (ICU) beds could be not sufficient for the patients with severe respiratory distress (ARDS). Many recommendations suggest, in these contests, that the physicians should guarantee the healthcare resources to the patients with a higher life expectancy. The evaluation for the need for intensive care should include the severity of the disease, the comorbidity and the presence of multi-organ failure. Have still, in this period, the insight of patient goals such as wishes, advance care planning and even end of life preferences a central value? This chapter would analyse this prerogative in light of the severity of COVID pandemic.

Family members of older incompetent patients are increasingly playing an essential role in the decision-making process relating to medical treatment. Furthermore, rights of patients and carers and the extent of their legal involvement vary widely across the European Union. Starting with an illustrative case within the Italian legal framework, this review focuses on statutory laws in the European Union to analyse the role and the rights of surrogates on behalf of older incompetent patients. The authors have identified two main essential areas of surrogate's law in Europe, in the absence of the advance directives: the role of family members automatically accepted as surrogates by law and a legal representative appointed by a court.

Over the last two decades thanks to the advances in pharmacologic therapy, non-invasive positive pressure ventilation (NIPPV) and advanced directives, intubations in elderly patients with ARF decreased in the emergency department. This trend is associated with the progressively more evident efficacy of NIV as a palliative measure and in elderly patients. The ongoing management of NIV varies across Europe and the USA. In this chapter, the authors reported the main features of European and non-European perspectives in the use of the NIV in elderly patients and palliative context.

Acute respiratory failure (ARF) is a severe medical condition associated with high mortality and prolonged hospital stay. The management of ARF may require an escalation therapy that varies from oxygen therapy to mechanical ventilation both invasive than non-invasive [1], hence the necessity of a team with specific skills and expertise. The integrated management of a patient with ARF or acute-on-chronic respiratory failure in an acute hospital setting involves different physicians with different abilities that are in different environments (emergency room, pneumology wards, medicine wards, respiratory intermediate care units (RICUs), and intensive care units (ICUs)) [2]. For these reasons, ARF managing requires specific hospital health care plans that realise an efficient integration of the hospital physicians. In this way, the caring for the patients with ARF shall be adequate, safe, and may allow optimising the available hospital resources. The plans may vary according to the hospital setting.

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries. info:eu-repo/semantics/publishedVersion

Slow ventricular tachycardia (VT) in patients with devices such as an implantable cardioverter - defibrillator (ICD) is more common than in the rest of the population. The incidence in elderly patients with an ICD remains largely unknown. In younger patients, slow VT is generally asymptomatic or associated with limited clinical relevance. It may be efficiently and safely terminated by anti-tachycardia pacing. We present a case of slow VT in a 91-year-old man with ICD with type 1 acute respiratory failure and drowsiness. Very elderly patients who have poor cardiac reserve and minor deterioration in cardiac function can face serious consequences such as ventricular fibrillation, cardiac arrest, and sudden cardiac death. The persistent ventricular rhythm may have a deleterious effect on their haemodynamic status, with potential aggravation of symptoms of heart failure and further impairment of ventricular function.

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.

Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies against coagulation factor VIII and characterized by spontaneous hemorrhage in patients with no previous family or personal history of bleeding [1]. Bleeding is variable, ranging from acute, lifethreatening hemorrhage (for example, intracranial, retroperitoneal and gastrointestinal in 8–22 %) to mild bleeding that requires no treatment. Moreover, bleeding events could occur even after diagnosis or could be absent [2, 3]. The yearly incidence of AHA is reported as 1.5 million/ year with a typical bimodal age distribution: first peak among young adult, mainly in women who develop this complication in the post-partum period and second peak in the elderly [3, 4]. The median age is 78 years and the incidence per million/per year is increasing with age from 0.3 in 16–64-year-olds to 9 in 65–84-year-olds and 15 in those aged 85 and older [4]. The mortality rate is about 21 % although among elderly patients may be even higher [5–7]. Early and correct diagnosis and prompt treatment are crucial for the prognosis of this disorder. We report our experience with two consecutive elderly patients with AHA admitted to geriatric ward of San Giuseppe Moscati Hospital, Avellino, between 2012 and 2013. Their diagnoses were idiopathic AHA for first patient and AHA autoimmune disorders related for the second patient.

Introduction A leading role for non-invasive ventilation (NIV), as comfort treatment or palliative care, is actually recognized for very old patients suffering from ARF. NIV was frequently used in both ICU and respiratory ICU (RICUs) for very old patients and it is associated with a reduced rate of endotracheal intubations and mortality. This study aims to evaluate the effects of NIV, performed in a setting of half-open geriatric ward with family support, in a cohort of very old patients with ARF and DNI decision. Methods A consecutive cohort of 20 very old patients with DNI decision was admitted in our 26-bed geriatric ward during a 6 months’ period. DNI decision was obtained in emergency room with an intensive care physician supported by a psychologist. Pressure support ventilation was the first choice of NIV. NIV has been performed by three adequately trained geriatricians, with one of them experienced in ICU, and in close collaboration with intensive care physicians. Arterial blood gases, to assess the response to ventilation, were obtained after 1, 6 and 12 h. NIV settings were modified according to arterial blood gas analyses or respiratory fatigue, if needed. Results Therefore, 75 % of patients were discharged home and 12 out of 20 patients had home respiratory support. PaO2/FiO2 ratio and pH increased while PaCO2 decreased during the 12 h of NIV with statistical significance. At the admission, alive patients had PaCO2 significantly lower than dead patients. After 12 h, alive patients had a better pH than dead patients. Dead patients experienced more complication than survivors. Conclusion Very old DNI patients with ARF could be treated with NIV in half-open geriatric ward with trained physicians and nurses. The presence of family members may improve patients’ comfort and reduce anxiety level even at the end of life. Further studies are needed to address the effective role of NIV in very old patients with DNI decisions.

The activity of the hypothalamic-GH-insulin-like growth factor (IGF) network declines with age. It has recently been shown that increased cardiovascular mortality occurs in adults with GH deficiency. As hypercholesterolemia is common in GH-deficient adults, and because there is experimental evidence that GH may play a role in regulating plasma cholesterol, we decided to investigate the activity of the GH-IGF axis in an elderly population by measuring serum IGF-I, IGF-II, and IGF-binding protein-3 (IGFBP-3) levels and to study their relationship with blood lipid levels. One hundred and thirty-two elderly subjects, 52 men and 80 women, were studied (age range, 60–91 yr). Men had significantly lower levels of IGFBP-3, high density lipoprotein cholesterol (HDL-C) and apoprotein A1 (ApoA1) compared to the women, whereas IGF-I and IGF-II were only slightly lower. Using linear regression analysis, we observed an inverse relationship of age with IGF-I (r = −0.35; P < 0.001), IGF-II (r = 0.40; P < 0.001), IGFBP-3 (r = 0.52; P < 0.001), body mass index, and lipid levels. Univariate regression analysis showed a strong and positive correlation of both IGF-I and IGFBP-3 with HDL-C and ApoA1. Partial correlation analysis, after adjustment for age and body mass index, showed that IGFBP-3 and IGF-II were still significantly and positively related to HDL-C and ApoA1. Furthermore, a strong association was documented among IGF-I, IGF-II, and IGFBP-3. These data demonstrate that even in an elderly population, further aging is accompanied by a progressive decline in circulating IGF-I, IGF-II, and IGFBP-3, suggesting a continuing diminution of the GH-IGF axis throughout aging. Moreover, the strong correlation between HDL-C and an index of GH secretion, such as IGFBP-3, suggests that GH might play an important role in lipid metabolism in healthy elderly subjects.

Background and aims: The aim of our study was to understand how demographic and environmental factors may be associated with cognitive functions in a rural population of Southern Italy, with a very high percentage of elderly persons with little formal education. Materials and methods: From the population registry of San Marcellino (province of Caserta), out of 1089 persons aged over 60 years, a random sample of 300 residents received a door-to-door visit. Two hundred and twenty-six subjects were judged as not having significant cognitive impairment, on the basis of their personal history and Clinical Dementia Rating score (