How do older ventilated patients fare? A survival/functional analysis of 641 ventilations

doi:10.1016/j.jcrc.2009.01.015

Journal of Critical Care

Volume 24, Issue 3, September 2009, Pages 340-346

https://doi.org/10.1016/j.jcrc.2009.01.015 Get rights and content

Abstract

Background

The outcome of mechanical ventilation in elderly patients should be evaluated by integrating survival rates with functional state over time after the ventilation episode.

Objectives

The aim of this study was to measure the survival rate and functional state of elderly ventilated patients and to present an integrated analysis of both outcome measures.

Methods

This is a prospective observational, noninterventional study of 641 invasive medical ventilations of elderly (65+ years) patients in medical wards and intensive care units.

The functional state, by the Functional Independence Measure scale, was measured before hospitalization, at discharge from the hospital, and 1 year later.

Results

Survival rates at the end of hospitalization and 3, 6, and 12 months later were 33%, 28%, 25%, and 22%, respectively. According to a combined survival/functional analysis, only 11% of all ventilated elderly patients were doing well (Functional Independence Measure scale score, ≥90) a year after the hospitalization. The rates for this condition ranged from 23% for acute exacerbation of chronic obstructive pulmonary disease to 0% for stroke and hospital-acquired pneumonia.

Conclusions

In elderly patients treated with mechanical ventilation, the outcomes in the period immediately after ventilation and later on are poor. In this group of patients, functional outcomes should be integrated with survival analysis for a meaningful assessment of the outcomes of treatment with mechanical ventilation to provide patients, families, practitioners, and society with reliable information on which life or death decisions can be based.

Introduction

The need for invasive mechanical ventilation in general and among elderly patients in particular entails a high mortality rate, both in the immediate time and at a later time [1], [2], [3], [4], [5], [6]. In addition, this treatment can cause a significant reduction in the functional state of elderly patients who survive ventilation [3], [7], [8], [9].

Over the last 2 decades, a large number of studies that assessed the outcome of mechanical ventilation have been published. A review of these articles points to 4 primary characteristics that they share: (a) most of these studies related only to patients who were ventilated in intensive care units (ICUs), ignoring all patients who were ventilated in other frameworks, usually medicine wards; (b) the age range of ventilated patients in those studies was usually very broad [6], [8], [10], [11], [12], [13] and only a few included elderly patients exclusively; (c) the outcome measure was usually in-hospital mortality (or survival), and only some of them presented data on the functional state of the patients as well [3], [7], [8], [9], [12], [13], [14], [15]; and (d) the outcome was usually measured at the end of hospitalization, and only in some cases [2], [3], [4], [5], [7], [9], [12], [13], [14], [15], [16] did the follow-up go beyond that point. In all the articles that were surveyed, there was no outcome study that related to all of the elderly patients (and only to them) who were ventilated in the hospital, their functional state, and the follow-up period after they were discharged from the hospital.

The central hypothesis of the study was that the outcome of mechanical ventilation in elderly patients should be evaluated by integrating survival rates with functional state over time after the ventilation episode. In light of this hypothesis, the aims of the present study were (a) to measure the survival rate and functional state of all elderly patients who were invasively ventilated for medical indications, at the end of hospitalization and 1 year later, and (b) to present an integrated analysis of survival and functional state, through their principal characteristics, in this study population at the 2 points in time.

Section snippets

Study population

All hospitalized patients 65 years or older who underwent tracheal intubation for mechanical ventilation during the study period for reasons unrelated to trauma and/or surgical intervention were included in the study. The patients were ventilated in 7 internal medicine wards and in the Department of Neurology (350 beds in all), in the general ICU, in the medicine ICU, and in the intensive coronary care unit (27 intensive care beds in all) in the Soroka University Medical Center in Beer-Sheva, a

Results

In the course of 2 years between July 1, 2004, and June 30, 2006, 641 ventilations for medical indications were carried out in 617 elderly patients 65 years or older (20 patients had 2 ventilations and 2 patients had 3 ventilations each in different hospitalizations during the study period, with an interval of at least 6 months between any 2 episodes) in the Soroka University Medical Center. This group of ventilations comprised the study population. Of these ventilations, 349 (54.4%) were

Discussion

The principal innovation of the present study is that it includes all the elderly patients who were ventilated mechanically for medical reasons in the hospital during the study period, most of them (54%) outside ICUs. This unique characteristic is particularly striking in view of the fact that almost all corresponding series in the literature included only patients who were ventilated in ICUs. The issue of triaging elderly ventilated patients to ICUs or other hospital wards is wide-ranging and

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Cited by (23)

In-hospital mortality associated factors in elderly patients with invasive mechanical ventilation in the emergency department
2021, Enfermeria Intensiva
Identificar los factores asociados a mortalidad intrahospitalaria, estimar la tasa de intubación y describir la mortalidad intrahospitalaria de mayores de 65 años que requirieron ventilación mecánica invasiva (VMI) en el servicio de urgencias.
Estudio de cohorte retrospectiva con pacientes mayores de 65 años, intubados en la central de emergencias del adulto entre 2016 y 2018 en un hospital de alta complejidad. Se consignaron datos demográficos, comorbilidades y scores de severidad al ingreso. Se realizaron análisis bivariado y multivariado con regresión logística en relación a mortalidad hospitalaria y posibles confundidores.
Un total de 285 pacientes con media de 80 años requirieron VMI en urgencias durante una mediana de 3 días, y con media de 20 puntos de severidad según APACHE II. La tasa de VMI resultó 0,48% (IC95% 0,43-0,54), y 55,44% (158) fallecieron. Los factores asociados a mortalidad tras el ajuste por edad y sexo fueron: accidente cerebrovascular (OR 2,13; IC95%1,21-3,76), insuficiencia renal crónica (OR 4,38; IC95%1,91-10,04), índice de Charlson (OR 1,19; IC95%1,02-1,38), APACHE II (OR 1,07; IC95%1,02-1,12) y SOFA (OR 1,14; IC95%1,03-1,27).
Nuestra tasa de VMI fue inferior a la declarada por Johnson et al. en Estados Unidos en 2018 (0,59%). La mortalidad intrahospitalaria de nuestro estudio superó la predicha por el score de APACHE II (40%) y de SOFA (33%), sin embargo fue consistente con la reportada por Lieberman et al. en Israel y Esteban et al. en Estados Unidos.
Si bien la tasa de requerimiento de VMI en el servicio de emergencias fue baja, más de la mitad fallecieron durante su hospitalización. Las enfermedades cerebrovasculares y renales preexistentes y los altos puntajes en el índice de comorbilidades y en los scores de gravedad al ingreso fueron predictores independientes para mortalidad intrahospitalaria.
To identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED).
Retrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders.
A total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43-.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95%CI 1.21-3.76), chronic kidney failure, (OR 4.,38; 95%CI 1.91-10.04), Charlson index (OR 1.19; 95%CI 1.02-1.38), APACHE II score (OR 1.07; 95%CI 1.02-1.12), and SOFA score (OR 1.14; 95%CI 1.03-1.27).
Our IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States.
Although the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.
Elderly patients and intensive care: Systematic review and geriatrician's point of view
2017, Journal Europeen des Urgences et de Reanimation
This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy).
This article is a republication of an article published in La revue de médecine interne https://doi.org/10.1016/j.revmed.2017.01.014.
The Editor in chief of La revue de médecine interne, the French Society of Internal Medicine and the corresponding author had first given their agreement for this republication.
However, this article is finally retracted at the request of the three authors, Hélène Vallet, Jacques Boddaert and Bruno Riou, who finally disagree with this republication.
Elderly patients and intensive care: Systematic review and geriatrician's point of view
2017, Revue de Medecine Interne
Avec le vieillissement de la population, le taux d’admission des patients âgés admis en réanimation augmente de manière importante. L’objectif de cette mise au point est de faire un état des lieux de la littérature sur la réanimation du sujet âgé concernant les données démographiques, les critères d’admission, la mortalité, le pronostic fonctionnel et les aspects éthiques. Nous aborderons également plus spécifiquement les données sur l’arrêt cardiorespiratoire, l’état de choc, la détresse respiratoire aiguë et la confusion. La mortalité du patient de plus de 80 ans en réanimation peut atteindre jusqu’à 70 % à 1 an, mais est dépendante de nombreux facteurs, tels que les comorbidités ou la fragilité. Surtout, plus de la moitié des patients âgés recouvrent leur autonomie antérieure à long terme, et leur qualité de vie est identique à celle de la population du même âge. L’essentiel du pronostic vital et fonctionnel se jouant dans les 3 premiers mois qui suivent le passage en réanimation, nous aborderons les stratégies d’amélioration de la prise en charge via la création de filières dédiées de réanimation-gériatrie.
The global population is aging and intensive care unit admission rate of elderly patients is dramatically increasing. The objective of this review is to provide an overview of the literature about the management of elderly patients in intensive care unit and more specifically about epidemiology, admission criteria, mortality, functional prognosis and ethical aspects. We also discuss the data on cardiorespiratory arrest, shock, acute respiratory failure and delirium. The mortality rate of patients over 80 years old in intensive care unit can reach up to 70% at 1 year, but is dependent on many factors, such as comorbidities or frailty. Above all, more than half of elderly patients recover their long-term autonomy. Their quality of life is comparable to that of the same age population. Considering that the first 3 months after an intensive care unit stay are the most decisive in terms of vital and functional prognosis, we will discuss strategies to improve care through the creation of dedicated intensive care-geriatrics networks.
Outcome of mechanically ventilated patients initially denied admission to an intensive care unit and subsequently admitted
2016, European Journal of Internal Medicine
Citation Excerpt :
Nearly 60% of the mechanically ventilated patients in the current study were treated in non-ICU settings, in line with previous local observations [11]. Few studies (5 from Israel and 1 from Hong Kong) addressed outcomes and factors associated with in-hospital mortality of mechanically ventilated patients in a non-ICU setting [10,22–26]. Undoubtedly, the most consistent and significant factor associated with in-hospital mortality throughout all these studies was age.
The outcome of mechanically ventilated patients initially denied admission to an intensive care unit (ICU) and subsequently admitted is unclear. We compared outcomes of patients denied ICU admission and subsequently admitted, to those of patients admitted to the ICU and to patients refused ICU admission. The medical records of all the patients who were subjected to mechanical ventilation for at least 24 h over a 4 year period (2010–2014) were reviewed. Of 707 patients (757 admissions), 124 (18%) were initially denied ICU admission and subsequently admitted. Multivariate stepwise logistic regression analysis showed significant association with death of: age, length of stay, nursing home residency, duration of mechanical ventilation, previous admission with mechanical ventilation, cause for mechanical ventilation, rate of failed extubations, associated morbidity (previous cerebrovascular accident, dementia, chronic renal failure), and occurrence of nosocomial bacteremia. The odds for death among patients denied ICU admission and subsequently transferred to the ICU compared to patients admitted directly to the ICU was 3.6 (95% CI: 1.9–6.7) (P < 0.0001). The odds for death among patients refused ICU admission compared to those who were initially denied and subsequently admitted were not statistically significant (OR = 1.7, 95% CI: 0.8–3.8). In conclusion, patients denied ICU admission and subsequently admitted face a considerable risk of morbidity and mortality. Their odds of death are nearly three times those admitted directly to the ICU. Late admission to the ICU does not appear to provide benefit compared to patients who remain in general medicine wards.
The impact of age on outcomes of elderly ED patients ventilated due to community acquired pneumonia
2015, American Journal of Emergency Medicine
Citation Excerpt :
In-hospital mortality of patients aged 85 years or older was 2-fold greater than that of patients aged 65 to 74 years [20]. Several other studies have reported poor prognoses for advanced age receiving mechanical ventilation [2-6]. In contrast, Ely et al [18] discussed that there were no differences with regard to the duration of mechanical ventilation, length of ICU stay, length of hospital stay, or mortality rate when using 65, 75, and 80 years as the cut-off points to define age groups for advanced age who received mechanical ventilation for several kinds of diseases, not limited to CAP.
There is no consensus on whether mechanical ventilation should be initiated for advanced age with community-acquired pneumonia (CAP). This study investigated the effects of age on the outcomes of mechanical ventilation in the emergency department (ED) for advanced age with CAP.
We retrospectively investigated the medical records of advanced age (age, ≥ 65 years) with CAP who required mechanical ventilation in the ED of our hospital between January 2006 and December 2012. The patients were divided into 65 to 74, 75 to 84, and 85 years or older age groups. The following outcomes were measured: number of patients weaned from mechanical ventilation, in-hospital mortality, ventilator-free days, and intensive care unit days. Multiple logistic regression analysis was used to identify risk factors associated with mortality and weaning from mechanical ventilation.
Seventy-one patients (mean age, 79.5 years) were included. The overall in-hospital mortality rate was 43.7%. No significant differences were observed among the 3 groups with regard to weaning from mechanical ventilation (P = .59), in-hospital mortality (P = .90), ventilator-free days (P = .83), or intensive care unit days (P = .12). Age was not significantly associated with weaning from mechanical ventilation or in-hospital mortality among advanced age. Diabetes mellitus was an independent factor for weaning from mechanical ventilation (P = .048) and was relatively associated with mortality (P = .051).
Age, in itself, may not be a factor limiting the initiation of mechanical ventilation in the ED in advanced age with CAP. Further studies should determine appropriate indications for mechanical ventilation in the ED for these patients.
Prognosis of elderly patients subjected to mechanical ventilation in the ICU
2013, Medicina Intensiva
Analizar el pronóstico de los pacientes ancianos ventilados mecánicamente en la Unidad de Cuidados Intensivos (UCI).
Análisis secundario de un estudio observacional prospectivo y multicéntrico llevado a cabo durante un periodo de 2 años en 13 UCI españolas.
Pacientes adultos que precisaron ventilación mecánica (VM) invasiva durante más de 24 horas.
Ninguna.
Datos demográficos, APACHE II, SOFA, motivo de VM, comorbilidad, situación funcional, reintubación, duración de la VM, traqueotomía, mortalidad en la UCI, mortalidad hospitalaria.
Se incluyeron 1.661 pacientes. De ellos 1.127 (67,9%) eran hombres. Edad: 62,1 ± 16,2 años. APACHE II: 20,3 ± 7,5. SOFA total: 8,4 ± 3,5. Cuatrocientos veintitrés pacientes (25,4%) tenían 75 años o más. Los índices de comorbilidad y capacidad funcional fueron peor en este grupo de pacientes (p < 0,001 para ambas variables). La mortalidad en la UCI fue superior en este grupo (33,6%) que en los más jóvenes (25,9%) (p = 0,002), al igual que la mortalidad hospitalaria (41,8 vs 31,8%; p < 0,0001). No hubo diferencias en cuanto a tiempo de VM, incidencia de traqueotomías o índice de reintubaciones. Por causas de VM solo los pacientes ≥ 75 años ventilados por neumonía, sepsis o trauma presentaron una mortalidad en UCI más alta que los menores de esa edad (46,3 vs 33,1% p = 0,006; 55 vs 25,8% p = 0,002; 63,6 vs 4,5% p < 0,001 respectivamente).
Los ancianos (≥ 75 años) tienen una mayor mortalidad en UCI y hospitalaria que los más jóvenes sin diferencias en la duración de la VM. Las diferencias son a expensas de patologías como neumonía, sepsis y trauma.
To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU).
Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain.
Adult patients who required mechanical ventilation (MV) for longer than 24 hours.
None.
Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality.
A total of 1661 patients were recruited. Males accounted for 67.9% (n = 1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p < 0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p = 0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p = 0.006; 55% vs 25.8%, p = 0.002; 63.6% vs 4.5%, p < 0,001, respectively). No differences were found referred to other reasons for MV.
Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma.

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^☆: There are no conflicts of interest to declare.

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How do older ventilated patients fare? A survival/functional analysis of 641 ventilations☆

Abstract

Background

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Results

Discussion

Chest

Eur J Intern Med

Chest

Chest

Chest

Outcome and function following prolonged mechanical ventilation

Arch Intern Med

Long-term mortality and quality of life after prolonged mechanical ventilation

Crit Care Med

Morbidity, mortality, and quality-of-life outcomes of patients requiring ≥14 days of mechanical ventilation

Crit Care Med

Survival and quality of life: short-term versus long-term ventilator patients

Crit Care Med

Mechanical ventilation for the elderly patient in intensive care. Incremental changes and benefits

JAMA