Non Invasive Mechanical Ventilation in Elders with Acute Heart Failure

Research Article

Austin J Clin Cardiolog. 2015; 2(2): 1040.

Non Invasive Mechanical Ventilation in Elders with Acute Heart Failure

Calvo SG1* and Padilla LD2

¹Respiratory Unit, Hospital King Juan Carlos, Mostoles, Spain

²Respiratory Unit, Hospital Universitario 12 de Octubre, Madrid, Spain

*Corresponding author: Gonzalo Segrelles Calvo, c/Gladiolo s/n; Hospital King Juan Carlos, Mostoles, Madrid, Spain

Received: November 18, 2014; Accepted: September 13, 2015; Published: October 08, 2015


The aim of the study was to confirm the usefulness of Non-Invasive Ventilation (NIV) in elders with multiple comorbidities,admittedfor Respiratory Acidosis (RA) due to Heart Failure (HF), and to determine their survival one year after discharge.

Design: Observational prospective trial made at the Hospital Universitario La Princesa (Madrid) between October of 2009 and December of 2012. We included 42 elderly patients with HF and AR treated with NIV.

Results: 62% were females, with a mean age of 78.2 years. Charlson Index was 3.41 and the mean of prescriptions per day was 5.8. The main complication during admission was cardiovascular disease, and 25% of patients passed away during admission. The most frequentre-admissiondiagnosiswas HF. Global survival was 60%.

Discussion: NIV is a useful treatment for elderly patients with HF and nonintubation orders. The principal factors associated to mortality were: low pH and high PaCO2 at ER, high respiratory rate and previous comorbidities.

Keywords: Heart failure; Noninvasive ventilation; Respiratory acidosis; Elderly; Non-intubation orders


Heart Failure (HF) has an incidence of 10% in patients older than 65 years, reaching a 40% in those older than 80 [1], which translates to be the cause of 75% of hospitalizations in this group [2,3]. HF is more frequent in women, producing a 50-60% of total, according to previous studies [2]. The physiopathology of HF in elders is complex and various factors are involved, related not only to age but also to associated comorbidities [4].

Non-Invasive Ventilation (NIV) is advised in acute HF secondary to Acute Pulmonary Edema (APE), reducing the risk of intubation, as well as improving symptoms and gas exchange parameters [5,6]. NIV is more efficient than oxygen therapy [7] and similar to Continuous Positive Air way Pressure (CPAP) regarding clinical outcomes [8,9]. Further more, latest guidelines recommend the use of either NIV or CPAP for acute HF [10,11].

Now a days, there is not sufficient data concerning the indication of NIV in elderly patients admitted for Acute HF (AHF), considering their multiple comorbidities and performance status limitations. The hypothesis of our study was that NIV is useful in this clinical scenario. The main objective was to determine the benefit (efficiency, utility, suitability) of NIV in elder patients admitted for acute HF causing respiratory acidosis, defined as time to gas exchange normalization, days of hospitalization, complications during treatment, mortality rate, and evolution 1 year after hospital discharge.


Study design

Prospective observational study carried out in the Respiratory Care Unit (RCU) of Hospital UniversitarioLa Princesa (HULP), from October of 2009 to December of 2012. The HULP is a tertiary hospital located in Madrid, Spain, which provides health care to an estimated population of 350.000 habitants. Our RCU has 4 beds integrated to the Respiratory Ward, allowing non-invasive monitoring of hemodynamic parameters (blood pressure, heart rate, Respiratory Rate (RR), peripheral pulseoximetry (SpO2) and continuous electrocardiography) and respiratory support by NIV along with mechanical invasive ventilation in selected patients on which a tracheostomy was performed. Specialized nursing care providers and a Respiratory Care physician are in charge of the RCU during morning shifts, whereas a physician assumes its supervision during night shifts and weekends. The entire population of this study were treated with Bi-Level Positive Airway Pressure (BiPAP) in Pressure Support (PS) mode.

Study population

Patients admitted to our RCU for HF and respiratory acidosis (pH < 7.35 and PaCO2 >45mmHg), treated with NIV and at least 70 years old were included. HF diagnosis was based on the European Society of Cardiology recommendations [10], while the Chronic Respiratory Obstructive Disease (COPD) diagnosis followed the Spanish Guideline of COPD (GesEPOC) [12]. A “do-not-intubate” indication was considered in the entire population since the following criteria: 1.The patient decided not to be treated by invasive respiratory support through an orotracheal intubation, or had previously stated this wish signing a legal document regarding this matter. 2. The corresponding physician who treated the patient during an acute scenario (Emergency Room (ER), Intensive Care Unit (ICU), Respiratory or Internal Medicine Ward) had not considered the patient as an optimal candidate for invasive respiratory support since a poor prognosis or lacking life performance status were concluded. 3. A legal representative orcare giver manifested their wish to avoid any intensive care measure. The following patients were excluded: 1. Patients admitted to the RCU, however without NIV required. 2. Patients where NIV was initiated in the other units other than the RCU, and after wards were not admitted to the latter. 3. Patients who rejected NIV. The ethics committee of the HULP approved the study, and informed consent was given by all the participants. All data was retrieved from the HULP databases, allowing access to clinical variables in order to complete the 1-year follow up.

Variables And Statistical Analysis

The SPSS 15.0 package for Windows (SPSS Inc., Chicago IL) was used for the statistical analysis. Table 1 shows the variables included in the study. Descriptive analysis is presented using parameters such as means, range and Standard Deviation (SD), and qualitative data is shown as absolute numbers and percentages. Normality in the distribution was assessed by the Kolmogorov-Smirnov test. The difference between quantitative variables was analyzed by the t-student test, and qualitative data by the chi-square and Fisher exact. A p-value < 0.05 was considered statistically significant.