Resultados de la ventilación mecánica no invasiva en pacientes no candidatos a intubación en un hospital de subagudos. Estudio de seguimiento a un año / Non-invasive ventilation in ‘do-not-intubate’ patients in a chronic disease hospital. One year follow-up study

El fracaso ventilatorio agudo, especialmente en la enfermedad pulmonar obstructiva crónica, es una causa frecuente de ingreso en pacientes ancianos con pluripatología y limitación de esfuerzo terapéutico. Cada vez hay más datos de la utilidad de la ventilación mecánica no invasiva (VMNI) en este contexto. Nuestro centro desarrolló en 2010 una vía clínica integrada urgencias-hospitalización para el uso de la VMNI en el fracaso ventilatorio agudo. El objetivo de este trabajo fue evaluar el resultado de la VMNI en el fracaso ventilatorio agudo en pacientes con orden de no intubar en un hospital de subagudos. Material y método. Estudio observacional, con un año de seguimiento. Las variables principales son la mortalidad al ingreso y al año. Se recogen todos los casos que reciben VMNI, a través de un registro específico. Otras variables recogidas son: datos demográficos, clínicos y funcionales, enfermedad de base, situación funcional basal, gasometría, estancia y reingresos. Resultados. Se incluyeron 102 pacientes con una edad media de 81 años, un índice de Charlson de 3,7 y un índice de Barthel de 54, estando el 22% institucionalizados. La mortalidad durante el ingreso fue del 33%. Entre los pacientes sin indicación ajustada a protocolo, la mortalidad fue del 71%. La supervivencia global al año fue del 46%, resultando asociada en el análisis estadístico multivariante a obesidad-hipoventilación e índice de Barthel > 50. Conclusiones. La VMNI es una técnica de utilidad en pacientes ancianos con limitación de esfuerzo terapéutico. A pesar de la severidad y la comorbilidad, se obtienen tasas aceptables de supervivencia. Los pacientes con mejor situación funcional basal y obesidad-hipoventilación tienen mayor supervivencia (AU)

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 (AU)

[Non-invasive ventilation in 'do-not-intubate' patients in a chronic disease hospital. One year follow-up study]. / Resultados de la ventilación mecánica no invasiva en pacientes no candidatos a intubación en un hospital de subagudos. Estudio de seguimiento a un año.

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.

Tratamiento inhalado con colistina a largo plazo en pacientes ancianos con infección crónica por Pseudomonas aeruginosa y bronquiectasias / Inhaled colistin in elderly patients with non-cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa bronchial infection

Introducción: Las bronquiectasias son una causa frecuente de ingreso en ancianos. Aunque algunas guías recomiendan el uso de antibiótico inhalado a largo plazo en bronquiectasias sin fibrosis quística falta evidencia que avale el uso de estos tratamientos en esta población. El objetivo de nuestro trabajo es evaluar la efectividad y tolerancia del tratamiento inhalado con colistina a largo plazo en pacientes ancianos con bronquiectasias sin fibrosis quística e infección crónica por P aeruginosa para reducir las exacerbaciones graves que precisan ingreso. Material y métodos: Estudio cuasi experimental, prospectivo, controlado, abierto. Incluimos pacientes con bronquiectasias diagnosticadas por TAC y persistencia de Pseudomonas aeruginosa en esputo después de tratamiento apropiado. Todos los pacientes recibieron educación y fisioterapia respiratoria. El grupo de intervención recibió además colistina inhalada 1 millón UI dos veces al día. Se recogieron datos demográficos, características clínicas y funcionales, ingresos y visitas a urgencias en el año previo. Los pacientes fueron seguidos durante un año recogiendo cada 2 meses cultivo de esputo, datos clínicos funcionales, y uso de recursos sanitarios. Resultados: Se incluyeron 39 pacientes, 20 en el grupo con colistina y 19 en el grupo de tratamiento convencional. No hubo diferencias significativas entre los 2 grupos en las características basales. La edad media fue de 77,7 +/- 5, y el FEV1 41 %. Cinco pacientes (25 %) interrumpieron el tratamiento por efectos secundarios.Pseudomonas aeruginosa desapareció del esputo en 9 pacientes del grupo de tratamiento (45 %) y solo en uno del grupo control, con significación estadística, sin embargo, al final del año de estudio no hubo diferencias en el número de ingresos (grupo control 1,6 +/- 1,7 and 2,7 +/- 3 grupo con colistina) ni en días ingresados (19 +/- 31 and 23 +/- 20). Tampoco se detectaron diferencias entre los dos grupos en resultados funcionales o síntomas clínicos. No hubo cambios en la flora ni en la sensibilidad antibiótica. Conclusiones: El tratamiento inhalado con colistina a largo plazo en pacientes ancianos colonizados por Pseudomonashizo que disminuyera la presencia de Pseudomonas aeruginosa en esputo, pero esto no se tradujo en una disminución en el uso de recursos sanitarios, ni en mejoría clínica o funcional. Los efectos secundarios fueron frecuentes. Son necesarios más estudios para identificar subgrupos de pacientes que se beneficien de estos tratamientos a largo plazo (AU)

Background: Bronchiectasis is a frequent cause of admission for elderly patients and chronic respiratory diseases. Although some guidelines recommend long-term treatment with inhaled antibiotics in non-cystic fibrosis bronchiectasis with chronic Pseudomonas aeruginosa (P. aeruginosa) infection, there is limited evidence supporting these prolonged antibiotic treatments in this population. The aim of this study was to assess the effectiveness of inhaled colistin in elderly patients with bronchiectasis and chronic bronchial P. aeruginosainfection in reducing hospital readmissions. Material and methods: A prospective, controlled and open label study was conducted on patients with bronchiectasis diagnosed by computed tomography and persistence of P. aeruginosa in sputum after appropriate antimicrobial therapy. All patients received education, and physiotherapy training. The intervention group also received nebulized colistin 1 million IU twice a day for one year. Data were collected on the demographics, clinical and functional characteristics, admissions in previous year, and sputum microbiology. Patients were followed up every two months for one year, with readmissions, microbiological results, functional tests, and deaths being evaluated. Results: The study included 39 patients, of whom 20 received nebulized colistin and 19 conventional therapy. There were no differences between the two groups in baseline clinical and functional characteristics or previous hospital stay. The mean age was 77.7 +/- 5, Charlson index 2.85, and FEV1 % 41.3 +/- 15. Five patients (25 %) stopped the nebulized treatment because of adverse effects. P. aeruginosa was eradicated in 45 % of the colistin treated patients, and in only one of the control group (statistically significant), but at the end of the study year, there were no differences in the number of hospital admissions (control group 1.6 +/- 1.7 and 2.7 +/- 3 colistin group), or days of stay (19 +/- 31 and 23 +/- 20). There were no differences in lung function or clinical symptoms between the two groups No significant changes were observed in P. aeruginosa A antibiotic sensitivity or in sputum flora. Conclusions: More patients in the treatment group achieved Pseudomonas eradication, but benefits in clinical symptoms, lung function or use of healthcare resources in our elderly patients, could not be demonstrated. Adverse effects were common. Further studies are needed in order to identify factors associated with response, or subgroups of patients with bronchiectasis and chronic infection with P. aeruginosa, who benefit from (expensive) long term treatments with inhaled antibiotics (AU)

[Inhaled colistin in elderly patients with non-cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa bronchial infection]. / Tratamiento inhalado con colistina a largo plazo en pacientes ancianos con infección crónica por Pseudomonas aeruginosa y bronquiectasias.

BACKGROUND: Bronchiectasis is a frequent cause of admission for elderly patients and chronic respiratory diseases. Although some guidelines recommend long-term treatment with inhaled antibiotics in non-cystic fibrosis bronchiectasis with chronic Pseudomonas aeruginosa (P. aeruginosa) infection, there is limited evidence supporting these prolonged antibiotic treatments in this population. The aim of this study was to assess the effectiveness of inhaled colistin in elderly patients with bronchiectasis and chronic bronchial P. aeruginosa infection in reducing hospital readmissions. MATERIAL AND METHODS: A prospective, controlled and open label study was conducted on patients with bronchiectasis diagnosed by computed tomography and persistence of P. aeruginosa in sputum after appropriate antimicrobial therapy. All patients received education, and physiotherapy training. The intervention group also received nebulized colistin 1 million IU twice a day for one year. Data were collected on the demographics, clinical and functional characteristics, admissions in previous year, and sputum microbiology. Patients were followed up every two months for one year, with readmissions, microbiological results, functional tests, and deaths being evaluated. RESULTS: The study included 39 patients, of whom 20 received nebulized colistin and 19 conventional therapy. There were no differences between the two groups in baseline clinical and functional characteristics or previous hospital stay. The mean age was 77.7+/-5, Charlson index 2.85, and FEV1% 41.3+/-15. Five patients (25%) stopped the nebulized treatment because of adverse effects. P. aeruginosa was eradicated in 45% of the colistin treated patients, and in only one of the control group (statistically significant), but at the end of the study year, there were no differences in the number of hospital admissions (control group 1.6+/-1.7 and 2.7+/-3 colistin group), or days of stay (19+/-31 and 23+/-20). There were no differences in lung function or clinical symptoms between the two groups No significant changes were observed in P. aeruginosa A antibiotic sensitivity or in sputum flora. CONCLUSIONS: More patients in the treatment group achieved Pseudomonas eradication, but benefits in clinical symptoms, lung function or use of healthcare resources in our elderly patients, could not be demonstrated. Adverse effects were common. Further studies are needed in order to identify factors associated with response, or subgroups of patients with bronchiectasis and chronic infection with P. aeruginosa, who benefit from (expensive) long term treatments with inhaled antibiotics.