r 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afn060 All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Published electronically 3 April 2008
REVIEW
Abstract
Acute respiratory failure (ARF) in patients over 65 years is common in emergency departments (EDs) and is one of the key
symptoms of congestive heart failure (CHF) and respiratory disorders. Searches were conducted in MEDLINE for published
studies in the English language between January 1980 and August 2007, using ‘acute dyspnea’, ‘acute respiratory failure
(ARF)’, ‘heart failure’, ‘pneumonia’, ‘pulmonary embolism (PE)’ keywords and selecting articles concerning patients aged
65 or over. The age-related structural changes of the respiratory system, their consequences in clinical assessment and the
pathophysiology of ARF are reviewed. CHF is the most common cause of ARF in the elderly. Inappropriate diagnosis that is
frequent and inappropriate treatments in ED are associated with adverse outcomes. B-type natriuretic peptides (BNPs) help
to determine an accurate diagnosis of CHF. We should consider non-invasive ventilation (NIV) in elderly patients hospitalised
with CHF or acidotic chronic obstructive pulmonary disease (COPD) who do not improve with medical treatment. Further
studies on ARF in elderly patients are warranted.
Keywords: acute respiratory failure, elderly, pulmonary embolism, BNP, congestive heart failure
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S. Delerme and P. Ray
a decline in tests of forced expiration (i.e. increasing airway functions, i.e. oxygenation (PaO2 <60 mmHg) of and/or
resistance), an obstructive pattern could exist even in women elimination of carbon dioxide (arterial carbon dioxide tension
who are non-smokers. Furthermore, studies suggest that (PaCO2 ) >45 mmHg) [11]. Both cut-off values simply serve
the ß-adrenoceptor dysfunction explains a less response to as a general guide in combination with the history and
bronchodilation in older asthmatic patients [7]. clinical assessment of the patient. Thus, ARF could also be
Other common important changes include loss of suspected by ‘simple’ clinical criteria: polypnea >30 per min,
diaphragmatic mass and strength with age [8]. Finally, as contraction of the accessory inspiratory muscles, abdominal
a consequence of poor nutritional status, decreased T-cell respiration, orthopnea cyanosis, and asterixis. Orthopnea is
function, decline in mucociliary clearance, poor dentition frequently associated with all causes of ARF, and is neither a
with oropharyngeal colonisation, and swallowing dysfunction sensible nor specific predictor of CHF [3].
(Parkinson’s disease, Alzheimer’s disease and stroke), The four pathophysiological mechanisms related to
community-acquired (CAP) and aspiration pneumonia is hypoxaemic ARF (1) ventilation/perfusion inequality which
exceedingly common in elderly patients [9]. is the main mechanisms in an emergency setting (CHF or
Furthermore, decreased sensitivity of respiratory centres pneumonia), (2) increased shunt (acute respiratory distress
to hypoxaemia, hypercapnia, or added resistive loads will syndrome), (3) alveolar hypoventilation [chronic obstructive
result in a diminished ventilatory response in cases of ARF; pulmonary disease (COPD)], and (4) diffusion impairment
and could delay diagnosis because of the poor perception of (pulmonary fibrosis) [11].
the respiratory insults [4]. Failure of the pump (or ventilatory failure) results in
alveolar hypoventilation with an increase in PaCO2 (Table 1).
Cardiovascular changes Mechanisms responsible are decreasing minute ventilation
The physiological cardiovascular changes involve the and increasing dead space. In elderly patients, the major
decrease of myocyte number, intrinsic contractility, coronary cause is severe hyperinflation, with flattened diaphragm and
flow reserve, ventricular compliance and ß-adrenoceptor- reduced mechanical action of the inspiratory muscles (COPD
mediated modulation of inotropy. exacerbation) [4].
The ageing heart increases cardiac output by increasing Actually, hypoxaemic ARF is a situation accompanied by
stroke volume rather than increasing heart rate. However, increased work of breathing. However, energy availability is
this compensatory mechanism is dependent on the effective reduced due to hypoxaemia, resulting in muscle fatigue and
atrial contribution to late diastolic filling (>30% in the elderly
patient) [10]. This explains the frequency of CHF caused by
rapid atrial fibrillation in the elderly. Table 1. Principal causes of acute respiratory failure
Cardiac and respiratory systems are dependent. For (adapted from [11])
example, (1) a bout of pneumonia is sufficient to trigger
Decreased central drive
an acute exacerbation of heart failure, (2) a reduction in
Morphine (or other drugs: sedatives)
cardiac output accompanying septic shock is a cause of Central nervous system diseases (encephalitis, stroke, trauma)
ARF caused by diaphragm hypoperfusion leading to alveolar Altered neural and neuromuscular transmission
hypoventilation, and respiratory arrest. Spinal cord trauma, transverse myelitis, tetanus, amyotrophic lateral
sclerosis, poliomyelitis, Guillain–Barre’ syndrome
Other relevant changes Myasthenia gravis, botulism
Muscle abnormalities
Decrease in glomerular filtration rate (approximately 45% Muscular dystrophy, disuse atrophy
by the age of 80) with ageing has important implications in Chest wall and pleural abnormalities
terms of drug dosing, as most drugs are renally excreted [2]. Kyphoscoliosis
Chest wall trauma (flail chest, diaphragmatic rupture)
Most studies have shown an imbalance between
Lung and airways diseases
procoagulant/antifibrinolytic and anticoagulant factors, Acute asthma
which could contribute to an increased incidence of PE. Acute exacerbation of chronic obstructive pulmonary disease
Congestive heart failure and non-cardiogenic pulmonary oedema
Definition and pathophysiology of acute (acute respiratory distress syndrome)
Pneumonia, tuberculosis
respiratory failure Upper airways obstruction
Lung cancer, pulmonary fibrosis
The respiratory system consists of two parts: the lung, i.e. Pneumothorax, pleural effusion
the gas-exchanging organ, and the pump [11]. The pump Bronchiectasis
consists of the chest wall, including the respiratory muscles Vascular diseases
(essentially the diaphragm), the respiratory controllers in Pulmonary embolism
the central nervous system and the pathways that connect Severe haemoptysis
the central controllers with the respiratory muscles (spinal Other
Severe sepsis or septic shock, other shock
and peripheral nerves). ARF is a condition in which the
respiratory system fails in one or both of its gas exchange The main causes of ARF in elderly patients are in bold.
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ARF in the elderly: diagnosis and prognosis
15
Percent of patients
Number of Days
Number of Days
NS
P<0.001 30
30
P<0.001
10 10
20 20
5 5
10 10
0 0 0 0
Hospital ICU Death Hospital ICU Death
A Free Days B Free Days
Figure 1. (a) Effects of an appropriate (black bars) or inappropriate (white bars) initial diagnosis in the emergency department on
prognosis (used with permission from Ray P. [3]). (b) Effects of an appropriate (black bars) or inappropriate (white bars) initial
treatments in the emergency department on prognosis (used with permission from Ray P. [3]).
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S. Delerme and P. Ray
Suspected CHF
BNP
or NT-proBNP
BNP < 100 pg/mL 100 < BNP < 500 BNP > 500 pg/mL
Further investigations
CT chest with parenchymal
windows, then protocole PE
or lung ultrasonography
Figure 2. Diagnostic strategy based on B-type natriuretic peptide levels in elderly patients admitted for ARF in the emergency
department. 1 In the grey zone (BNP between 100 and 500 pg/ml), which represents less than a quarter of patients, further
investigations are needed, and ER physicians should consider massive PE, CHE, severe exacerbation of COPD or severe
pneumonia as possible diagnoses. 2 Physicians should keep in mind that half of elderly patients with ARF has more than one
diagnosis, i.e. a BNP greater than 500 pg/ml strongly suggests CHF, but other diagnosis that could have precipitated CHF.
CXR: chest X-ray; EKG: electrocardiogram; ABG: arterial blood gas analysis; CHF: congestive heart failure; ACS: acute coronary
syndrome; CT: computed tomography; IV: intravenous; NIV: non-invasive ventilation including continuous positive airway
pressure; ACEi: angiotensin converting enzyme inhibitor; EC: echocardiography.
an elderly patient to an ICU should be based on the patients’ 1 in the supplementary data on the journal’s website
co-morbidities, acuity of illness, pre-hospital functional status http://www.ageing.oxfordjournals.org) [35].
and the patient’s preferences [2].
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ARF in the elderly: diagnosis and prognosis
255
S. Delerme and P. Ray
and decrease mortality [63]. One study demonstrated that, 1. Aminzadeh F, Dalziel WB. Older adults in the emergency
compared to medical treatment, continuous positive air- department: a systematic review of patterns of use, adverse
way pressure (CPAP) decreased respiratory rate, decreased outcomes, and effectiveness of interventions. Ann Emerg Med
PaCO2 , and improved oxygenation compared with baseline 2002; 39: 238–47.
in elderly patients with hypoxaemic CHF [64]. However, the 2. Marik PE. Management of the critically ill geriatric patient. Crit
in-hospital mortality (28% versus 30%) was not different. Care Med 2006; 34: S176–82.
3. Ray P, Birolleau S, Lefort Y et al. Acute respiratory failure in
There is no difference in outcome between NPPV and CPAP
the elderly: etiology, emergency diagnosis and prognosis. Crit
for CHF [65]. Care 2006; 10: R82.
4. Rossi A, Ganassini A, Tantucci C et al. Aging and the respiratory
Conclusion system. Aging (Milano) 1996; 8: 143–61.
CHF is the most common cause of ARF in the elderly 6. Guenard H, Marthan R. Pulmonary gas exchange in elderly
subjects. Eur Respir J 1996; 9: 2573–7.
but half of the patients had more than two diagnoses.
7. Banerji A, Clark S, Afilalo M et al. Prospective multicenter study
As inappropriate treatment is associated with increased of acute asthma in younger versus older adults presenting to
morbidity and mortality, accurate diagnostic tools, such the emergency department. J Am Geriatr Soc 2006; 54: 48–55.
as BNP, should be available in an ED 24 h a day. We 8. Polkey MI, Harris ML, Hughes PD et al. The contractile
should consider non-invasive ventilation (NIV) in elderly properties of the elderly human diaphragm. Am J Respir
patients hospitalised with acidotic COPD exacerbations or Crit Care Med 1997; 155: 1560–4.
CHF who do not improve with medical treatment. ICU 9. Marrie TJ. Community-acquired pneumonia in the elderly. Clin
admission decisions should not be based on age alone but Infect Dis 2000; 31: 1066–78.
on factors such as the patient’s baseline level of function and 10. Miyatake K, Okamoto M, Kinoshita N et al. Augmentation
co-morbidities, severity of illness, and preferences for life of atrial contribution to left ventricular inflow with aging as
support. assessed by intracardiac Doppler flowmetry. Am J Cardiol
1984; 53: 586–9.
11. Roussos C, Koutsoukou A. Respiratory failure. Eur Respir J
Suppl 2003; 47: 3s–14s.
Key points 12. Bordin P, Da Col PG, Peruzzo P et al. Causes of death and
• Causes of ARF in the elderly are often difficult to diagnose. clinical diagnostic errors in extreme aged hospitalized people:
• A misdiagnosis in the ED is associated with increased a retrospective clinical-necropsy survey. J Gerontol A Biol Sci
morbidity and mortality. Med Sci 1999; 54: M554–9.
• Use of BNP or NT-proBNP for suspected CHF improves 13. Ely EW, Wheeler AP, Thompson BT et al. Recovery rate and
diagnostic accuracy and outcome. prognosis in older persons who develop acute lung injury and
• NIV should be an option for severe CHF or COPD the acute respiratory distress syndrome. Ann Intern Med 2002;
136: 25–36.
exacerbation.
14. Riquelme R, Torres A, el-Ebiary M et al. Community-acquired
pneumonia in the elderly. Clinical and nutritional aspects. Am
Ackowledgements J Respir Crit Care Med 1997; 156: 1908–14.
15. Gehlbach BK, Geppert E. The pulmonary manifestations of
The authors would like to thank the physicians and left heart failure. Chest 2004; 125: 669–82.
nursing staff working in the emergency department of Pitié- 16. Jorge S, Becquemin MH, Delerme S et al. Cardiac asthma in
Salpêtrière Hospital for their co-operation and support. We elderly patients: incidence, clinical presentation and outcome.
also would like to thank Dr Joanne Ho (Internal Medicine, BMC Cardiovasc Disord 2007; 7: 16.
Toronto, Canada) for the review of the manuscript. 20. Couturaud F, Parent F, Meyer G et al. Effect of age
on the performance of a diagnostic strategy based on
Conflict of interest clinical probability, spiral computed tomography and venous
compression ultrasonography: the ESSEP study. Thromb
None Haemost 2005; 93: 605–9.
21. Masotti L, Landini G, Cappelli R et al. Doubts and certainness
Supplementary data in diagnosis of pulmonary embolism in the elderly. Int J Cardiol
Supplementary data for this article are available online at 2006; 112: 375–7.
22. Righini M, Le Gal G, Perrier A et al. The challenge of diagnosing
http://ageing.oxfordjournals.org.
pulmonary embolism in elderly patients: influence of age on
commonly used diagnostic tests and strategies. J Am Geriatr
Soc 2005; 53: 1039–45.
References 26. Vinson JM, Rich MW, Sperry JC et al. Early readmission of
(Due to the large number of references, only 40 are listed below and elderly patients with congestive heart failure. J Am Geriatr Soc
are represented by boldtype throughout the text. The full list can 1990; 38: 1290–5.
be found in the supplementary data online, on the journal website 29. Kaarlola A, Tallgren M, Pettila V. Long-term survival, quality
http://www.ageing.oxfordjournals.org as Appendix 3.) of life, and quality-adjusted life-years among critically ill elderly
patients. Crit Care Med 2006; 34: 2120–6.
256
ARF in the elderly: diagnosis and prognosis
31. Herman PG, Khan A, Kallman CE et al. Limited correlation 52. Joosten SA, Koh MS, Bu X et al. The effects of oxygen
of left ventricular end-diastolic pressure with radiographic therapy in patients presenting to an emergency department
assessment of pulmonary hemodynamics. Radiology 1990; with exacerbation of chronic obstructive pulmonary disease.
174: 721–4. Med J Aust 2007; 186: 235–8.
34. Randazzo MR, Snoey ER, Levitt MA et al. Accuracy of 53. Pauwels RA, Buist AS, Calverley PM et al. Global
emergency physician assessment of left ventricular ejection strategy for the diagnosis, management, and prevention of
fraction and central venous pressure using echocardiography. chronic obstructive pulmonary disease. NHLBI/WHO Global
Acad Emerg Med 2003; 10: 973–7. Initiative for Chronic Obstructive Lung Disease (GOLD)
35. Arques S, Roux E, Sbragia P et al. Accuracy of tissue Workshop summary. Am J Respir Crit Care Med 2001; 163:
Doppler echocardiography in the emergency diagnosis of 1256–76.
decompensated heart failure with preserved left ventricular 56. Meehan TP, Fine MJ, Krumholz HM et al. Quality of care,
systolic function: comparison with B-type natriuretic peptide process, and outcomes in elderly patients with pneumonia.
measurement. Echocardiography 2005; 22: 657–64. JAMA 1997; 278: 2080–4.
36. Ray P, Arthaud M, Lefort Y et al. Usefulness of B-type 58. Cotter G, Metzkor E, Kaluski E et al. Randomised trial of high-
natriuretic peptide in elderly patients with acute dyspnea. dose isosorbide dinitrate plus low-dose furosemide versus
Intensive Care Med 2004; 30: 2230–6. high-dose furosemide plus low-dose isosorbide dinitrate in
38. Mueller C, Laule-Kilian K, Frana B et al. The use of B-type severe pulmonary oedema. Lancet 1998; 351: 389–93.
natriuretic peptide in the management of elderly patients with 59. Sacchetti A, Ramoska E, Moakes ME et al. Effect of ED
acute dyspnoea. J Intern Med 2005; 258: 77–85. management on ICU use in acute pulmonary edema. Am J
40. Metlay JP, Schulz R, Li YH et al. Influence of age on Emerg Med 1999; 17: 571–4.
symptoms at presentation in patients with community-acquired 62. Ahmed A. American College of Cardiology/American
pneumonia. Arch Intern Med 1997; 157: 1453–9. Heart Association Chronic Heart Failure Evaluation and
41. Hausfater P, Juillien G, Madonna-Py B et al. Serum Management guidelines: relevance to the geriatric practice.
procalcitonin measurement as diagnostic and prognostic J Am Geriatr Soc 2003; 51: 123–6.
marker in febrile adult patients presenting to the emergency 63. Peter JV, Moran JL, Phillips-Hughes J et al. Effect of non-
department. Crit Care 2007; 11: R60. invasive positive pressure ventilation (NIPPV) on mortality in
43. Christ-Crain M, Jaccard-Stolz D, Bingisser R et al. Effect of patients with acute cardiogenic pulmonary oedema: a meta-
procalcitonin-guided treatment on antibiotic use and outcome analysis. Lancet 2006; 367: 1155–63.
in lower respiratory tract infections: cluster-randomised, single- 64. L’Her E, Duquesne F, Girou E et al. Noninvasive continuous
blinded intervention trial. Lancet 2004; 363: 600–7. positive airway pressure in elderly cardiogenic pulmonary
45. Perrier A, Roy PM, Sanchez O et al. Multidetector-row edema patients. Intensive Care Med 2004; 30: 882–8.
computed tomography in suspected pulmonary embolism. 65. Mehta S, Jay GD, Woolard RH et al. Randomized, prospective
N Engl J Med 2005; 352: 1760–8. trial of bilevel versus continuous positive airway pressure in
47. Webb WR, Müller NL, Naidich DP. High-resolution CT of acute pulmonary edema. Crit Care Med 1997; 25: 620–8.
the Lung. Philadelphia, PA Lippincott Williams Wilkins, 2000.
51. Hohl CM, Dankoff J, Colacone A et al. Polypharmacy, adverse Received 12 April 2007; accepted in revised form 7 November
drug-related events, and potential adverse drug interactions in 2007
elderly patients presenting to an emergency department. Ann
Emerg Med 2001; 38: 666–71.
257