Letter to the Editor
Reply
Réplica
Gonzalo Segrelles Calvo
, Enrique Zamora García, Julio Ancochea
Corresponding author
Servicio de Neumología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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"titulo" => "Reply" "tieneTextoCompleto" => true "saludo" => "Dear Madam," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "80" "paginaFinal" => "81" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gonzalo Segrelles Calvo, Enrique Zamora García, Julio Ancochea" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Gonzalo" "apellidos" => "Segrelles Calvo" "email" => array:1 [ 0 => "gsegrelles@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Enrique" "apellidos" => "Zamora García" ] 2 => array:2 [ "nombre" => "Julio" "apellidos" => "Ancochea" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neumología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Réplica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Firstly, I would like to thank Drs A. Esquinas and C. Zamarro for their comments on our paper.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The ageing of the population is a current reality. On a worldwide level, it is estimated that by 2050, around 2 billion people will be over 60 years of age.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This phenomenon will be more acute in countries such as Spain, Italy and Japan. Ageing in itself is not a disease state, but fragile individuals are likely to be more susceptible to a series of comorbidities.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This situation means that specific strategies for acute respiratory failure in the elderly must be implemented and, above all, we should further develop our understanding of the patients who would benefit most from non-invasive mechanical ventilation (NIMV).</p><p id="par0020" class="elsevierStylePara elsevierViewall">In response to the questions raised by Drs Esquinas and Zamarro:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0025" class="elsevierStylePara elsevierViewall">In our study, 65% of the patients had a “do not intubate” (DNI) order. The main reason for signing the DNI orders was the patients’ underlying situation and advanced stage of disease. While no guidelines are currently available for placing a patient on a DNI order, the decision is made by the treating pulmonologist in the Respiratory Monitoring Unit (RMU) or the on-duty pulmonologist, and, in the large majority of cases, agreed with family members after they have been informed of the patient's clinical situation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">At present, our group is performing a study in patients on a limited treatment plan (LTP), in an attempt to define the characteristics of this population, and our aim is publish these data shortly. In general, according to the preliminary data, we limit therapeutic intervention in patients who are more highly dependent (as determined using the Barthel index), those with more comorbidities and those of more advanced age.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0035" class="elsevierStylePara elsevierViewall">We agree that heart failure had an impact on mortality and was one of the reasons why mortality was higher than that in other series which included more patients with a diagnosis of chronic obstructive pulmonary disease (COPD).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our analysis, patients with COPD with a worse prognosis during their hospital stay had lower pH levels and higher PaCO<span class="elsevierStyleInf">2</span> levels. They also had higher C-reactive protein levels (<span class="elsevierStyleItalic">P</span><.008) and a higher percentage of neutrophils (<span class="elsevierStyleItalic">P</span><.009). Other factors increasing the relative risk (RR) of readmission in this group were home oxygen therapy on discharge (RR=1.65; 95% confidence interval [95% CI], −2.62 to 5.92) and previous admissions with respiratory acidosis requiring NIMV (RR=2.18; 95% CI, 1.77–2.59). We did not specifically analyse any data on the underlying life situation of the patients, although we are developing a hypothesis on the possible impact of the patient's life situation on readmission.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0045" class="elsevierStylePara elsevierViewall">In our experience, patients who required NIMV in subsequent readmissions were managed in the RMU under the same care protocol. With some exceptions, when NIMV was initiated outside the RMU, the patient was transferred to this unit within 24–48<span class="elsevierStyleHsp" style=""></span>h, depending on the availability of beds.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0050" class="elsevierStylePara elsevierViewall">Any complications that the patients presented during their RMU stay, including cardiovascular and renal problems, were managed by the unit pulmonologist or the on-duty pulmonologist. If the patient required specialised care or if specific techniques needed to be performed, the case was discussed with the appropriate specialist. The application of specific techniques, such as dialysis in the case of renal failure or the use of biogenic amines, was limited on a case-by-case basis, after a multidisciplinary assessment of the patient and with the agreement of the patient and/or the family.</p><p id="par0055" class="elsevierStylePara elsevierViewall">With regard to your question on when NIMV should be limited, no data are currently available to support a clear answer. In our practice, we base the decision on clinical criteria and in accordance with the wishes of the patient and the family. The data from our ongoing LTP study will allow us to define more clearly the characteristics of the patients for whom the decision is taken to limit treatment and reasons for coming to that decision. We believe that these data will help us to plan larger studies and establish action guidelines.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Home mechanical ventilation (HMV) is prescribed for COPD after a second admission with respiratory acidosis and hypercapnia. In this subgroup, HMV was a protective factor against readmission (RR=0.76; 95% CI, 0.35–1.17).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0065" class="elsevierStylePara elsevierViewall">We have not carried out a cost-efficacy analysis, so we cannot provide any specific data in that respect. According to data from other studies, a bed in a RMU is cheaper than an intensive care unit bed.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Thus, the use of specialised units which shorten hospital stay and reduce complications should entail a reduction in costs. In any case, this would be an interesting basis for a future study that might confirm this supposition.</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion, we agree on the need for the creation of specific spaces for the application of NIMV and for multidisciplinary protocols, both during admission and on discharge, aimed specifically at the elderly population.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Segrelles Calvo G, Zamora García E, Ancochea J. Réplica. Arch Bronconeumol. 2014;50:80–81.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilación mecánica no invasiva en una población anciana que ingresa en una unidad de monitorización respiratoria: causas, complicaciones y evolución al año de seguimiento" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Segrelles Calvo" 1 => "E. Zamora García" 2 => "R. Girón Moreno" 3 => "E. Vázquez Espinosa" 4 => "R.M. Gómez-Punter" 5 => "G. 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Available from <a id="intr0010" class="elsevierStyleInterRef" href="http://www.who.int/thinfo/bodgbd2002revised/en/index/html">www.who.int/thinfo/bodgbd2002revised/en/index/html</a> [accessed 20.12.12]." ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The global burden of chronic diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Yach" 1 => "C. Hankes" 2 => "C. Gould" 3 => "K. 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| 2019 May | 15 | 5 | 20 |
| 2019 April | 27 | 9 | 36 |
| 2019 March | 23 | 14 | 37 |
| 2019 February | 26 | 12 | 38 |
| 2019 January | 25 | 9 | 34 |
| 2018 December | 24 | 12 | 36 |
| 2018 November | 45 | 17 | 62 |
| 2018 October | 26 | 18 | 44 |
| 2018 September | 21 | 5 | 26 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 13 | 0 | 13 |
| 2018 April | 22 | 4 | 26 |
| 2018 March | 21 | 4 | 25 |
| 2018 February | 25 | 5 | 30 |
| 2018 January | 59 | 6 | 65 |
| 2017 December | 59 | 5 | 64 |
| 2017 November | 17 | 7 | 24 |
| 2017 October | 13 | 7 | 20 |
| 2017 September | 8 | 6 | 14 |
| 2017 August | 16 | 8 | 24 |
| 2017 July | 15 | 3 | 18 |
| 2017 June | 30 | 8 | 38 |
| 2017 May | 14 | 5 | 19 |
| 2017 April | 24 | 3 | 27 |
| 2017 March | 9 | 3 | 12 |
| 2017 February | 7 | 0 | 7 |
| 2017 January | 10 | 3 | 13 |
| 2016 December | 21 | 9 | 30 |
| 2016 November | 33 | 5 | 38 |
| 2016 October | 16 | 16 | 32 |
| 2016 September | 27 | 9 | 36 |
| 2016 August | 31 | 8 | 39 |
| 2016 July | 16 | 7 | 23 |
| 2016 March | 7 | 0 | 7 |
| 2015 December | 5 | 0 | 5 |
| 2015 October | 55 | 3 | 58 |
| 2015 September | 51 | 10 | 61 |
| 2015 August | 65 | 18 | 83 |
| 2015 July | 56 | 11 | 67 |
| 2015 June | 44 | 5 | 49 |
| 2015 May | 72 | 21 | 93 |
| 2015 April | 53 | 17 | 70 |
| 2015 March | 42 | 10 | 52 |
| 2015 February | 35 | 4 | 39 |
| 2015 January | 43 | 10 | 53 |
| 2014 December | 32 | 11 | 43 |
| 2014 November | 38 | 14 | 52 |
| 2014 October | 64 | 21 | 85 |
| 2014 September | 43 | 20 | 63 |
| 2014 August | 67 | 27 | 94 |
| 2014 July | 52 | 16 | 68 |
| 2014 June | 98 | 26 | 124 |
| 2014 May | 38 | 15 | 53 |
| 2014 April | 0 | 1 | 1 |
| 2014 March | 0 | 3 | 3 |
Show all
