The impact of fragility on noninvasivemechanical ventilation application and

results

Kara İ*, Yıldırım F*, Zerman A*, Güllü Z*, Boyacı N*, Aydoğan BB*, Gaygısız Ü*, Gönderen K*, Arık G**, Türkoğlu M*, Aydoğdu M*, Aygencel G*, Ülger Z**, Gürsel G*

*Gazi Üniversitesi Tıp Fakültesi Yoğun Bakım Eğitim Programı

** Gazi Üniversitesi Tıp Fakültesi Geriatri Bilim Dalı

Aim

• The majority of patients in the ICU is fragile and this situationadversely affect the treatment and prognosis of patients in ICU.

• In literature , there is no more data about the relationship betweenfragility and noninvasive mechanical ventilation (NIV) treatment and outcomes.

• In this study, we investigated the effect of fragility on the applicationand results of NIV in ICU patients.

Method

• The patients who were over 50 years old and admitted to GaziUniversity Medical Faculty, Department of Chest Diseases and Internal Medicine ICUs enrolled the study.

• In this prospective and observational study Fried, Edmonton and clinical fragility scores were used.

• The impact of fragility on the challenges and consequences of NIV in intensive care patients were evaluated.

• Fried Fragility Score ≥ 3

• Clinical Fragility Score ≥5

• Edmonton Fragility Score ≥8,

patients were considered fragile.

Patients Over 50 years in ICU

Fried Fragility Score

Clinical Fragility Score

Edmonton Fragility Score

Cognition Please imagine that this pre-drawn circle is a clock. I would like you to place the numbers in the correct positions then place the hands to indicate a time of ‘ten after eleven’

No errors Minor spacing errors

Other errors

General health status In the past year, how many times have you been admitted to a hospital? 0 1–2 ≥2

In general, how would you describe your health? ‘Excellent’, ‘Very good’, ‘Good’

‘Fair’ ‘Poor’

Functional independence

With how many of the following activities do you require help? (meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications)

0–1 2–4 5–8

Social support When you need help, can you count on someone who is willing and able to meet your needs?

Always Sometimes Never

Medication use Do you use five or more different prescription medications on a regular basis?

No Yes

At times, do you forget to take your prescription medications? No Yes

Nutrition Have you recently lost weight such that your clothing has become looser? No Yes

Mood Do you often feel sad or depressed? No Yes

Continence Do you have a problem with losing control of urine when you don’t want to?

No Yes

Functionalperformance

I would like you to sit in this chair with your back and arms resting. Then, when I say ‘GO’, please stand up and walk at a safe and comfortable pace to the mark on the floor (approximately 3 m away), return to the chair and sit down’

0–10 s 11–20 s One of >20 s patient unwilling, or requires assistance

• Information related to health status of the patients in the last 6 months were obtained from the patients or their relatives at admission and all three fragilityscores were calculated.

• Comprehensive geriatric assessment scores were calculated by a geriatric physician.

• The demographic characteristics of patients, hospitalization diagnosis, underlying diseases, noninvasive data and results were recorded.

• PaO2>60 mmHg

• PaCO2<50 mmHg

• pH=7,35-7,45

• Improvement of respiratory effort (dyspnea, tachypnea, intercostalretractions, etc.) (RR≤25)

• Recovery of consciousness (GCS>8)

The success of NIV is defined as achieving success in at least two of the followings:

Application Problems were defined as:

• Cooperation problems

• Hearing problems

• Delirium / agitation (Richmond Agitation Sedation Score)

• Claustrophobia

• Alzheimer

• Chin, mouth,tooth structures

• Leak >35L/min etc.

Hospitalization Diagnosis

n (%)

Noninvasive mechanical ventilation was applied to 75 patients of total 154 patients over the age of 50.

CHF-Pulmonary Edema 30(%40,0)

COPD 38(%50,7)

Pneumonia 27(%36,0)

Postextubation 11(%14,7)

Postoperative 1(%1,3)

OHS 8(%10,7)

OSAS 9(%12,0)

Restrictive Lung Disease 8(%10,7)

Admission blood gas values

n (%)

pH 7,36+0,07(7,19-7,51)

PaO2 72,03+17,45(39,60-145,0)

PaCO2 54,45+13,32(27,00-78,70)

HCO3 29,02+6,18(14,00-43,30)

Sat% 95,20+ 4,62(77,00-99,00)

Fragility scores

Mean ± std n(%)

Fried fragility Score ≥3 2,97±1,62(0-5) 47/75(%62,7)

Clinical fragility Score≥5 4,50±1,58(2-8) 31/75(%41,3)

Edmonton fragility Score≥8 5,84±2,73(0-12) 20/75(%26,7)

Application Problem(+) Application Problem (-) p

Fried fragility Score ≥3 29(%69) 13(%31) 0,612

Clinical fragility Score≥5 23(%79,3) 6(%20,7) 0,049

Edmonton Score≥8 14(%73,7) 5(%26,3) 0,394

APACHE II 21,36+6,12 20,65+5,12 0,631

Age 74,00+10,58 69,00+11,36 0,075

NIV application problem

NIV success (+) NIV success (-) p

Fried fragility Score ≥3 34(%73,9) 12(%26,1) 0,571

Clinical fragility Score≥5 21(%67,7) 10(%32,3) 0,161

Edmonton fragility Score≥8 14(%70,0) 6(%30,0) 0,417

NIV success

Mortality fragile relationship

Died Survival p

Fried fragility Score ≥3 10(%21,3) 37(%78,7) 0,045

Clinical fragility Score≥5 9(%29) 22(%71) 0,006

Edmonton fragility Score≥8 5(%25) 15(%75) 0,109

Result

• Fragility rates were significantly different according to the scores.

• NIV application challenges in fragile patients according to clinical fragility scores were higher but it did not significantly affect the NIV success.

• According to Fried and clinical fragility scores, there is significant correlation between mortality and fragility.

Although the preliminary results of the study suggest that fragility may be related with NIV application problems and mortality in ICU patients, but fragility may not affect the success of the application. These results should need to be supported with larger analysis with more patients.