Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit
Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit
复制标题
DOI：
10.7326/0003-4819-131-2-199907200-00004
复制
发表时间：
1999-07-20
影响因子：
39.2
通讯作者：
Haponik, EF
中科院分区：
文献类型：
--
作者：
Ely, EW;Evans, GW;Haponik, EF
背景：有人认为，老年人的生命支持应该受到限制，以节省资源。随着这一人群的增加，在这一人群中评估机械通气的适当使用的重要性也将增加。目的：确定年龄是否对进入重症监护室（ICU）后接受机械通气治疗的患者的结局有独立影响。设计：前瞻性队列研究。设置：大学三级医疗中心。患者：63名75岁或以上的患者和237名75岁以下的患者从内科和冠状动脉ICU入组。测量指标：住院死亡率、机械通气持续时间、ICU和住院时间以及护理费用。结果：机械通气的中位持续时间为4.2天（四分位距，2.1 - 9.3天），对于75岁或以上的患者，6.4天（四分位距，3.4至11.4天）对于75岁以下的患者（P = 0.14）。当“通过”每日脱机变量筛选试验所需的时间长度被用作呼吸衰竭恢复的指标时，老年患者比年轻患者更早通过（风险比，1.58 [95%CI，1.13至2.22]; P = 0.03）。老年患者的ICU护理费用（12 822美元[CI，9821美元至26 313美元]）低于年轻患者（19 316美元[CI，9699美元至39 950美元]）（P = 0.03）。老年组的中位住院费用倾向于较低（21 292美元与29 049美元; P = 0.17）。在多变量logistic回归分析中调整种族、性别和疾病严重程度后，患者年龄≥ 75岁可预测使用呼吸机的天数减少1天（CI，-2.8至1.2天）。在这些调整后，75岁或以上的人在ICU（β系数，-0.5天[CI，-3.0至2.7天]）和医院（β系数，0.3天[CI，-3.7至5.5天]）的停留时间没有差异（P > 0.1）。然而，老年人的重症监护室和住院费用较低（P = 0.02）。老年患者的住院死亡率为38.1%，年轻患者为38.8（P > 0.2）;考克斯比例风险分析证实两组间生存率无差异（老年患者的相对风险为0.82 [CI，0.52 - 1.29]）。在调整疾病严重程度后，老年患者在机械通气、ICU和医院的时间相似，但护理成本低于年轻患者。这些结果不能用死亡率的差异来解释，并表明不应根据年龄限制老年呼吸衰竭患者的机械通气。
Background: It has been argued that life support for the elderly should be limited to conserve resources. As this population increases, so will the importance of evaluating appropriate use of mechanical ventilation in this group.Objective: To determine whether age has an independent effect on the outcomes of patients treated with mechanical ventilation after admission to an intensive care unit (ICU).Design: Prospective cohort study.Setting: University-based tertiary care medical center.Patients: 63 patients 75 years of age or older and 237 patients younger than 75 years of age enrolled from medical and coronary ICUs.Measurements: In-hospital mortality rate, duration of mechanical ventilation, lengths of stay in the ICU and in the hospital, and cost of care.Results: Median duration of mechanical ventilation was 4.2 days (interquartile range, 2.1 to 9.3 days) for patients 75 years of age or older and 6.4 days (interquartile range, 3.4 to 11.4 days) for patients younger than 75 years of age (P = 0.14). When the length of time required to "pass" a daily screening test of weaning variables was used as an indicator of recovery from respiratory failure, elderly patients passed earlier than younger patients (risk ratio, 1.58 [95% CI, 1.13 to 2.22]; P = 0.03). The cost of ICU care was lower for older ($12 822 [CI, $9821 to $26 313] than for younger ($19 316 [CI, $9699 to $39 950]) patients (P = 0.03). Median hospital costs tended to be lower in the older group ($21 292 compared with $29 049; P = 0.17). After adjustment for ethnicity, sex, and severity of illness in a multivariate logistic regression analysis, patient age of 75 years or older was predictive of 1 less day on the ventilator (CI, -2.8 to 1.2 days). Lengths of stay in the ICU (beta-coefficient, -0.5 days [CI, -3.0 to 2.7 days]) and in the hospital (beta-coefficient, 0.3 days [CI, -3.7 to 5.5 days]) did not differ for persons 75 years of age or older after these adjustments (P > 0.1). Intensive care unit and hospital costs, however, were lower for elderly persons (P = 0.02). The in-hospital mortality rate was 38.1% among elderly patients and 38.8% among younger patients (P > 0.2); Cox proportional hazards analysis confirmed that survival did not differ between the two groups (relative risk for older patients, 0.82 [CI, 0.52 to 1.29]).Conclusions: After adjustment for severity of illness, elderly patients spent similar time on mechanical ventilation and in the ICU and hospital but had a lower cost of care than younger patients. These outcomes are not explained by differences in mortality rate and suggest that mechanical ventilation should not be restricted in elderly patients with respiratory failure on the basis of chronologic age.