The reduced use of intubations in elderly patients in the emergency department: Many insights behind a historical trend

Johnson et al. in their article [ ] bring to light, albeit the limitations of the study, some important aspects about the reduction of intubations in elderly patients in the emergency department over the past two decades. The authors identified essentially three specific reasons behind this trend: the increased use of noninvasive mechanical ventilation (NIMV), the advancements in the medical management of cardiac heart failure (CHF) and increased use of advance directives. We agree with the fact that this phenomenon is multifactorial. The first cause is the substantial evidence of the use of NIMV in patients with COPD. In the 1990s there was the considerable evidence that the intermittent positive airway pressure delivered by facemask reduced the need for invasive mechanical ventilation in COPD patients with hypercapnic respiratory failure [ ]. Since then, this evidence has been strengthened by many systematic reviews and RCTs. Age did not imply a weaker response. The use of NIPPV has increased significantly over time among patients (of all classes of age) hospitalized for acute exacerbations of COPD, whereas the need for intubation and in-hospital mortality has declined [ ].