Letter to the Editor
Ethical limits for noninvasive ventilation prescription
Limites éticos para a prescrição de ventilação não invasiva
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Simões Saldanha Mendes, C. Ferreira, C. Dias, J. Moita" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Simões Saldanha Mendes" "email" => array:1 [ 0 => "marianacarocha@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Dias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Moita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Centro Hospitalar da Cova da Beira, CPE, Covilhã, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Pneumologia B, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Limites éticos para a prescrição de ventilação não invasiva" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Non-Invasive Ventilation (NIV) is the treatment of choice in acute respiratory failure (ARF) related to Chronic Obstructive Pulmonary Disease exacerbation and Acute Cardiogenic Pulmonary Edema.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It has also demonstrated good results in a set of other consensual and systematized pathologies.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In addition NIV has been used as an alternative for ARF patients who have “do-not-intubate” orders either due to poor prognosis associated with multiple comorbidities or terminal disease, or as palliative management of dyspnea.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Aiming to encourage discussion around this theme, the authors reviewed 508 medical records of patients undergoing NIV between November 2011 and May 2013, in <span class="elsevierStyleItalic">Hospital Geral do Centro Hospitalar e Universitário de Coimbra</span>, and identified 15 cases in which the use of NIV was the subject of ethical considerations: 6 patients with advanced cancer disease, 5 with multiple organ dysfunction, 3 with extensive stroke damage, and one patient with respiratory failure (RF) of central origin. The patients, 4 male and 11 females, had an average age of 65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15, and had an average age-adjusted Charlson comorbidity index of 6.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.1. Five patients presented type 1 RF, and 9 had type 2 RF. NIV was administered to one patient despite a lack of RF criteria. The average PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio was 187.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>60.2, and average PaCO<span class="elsevierStyleInf">2</span> was 58.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>25.0<span class="elsevierStyleHsp" style=""></span>mmHg. Seven patients presented acidosis (average pH: 7.19<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.13): mixed in 4 cases, respiratory in 2, and metabolic in one patient. The application of pressure support ventilation of 11.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.8<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, with 50.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>21.7% FiO<span class="elsevierStyleInf">2</span> led to improved pH, PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> and PaCO<span class="elsevierStyleInf">2</span> but showed no statistical significance (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). After 3.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.2 days of NIV 13 of the 15 patients died. None of the 10 patients capable of assessing the efficacy subjectively referred relief of dyspnea.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In conclusion, we do not consider it appropriate to use NIV in situations where there is no legitimate justification. On the contrary: it is an inefficient and costly approach and often leads to misperceptions about end of life management.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> With our limited public health resources providing differentiated treatments to those who do not benefit from them could be considered ethically reprehensible because, as a consequence, treatment may not then be available for those who would benefit. NIV can on occasions contribute to a patient’ comfort, when combined with other measures (like administration of morphine) in the appropriate institutions, but not in hospital emergency room.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">NIV, non-invasive ventilation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After NIV trial \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.31<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.600 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PaCO<span class="elsevierStyleInf">2</span> (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>25.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.507 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">187.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>60.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">192.25<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>67.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.882 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab885866.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Arterial Blood Gas (ABG) parameters evolution.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-invasive ventilation & weaning, principles and practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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"serieFecha" => "2007" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08732159/0000002000000005/v2_201509041759/S0873215914000518/v2_201509041759/en/main.assets" "Apartado" => array:4 [ "identificador" => "19161" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Cartas ao editor" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08732159/0000002000000005/v2_201509041759/S0873215914000518/v2_201509041759/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215914000518?idApp=UINPBA00004E" ]
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| 2021 December | 27 | 40 | 67 |
| 2021 November | 39 | 37 | 76 |
| 2021 October | 76 | 39 | 115 |
| 2021 September | 26 | 21 | 47 |
| 2021 August | 20 | 24 | 44 |
| 2021 July | 29 | 21 | 50 |
| 2021 June | 28 | 32 | 60 |
| 2021 May | 26 | 19 | 45 |
| 2021 April | 81 | 98 | 179 |
| 2021 March | 52 | 26 | 78 |
| 2021 February | 65 | 12 | 77 |
| 2021 January | 38 | 24 | 62 |
| 2020 December | 47 | 4 | 51 |
| 2020 November | 39 | 23 | 62 |
| 2020 October | 50 | 14 | 64 |
| 2020 September | 81 | 17 | 98 |
| 2020 August | 73 | 23 | 96 |
| 2020 July | 91 | 29 | 120 |
| 2020 June | 77 | 18 | 95 |
| 2020 May | 75 | 20 | 95 |
| 2020 April | 76 | 9 | 85 |
| 2020 March | 52 | 13 | 65 |
| 2020 February | 78 | 15 | 93 |
| 2020 January | 81 | 23 | 104 |
| 2019 December | 56 | 17 | 73 |
| 2019 November | 54 | 12 | 66 |
| 2019 October | 68 | 21 | 89 |
| 2019 September | 66 | 27 | 93 |
| 2019 August | 130 | 13 | 143 |
| 2019 July | 122 | 19 | 141 |
| 2019 June | 160 | 12 | 172 |
| 2019 May | 148 | 29 | 177 |
| 2019 April | 107 | 29 | 136 |
| 2019 March | 173 | 16 | 189 |
| 2019 February | 153 | 25 | 178 |
| 2019 January | 189 | 27 | 216 |
| 2018 December | 109 | 14 | 123 |
| 2018 November | 32 | 0 | 32 |
| 2018 October | 34 | 11 | 45 |
| 2018 September | 15 | 5 | 20 |
| 2018 August | 44 | 24 | 68 |
| 2018 July | 47 | 21 | 68 |
| 2018 June | 59 | 17 | 76 |
| 2018 May | 72 | 18 | 90 |
| 2018 April | 123 | 31 | 154 |
| 2018 March | 99 | 26 | 125 |
| 2018 February | 37 | 10 | 47 |
| 2018 January | 81 | 10 | 91 |
| 2017 December | 46 | 9 | 55 |
| 2017 November | 40 | 16 | 56 |
| 2017 October | 23 | 18 | 41 |
| 2017 September | 22 | 20 | 42 |
| 2017 August | 28 | 19 | 47 |
| 2017 July | 14 | 16 | 30 |
| 2017 June | 35 | 17 | 52 |
| 2017 May | 37 | 10 | 47 |
| 2017 April | 12 | 5 | 17 |
| 2017 March | 10 | 32 | 42 |
| 2017 February | 7 | 3 | 10 |
| 2017 January | 13 | 4 | 17 |
| 2016 December | 10 | 7 | 17 |
| 2016 November | 8 | 2 | 10 |
| 2016 October | 6 | 3 | 9 |
| 2016 September | 12 | 4 | 16 |
| 2016 August | 2 | 2 | 4 |
| 2016 July | 5 | 7 | 12 |
| 2016 May | 0 | 9 | 9 |
| 2016 April | 20 | 3 | 23 |
| 2016 March | 31 | 12 | 43 |
| 2016 February | 35 | 14 | 49 |
| 2016 January | 28 | 13 | 41 |
| 2015 December | 62 | 8 | 70 |
| 2015 November | 17 | 7 | 24 |
| 2015 October | 27 | 9 | 36 |
| 2015 September | 25 | 8 | 33 |
| 2015 August | 15 | 8 | 23 |
| 2015 July | 24 | 8 | 32 |
| 2015 June | 24 | 6 | 30 |
| 2015 May | 31 | 9 | 40 |
| 2015 April | 28 | 16 | 44 |
| 2015 March | 23 | 4 | 27 |
| 2015 February | 33 | 16 | 49 |
| 2015 January | 24 | 22 | 46 |
| 2014 December | 76 | 43 | 119 |
| 2014 November | 70 | 40 | 110 |
| 2014 October | 117 | 62 | 179 |
| 2014 September | 81 | 42 | 123 |
| 2014 August | 52 | 32 | 84 |
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