Letter to the Editor
Ethical limits for noninvasive ventilation prescription
Limites éticos para a prescrição de ventilação não invasiva
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A solid and poorly differentiated malignant neoplasm with extensive areas of necrosis (A – HE 200×). The tumor cells had abundant eosinophilic cytoplasm and round nuclei with evident nucleoli (B – HE 600×). Immunohistochemically, the neoplastic cells focally expressed vimentin (C – 600×) and synaptophysin (D – 600×) in the absence of epithelial and other markers (AE1/AE3, CK8/18, CK7, CK20, CK5, 34β12, EMA,TTF1, napsin-A, p63, calretinin, pS100, CD31, CD34, PLAP, beta-HCG, CD45, CD20, CD10, inhibin, C-kit, CD99, actin, desmin, GFAP, CD30, CD21, HMB45, CD56, CD23, alpha-fetoprotein, myeloperoxidase, lysozyme, WT1, ALK, HepPar-1). With those morphological and immunohistochemical characteristics in the appropriate clinical context, the diagnostic hypothesis of paraganglioma/pheochromocytoma was suggested.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.F. Cruz, L. Iglésias, M. Monteiro, M.J. Santos, T. Pimentel, R.P. 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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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Parameters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">After NIV trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.600 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PaCO<span class="elsevierStyleInf">2</span> (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.507 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.882 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab550772.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. Elliot" 1 => "S. Nava" 2 => "B. Schonhofer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "fecha" => "2010" "paginaInicial" => "71" "paginaFinal" => "77" "editorial" => "Hodder Arnold ND Hachette UK Company" "editorialLocalizacion" => "London" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Indicações e limites da VNI" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. Fernandes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Manual de Ventilação Mecânica Não Invasiva" "paginaInicial" => "16" "paginaFinal" => "23" "serieFecha" => "2012" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ethical and medico-legal aspects of assisted ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.A. Branthwaite" 1 => "J.-P. Garside" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Non-Invasive Respiratory support a practical handbook" "paginaInicial" => "345" "paginaFinal" => "354" "edicion" => "3rd ed." "serieFecha" => "2007" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735115/0000002000000005/v1_201408310143/S2173511514000864/v1_201408310143/en/main.assets" "Apartado" => array:4 [ "identificador" => "20584" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735115/0000002000000005/v1_201408310143/S2173511514000864/v1_201408310143/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511514000864?idApp=UINPBA00004E" ]
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