The İmpact of fragility on noninvasive mechanical ventilation application and results

1. The impact of fragility on noninvasive
mechanical 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

2. Aim
• The majority of patients in the ICU is fragile and this situation
adversely affect the treatment and prognosis of patients in ICU.
• In literature , there is no more data about the relationship between
fragility and noninvasive mechanical ventilation (NIV) treatment and
outcomes.
• In this study, we investigated the effect of fragility on the application
and results of NIV in ICU patients.

3. Method
• The patients who were over 50 years old and admitted to Gazi
University 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.

4. • Fried Fragility Score ≥ 3
• Clinical Fragility Score ≥5
• Edmonton Fragility Score ≥8,
patients were considered fragile.
Patients Over 50 years in ICU

5. Fried Fragility Score

6. Clinical Fragility Score

7. 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
Functional
performance
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

8. • 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 fragility
scores 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.

9. • PaO2>60 mmHg
• PaCO2<50 mmHg
• pH=7,35-7,45
• Improvement of respiratory effort (dyspnea, tachypnea, intercostal
retractions, etc.) (RR≤25)
• Recovery of consciousness (GCS>8)
The success of NIV is defined as achieving success in at least two
of the followings:

10. 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.

11. 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)

12. 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)

13. 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)

14. 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

15. 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

16. 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

17. 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.

18. 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.