PE diagnosis algorithm.
Treatment
Anticoagulation is the mainstay of treatment and results in a decrease in mortality.[58] Parenteral anticoagulation should be initiated after diagnosis is made. At one time, options were limited to IV unfractionated heparin. Recently, however, low molecular weight heparin and subcutaneous fondaparinux have become the preferred initial treatmentsdue to comparable mortality rates with superior morbidity.[59, 60] After the initial treatment, patients are usually transitioned to oral agents. The 2012 American College of Chest Physicians recommendations suggest the usage of warfarin as the agent of choice.[61] However, newer oral agents such as dabigatran or rivaroxaban may be considered in the appropriate clinical scenarios. These agents have the advantage of not requiring routine blood testing. However, they do not have an effective reversal agent so should be used with caution if the patient has an increased risk for falls or propensity for bleeding. Duration of therapyis dependent on risk factors for a recurrent embolic event and whether or not these risk factors are modifiable.
Special considerations in the elderly
Diagnosis of PE can be complicated in elderly patients, as D-dimer is a nonspecific marker for inflammation and is frequently elevated in the elderly due to comorbidities. This can decrease specificity of the D-dimer test.[62] Renal function naturally decreases with age, so caution must be exercised when using IV contrast for CT scans in older patients. Low molecular weight heparin must also be used with caution in this group for the same reason since it is renally metabolized. Finally, patients >65 years old and those at risk for falls are at an increased risk of bleeding while on anticoagulation, so great caution should be exercised with usage of these drugs.[59]
Interstial lung diseases
Interstitial lung diseases (ILD) are a heterogenous group of diseases that ultimately result in chronic lung damage and scarring. The diseases affect people of various ages; some causes are identifiable while others are idiopathic. Most forms of ILD are uncommon in older persons with the exception of idiopathic pulmonary fibrosis (IPF). The prevalence of IPF in patients aged 75 or older has been estimated at 227 per 100,000 compared to 4 per 100,000 in the 18- to 34-year-old demographic.[63]
Diagnosis
Patients with IPF typically have dyspnea on exertion that has progressed over several years with an associated nonproductive cough. Fine crackles are frequently heard on lung exam,[64] and clubbing may been seen in later stages of disease.[65] In IPF, pulmonary function tests reveal a restrictive pattern, and severity of restriction correlates with worse disease.[66] Radiographic studies are vital for diagnosis. Plain film chest x-rays typically demonstrate reticular opacities with a basilar predominance.[67] High-resolution chest CT can demonstrate subpleural and bibasilar reticular opacities with honeycombing or bronchiectasis, which is often diagnostic of the disease.[68]
Treatment
IPF is a serious illness with a mean survival after diagnosis of 5.6 years.[69] Unfortunately, to date, no pharmacological intervention has been proven to be efficacious.[70] Therefore, treatment recommendations are based on consensus guidelines and largely consist of supportive care with oxygen therapy and pulmonary rehabilitation. Corticosteroids have been frequently utilized, but current data do not support their efficacy,[71] and current American Thoracic Society recommendations do not support corticosteroid monotherapy.[70] Other regimens such as a combination of prednisone, azathioprine, and N-acetylcysteine have been studied, but the most recent trial on this combination was stopped due to increased mortality with this regimen.[72] Pirfenidone, an anti-inflammatory agent, is approved for use in Europe, and the FDA is reviewing promising data from recent clinical trials in the United States.[73] A recent phase III trial of the tyrosine kinase inhibitor nintedanib showed marked improvement in decreasing progression of loss of FVC in idiopathic pulmonary fibrosis, although further research on the mortality benefit of this medication is needed.[74]
Given the current lack of effective treatment options, advance care planning discussions are paramount, especially in the elderly patient presenting with advanced disease. Guidelines recommend against mechanical ventilation in this progressive and irreversible disease process.[70] Patients and their families should be made aware of this after diagnosis and counseled accordingly.
Nontuberculous mycobacterium
In the past few years, more attention has been focused on the diagnosis and treatment of nontuberculous mycobacterium (NTM). This group includes mycobacterium avium complex (MAC) and can result in progressive pulmonary illness. Two-year prevalence has been estimated at 20 per 100,000 people in those over age 55. Median age of incidence is 66 years old with an increased prevalence in females.[75]
Presentation and diagnosis
Two different clinical presentations of pulmonary infection are observed. One is seen primarily in older white men with pre-existing lung disease such as COPD. The disease resembles M. tuberculosis (TB) infection in these patients, with cough and weight loss, but the symptoms are not usually as severe as in TB. It can also have similar radiographic findings as TB, with cavitary lung lesions.[76]
NTM infection is also seen in people without underlying lung disease. These patients are usually elderly, nonsmoking women.[77] They present with a persistent cough of unclear etiology, and nodules and bronchiectasis are typically seen on chest imaging.[78] Signs and symptoms are vague and nonspecific and include cough, fatigue, malaise, dyspnea, weakness, and, less commonly, hemoptysis. Diagnosis requires a combination of pulmonary symptoms, radiographic changes, and a positive culture from at least two separate sputum samples or from one bronchial lavage sample.[79]
Treatment
Therapy for slowly progressive NTM infection is not always indicated and should be based on disease severity, symptom burden, and the patients’ wishes according to risks and benefits of therapy.[79] Treatment consists of multiple antibiotics and is usually recommended for at least one year. Patients with mild symptoms or significant other comorbidities, such as malignancy, may choose to forgo treatment. For those patients who do decide to undergo treatment, antibiotic susceptibility testing should be performed on the MAC isolates. The current recommended regimen consists of a daily combination of a macrolide, such as clarithromycin, plus rifampin plus ethambutol.[79] Treatment should continue until sputum cultures are consecutively negative for one year, if possible. It is important to note that an elderly patient undergoing treatment must be monitored closely, as these medications can have significant side effects to which the geriatric patient may be more prone due to the decline in metabolic clearance with aging. Gastrointestinal side effects and intolerance may be more pronounced in the older patients, necessitating dose reductions.
Sleep-related breathing disorders
Sleep-related breathing disorders refer to a variety of syndromes that result in either abnormal respiratory pattern such as apnea, or reduction in gas exchange during sleep. Between 12 and 18 million adults in the United States are affected with these disorders.[80] The most common two syndromes are obstructive sleep apnea (OSA) and central sleep apnea.
OSA is the most common of these disorders, with an estimated prevalence of 17% in men and 9% in women aged 50–70.[81] In addition to age and male gender, obesity is a significant risk factor, with obese individuals suffering up to a sixfold increased risk for OSA when compared to non-obese patients.[82] Smoking also increases risk significantly.[83] Presenting symptoms of OSA include daytime sleepiness, snoring, and witnessed apneas by a bed partner. Excessive sleepiness from OSA may result in daytime errors, and a threefold increase in motor vehicle crashes has been observed in patients with OSA.[84] OSA is a risk factor for systemic hypertension and multiple adverse cardiac effects, including coronary artery disease and arrhythmias.[85–87]
Diagnosis
Diagnosis is made via overnight polysomnography. Diagnosis is made when there are 15 or more apneas, hypopneas, or respiratory-effort-related awakenings per hour of sleep in asymptomatic patients or five or more events per hour in a patient with symptoms of disturbed sleep.[88] Diagnostic evaluation should be encouraged; the test is relatively safe, and treatment has large potential benefits on quality of life. Home sleep apnea testing is becoming increasingly available. Although it may be less informative than conventional polysomnography, it is less expensive and more convenient for patients.
Treatment
Treatment of choice of OSA is positive airway pressure therapy delivered via either continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) devices. Although improved morbidity and symptoms have been demonstrated with these therapies, no randomized controlled trial to date has demonstrated an improvement in mortality.[89] The pressure is titrated to the required setting during polysomnography either in a split-night fashion or with a second visit to the sleep laboratory. As with home diagnostic testing, out-of-center treatment with autotitrating positive pressure therapy is becoming available for patients with high pretest probability of uncomplicated, moderate OSA.
Critical care in the elderly
Elderly patients account for over 40% of patients in intensive care units (ICUs).[90] Despite the higher utilization of ICU resources by the elderly, age is frequently a factor in decisions to withhold aggressive therapies.[91] Many providers assume that geriatric patients have worse outcomes in the ICU when compared to younger patients. However, age itself is not nearly as important in predicting mortality risk as is severity of the acute illness and degree of underlying comorbidities.[92] Further, although many elderly survivors of critical illness are left with significant functional impairments, an overwhelming majority would choose to undergo ICU care again if necessary.[93] Therefore, the most important factor in whether an elderly person should be treated in an ICU setting is whether ICU treatment would be in congruence with the patient’s wishes. This can be difficult to ascertain if the patient does not have advance care planning (ACP) documentation or if that documentation is ambiguous. These situations are best averted by being proactive with ACP in the outpatient setting.[94]
There are many important issues that should be considered when caring for elderly patients in the ICU. Delirium is common, with approximately 70% of elderly patients suffering from delirium during a hospitalization requiring ICU care.[95] It is defined as an acute change in mentation that results in inattention and either disorganized thinking or an altered level of consciousness. Delirium is an independent predictor of both increased inhospital mortality and prolonged hospitalization.[96] Diagnosis in the ICU is frequently made using convenient bedside tools such as the Confusion Assessment Method-ICU (CAM-ICU) assessment tool. Given the association of delirium with worse outcomes, prevention may be important. Potential strategies include orientation protocols, environmental modifications such as dimming the lights at night in order to preserve the sleep-wake cycle, and early mobilization. Minimization of long-acting sedatives such as lorazepam has also been proven to be an effective prevention strategy.[97] These interventions may not always be possible in the critically ill patient but should be implemented when possible. (See Chapter 11, “Recognition, Management, and Prevention of Delirium.”)
Severe sepsis is one of the most common diagnoses leading to admission to critical care units, and elderly patients are at higher risk for hospitalization with severe sepsis than the general population. The yearly incidence of severe sepsis for patients over 80 years old is 26.2 per 1,000 compared to 3 per 1,000 overall. The incidence of severe sepsis in the elderly is expected to increase in the coming years as patients live longer with multiple comorbid conditions that increase the likelihood of sepsis, such as end-stage renal disease, COPD, cirrhosis, and malignancies.[98] Considering the high incidence of cardiac and renal dysfunction in the elderly, they benefit from early and aggressive resuscitation upon presentation with severe sepsis. Early appropriate antibiotics are also essential to good outcomes.
Geriatric patients are at higher risk for prolonged mechanical ventilation after acute illness.[99] Although recent strategies to improve mechanical ventilation liberation have improved the rates of prolonged ventilation, the most effective approach is still to avoid intubation when possible. Judicious use of noninvasive positive pressure ventilation in patients presenting with respiratory failure due to COPD or congestive heart failure reduces the incidence of mechanical ventilation and the risk of mortality.[27, 100]
Conclusion
Elderly patients suffer from the majority of pulmonary disease processes that are observed in young patients. However, due to their differing physiology and increased likelihood of comorbidities, older persons have numerous special diagnosis and treatment considerations. Practitioners should focus on utilizing the most effective therapies while minimizing potential harm to the patient. Further, one should make every effort to ensure that diagnosis and treatment strategies are in congruence with the patients’ wishes.
References
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