Non-invasive ventilation for frail elderly patients with acute respiratory failure.

We describe 3 elderly patients with acute respiratory failure who received respiratory assistance with nasal bi-level positive airway pressure (BiPAP) on the ward. In these patients with poor prognostic factors, non-invasive positive pressure ventilation was preferred as a reasonable alternative to invasive ventilation; indeed, their admission to the intensive care unit for mechanical support was considered inappropriate. Despite the small number of patients and limited experience with the technique, BiPAP is discussed here as a possible treatment for severe respiratory failure when endotracheal ventilation is controversial, especially in frail patients 80 years of age or older, because invasive ventilation is associated with high mortality and morbidity in these patients. Two questions nevertheless need further evaluation in this setting, and are also addressed. The first is technical: can transient non-invasive breathing assistance be delivered on the ward? The second is ethical: is BiPAP a possible alternative when invasive ventilation is considered inappropriate?