Age and Ageing 2008; 37: 251–257  The Author 2008.

r 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afn060 All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Published electronically 3 April 2008

REVIEW

Acute respiratory failure in the elderly: diagnosis

and prognosis
SAMUEL DELERME, PATRICK RAY
Emergency Department, CHU Pitié-Salpétriêre, 47-83 boulevard de l’hopital, 75013 Paris, Université Pierre et
Marie Curie-Paris 6, France
Address correspondence to: P. Ray. Tel: +33 1 42 17 72 42; Fax: +33 1 42 17 72 64. Email: patrick.ray@psl.aphp.fr

Abstract
Acute respiratory failure (ARF) in patients over 65 years is common in emergency departments (EDs) and is one of the key
symptoms of congestive heart failure (CHF) and respiratory disorders. Searches were conducted in MEDLINE for published
studies in the English language between January 1980 and August 2007, using ‘acute dyspnea’, ‘acute respiratory failure
(ARF)’, ‘heart failure’, ‘pneumonia’, ‘pulmonary embolism (PE)’ keywords and selecting articles concerning patients aged
65 or over. The age-related structural changes of the respiratory system, their consequences in clinical assessment and the
pathophysiology of ARF are reviewed. CHF is the most common cause of ARF in the elderly. Inappropriate diagnosis that is
frequent and inappropriate treatments in ED are associated with adverse outcomes. B-type natriuretic peptides (BNPs) help
to determine an accurate diagnosis of CHF. We should consider non-invasive ventilation (NIV) in elderly patients hospitalised
with CHF or acidotic chronic obstructive pulmonary disease (COPD) who do not improve with medical treatment. Further
studies on ARF in elderly patients are warranted.

Keywords: acute respiratory failure, elderly, pulmonary embolism, BNP, congestive heart failure

Introduction keywords and selecting articles concerning patients aged

Visits by older adults compose 12–21% of all emergency
department (ED) encounters [1]. Furthermore, studies
showed a progressive increase in the number of ED
attendances and emergency admissions hospital of older
patients in the last decade. Between 30 and 50% of all ED
visits by older patients result in a hospital admission. Lastly
when admitted, older emergency patients are more likely to
require an ICU (intensive care unit) bed [2]. Acute respiratory
failure (ARF) is a common complaint of elderly patients in
ED, and the key clinical presentation of cardiac [congestive
heart failure (CHF)] and respiratory disorders [3].
This article will summarise the age-related structural
changes of the respiratory system and their consequences in
clinical practice. It will also overview the causes, difficulties
in diagnosis, treatment and the prognosis of ARF in elderly
patients.
Searches were conducted in MEDLINE for published
studies in the English language between January 1980 and
August 2007, using ‘acute dyspnea’, ‘acute respiratory failure’,
‘heart failure’, ‘pneumonia’, ‘pulmonary embolism (PE)’
65 or over.
Physiological changes according to age
Several changes related to ageing need to be taken into
account before discussing ARF.
Pulmonary function
Chest wall compliance decreases progressively with age,
presumably related to structural changes within the rib
cage [4, 5].
Total lung capacity does not change with age, but the
functional residual capacity and the residual volume both
increase. There is an increased tendency in airway closure
at small volumes (senile emphysema) related to the loss
of supporting tissues around the airways [4]. Because a
significant proportion of peripheral airways do not contribute
to gas exchange (low V/Q ratio) zones, but also because of
a reduced alveolar area, ageing was classically thought to be
accompanied by a progressive decline in arterial oxygen
tension (PaO2 ). Actually, recent studies have found no
significant correlation between PaO2 and age [6]. Because of

251
S. Delerme and P. Ray
a decline in tests of forced expiration (i.e. increasing airway
resistance), an obstructive pattern could exist even in women
who are non-smokers. Furthermore, studies suggest that
the ß-adrenoceptor dysfunction explains a less response to
bronchodilation in older asthmatic patients [7].
Other common important changes include loss of
diaphragmatic mass and strength with age [8]. Finally, as
a consequence of poor nutritional status, decreased T-cell
function, decline in mucociliary clearance, poor dentition
with oropharyngeal colonisation, and swallowing dysfunction
(Parkinson’s disease, Alzheimer’s disease and stroke),
community-acquired (CAP) and aspiration pneumonia is
exceedingly common in elderly patients [9].
Furthermore, decreased sensitivity of respiratory centres
to hypoxaemia, hypercapnia, or added resistive loads will
result in a diminished ventilatory response in cases of ARF;
and could delay diagnosis because of the poor perception of
the respiratory insults [4].
Cardiovascular changes
The physiological cardiovascular changes involve the
decrease of myocyte number, intrinsic contractility, coronary
flow reserve, ventricular compliance and ß-adrenoceptor-
mediated modulation of inotropy.
The ageing heart increases cardiac output by increasing
stroke volume rather than increasing heart rate. However,
this compensatory mechanism is dependent on the effective
atrial contribution to late diastolic filling (>30% in the elderly
patient) [10]. This explains the frequency of CHF caused by
rapid atrial fibrillation in the elderly.
Cardiac and respiratory systems are dependent. For
example, (1) a bout of pneumonia is sufficient to trigger
an acute exacerbation of heart failure, (2) a reduction in
cardiac output accompanying septic shock is a cause of
ARF caused by diaphragm hypoperfusion leading to alveolar
hypoventilation, and respiratory arrest.
Other relevant changes
Decrease in glomerular filtration rate (approximately 45%
by the age of 80) with ageing has important implications in
terms of drug dosing, as most drugs are renally excreted [2].
Most studies have shown an imbalance between
procoagulant/antifibrinolytic and anticoagulant factors,
which could contribute to an increased incidence of PE.
Definition and pathophysiology of acute
respiratory failure
The respiratory system consists of two parts: the lung, i.e.
the gas-exchanging organ, and the pump [11]. The pump
consists of the chest wall, including the respiratory muscles
(essentially the diaphragm), the respiratory controllers in
the central nervous system and the pathways that connect
the central controllers with the respiratory muscles (spinal
and peripheral nerves). ARF is a condition in which the
respiratory system fails in one or both of its gas exchange
252
functions, i.e. oxygenation (PaO2 <60 mmHg) of and/or
elimination of carbon dioxide (arterial carbon dioxide tension
(PaCO2 ) >45 mmHg) [11]. Both cut-off values simply serve
as a general guide in combination with the history and
clinical assessment of the patient. Thus, ARF could also be
suspected by ‘simple’ clinical criteria: polypnea >30 per min,
contraction of the accessory inspiratory muscles, abdominal
respiration, orthopnea cyanosis, and asterixis. Orthopnea is
frequently associated with all causes of ARF, and is neither a
sensible nor specific predictor of CHF [3].
The four pathophysiological mechanisms related to
hypoxaemic ARF (1) ventilation/perfusion inequality which
is the main mechanisms in an emergency setting (CHF or
pneumonia), (2) increased shunt (acute respiratory distress
syndrome), (3) alveolar hypoventilation [chronic obstructive
pulmonary disease (COPD)], and (4) diffusion impairment
(pulmonary fibrosis) [11].
Failure of the pump (or ventilatory failure) results in
alveolar hypoventilation with an increase in PaCO2 (Table 1).
Mechanisms responsible are decreasing minute ventilation
and increasing dead space. In elderly patients, the major
cause is severe hyperinflation, with flattened diaphragm and
reduced mechanical action of the inspiratory muscles (COPD
exacerbation) [4].
Actually, hypoxaemic ARF is a situation accompanied by
increased work of breathing. However, energy availability is
reduced due to hypoxaemia, resulting in muscle fatigue and
Table 1. Principal causes of acute respiratory failure
(adapted from [11])
Decreased central drive
Morphine (or other drugs: sedatives)
Central nervous system diseases (encephalitis, stroke, trauma)
Altered neural and neuromuscular transmission
Spinal cord trauma, transverse myelitis, tetanus, amyotrophic lateral
sclerosis, poliomyelitis, Guillain–Barre’ syndrome
Myasthenia gravis, botulism
Muscle abnormalities
Muscular dystrophy, disuse atrophy
Chest wall and pleural abnormalities
Kyphoscoliosis
Chest wall trauma (flail chest, diaphragmatic rupture)
Lung and airways diseases
Acute asthma
Acute exacerbation of chronic obstructive pulmonary disease
Congestive heart failure and non-cardiogenic pulmonary oedema
(acute respiratory distress syndrome)
Pneumonia, tuberculosis
Upper airways obstruction
Lung cancer, pulmonary fibrosis
Pneumothorax, pleural effusion
Bronchiectasis
Vascular diseases
Pulmonary embolism
Severe haemoptysis
Other
Severe sepsis or septic shock, other shock
The main causes of ARF in elderly patients are in bold.

ventilatory failure through imbalance between demand and
supply [11].
ARF in elderly patients
Etiology of ARF
The EPIDASA study prospectively evaluated ARF in 514
patients (mean age of 80 years), presenting to the ED.
CHF (43%), pneumonia (35%), COPD exacerbation (32%),
and PE (18%) were the main causes [3]. Half of the
patients had more than two diagnoses (CHF and CAP
in 17%). Pneumothorax, lung cancer, severe sepsis and
acute asthma were less frequent (<5%). An autopsy study
of 234 elderly patients confirmed that the most common
causes of death were CAP and CHF, both frequently
underestimated [12]. Ely et al. reported the causes of being
mechanically ventilated: CHF (16%), CAP (16%), COPD
(14%), and sepsis (10%) [13].
Difficult diagnosis of ARF in the elderly
Ray et al. found that the sensitivity of the emergency physician
was 86% for pneumonia, 75% for PE, and 71% for CHF [3].
In this study, the variables associated to a missed diagnosis
were a final diagnosis of CHF, CAP or PE, highlighting the
fact that frequent causes of ARF are very challenging to diag-
nose in the ED. Riquelme et al. demonstrated that the definite
diagnosis of CAP was delayed for more than 72 h in 62% of
patients [14]. The association of dyspnea, cough, and fever,
was observed in only 32% of patients with CAP, and delirium
at admission was very common (45%) [9, 14]. Atypical signs
of CHF are frequent (confusion or leg swelling, or wheezing),
and confusing [15, 16, 17]. Unfortunately, an inappropriate
diagnosis is associated with an increased mortality (Figure 1a
and b) [3, 18]. The difficulties of diagnosing CHF and
PE [19, 20, 21, 22, 23, 24] are reported in Appendix 1 and
Appendix 2 in the supplementary data on the journal’s web-
site http://www.ageing.oxfordjournals.org (Figure 2 and see
Appendix 4 in the supplementary data on the journal’s
website http://www.ageing.oxfordjournals.org).
Emergency Diagnosis
20
P<0.001
15
Number of Days
NS
P<0.001 30
10
5 5
0 0
Hospital ICU
A Free Days
Figure 1. (a) Effects of an appropriate (black bars) or inappropriate (white bars) initial diagnosis in the emergency department on
prognosis (used with permission from Ray P. [3]). (b) Effects of an appropriate (black bars) or inappropriate (white bars) initial
treatments in the emergency department on prognosis (used with permission from Ray P. [3]).
ARF in the elderly: diagnosis and prognosis
Outcomes
The mortality rate associated with ARF in the elderly varies
according to the etiology. In a study, the crude mortality
of CAP requiring hospitalisation was 26%, and age by itself
was not a significant factor related to prognosis [14]. CHF
has an in-hospital mortality, ranging from 13 to 29%, with
a rate of early re-hospitalisation from 29 to 47% within
3–6 months of the initial discharge, and a 1 year survival of
50% [3, 16, 25, 26]. In the EPIDASA study, 29% of patients
were admitted to an ICU, and 16% died in hospital. The
five variables associated to death were: inappropriate initial
treatment, hypercapnia >45 mmHg, creatinine clearance
<50 ml/min, elevated B-type natriuretic peptides (BNP
and NT-proBNP), and clinical signs of ARF. Age was not
significantly associated with mortality.
Prognosis of elderly admitted in an ICU
Age is included in several scores of severity such as the
APACHE II, Fine’s score for CAP [27], and Aujesky’s
score for PE [2, 28]. However, the large majority of the
studies indicate that acute physiology disturbances and
diagnosis have larger relative contributions to prognosis
than age [2]. Kaarlola et al. reported that the cumulative 3-
year mortality rate among the elderly patients was lower than
that among the controls (40% versus 57%). However, 88%
of the elderly survivors assessed their present health state as
satisfactory [29].
Ethical considerations
The decision to admit a patient to the ICU from the ED
is challenging, as physicians must decide in a short time.
When a patient potentially requiring ICU care is admitted to
the ED, emergency physicians take the first decision as to
whether to propose the patient to the ICU. Thus, intensivists
are involved only if an ICU admission is requested for
the patient. Age over 85 years seems to be an independent
predictor of ICU refusal [30]. Actually, the decision to admit
Emergency Treatment
50 20 50
P<0.001
P<0.001
40 40
Percent of patients
15
Percent of patients
Number of Days
30
P<0.001
10
20 20
10 10
0 0
Death Hospital ICU Death
B Free Days
253
S. Delerme and P. Ray

Medical History, physical findings,

CXR, ABG, EKG

Unknown diagnoses Obvious diagnosis

Previous cardiac or lung disease CHF, CAP, ACS …

Suspected CHF

BNP
or NT-proBNP

BNP < 100 pg/mL 100 < BNP < 500 BNP > 500 pg/mL

CHF very likely2

CHF unlikely Possible CHF1
Respiratory disorders ? Nitrate IV bolus, diuretics,
Doppler-echocardiography
ACEi, NIV, Doppler-EC

Further investigations
CT chest with parenchymal
windows, then protocole PE
or lung ultrasonography

Figure 2. Diagnostic strategy based on B-type natriuretic peptide levels in elderly patients admitted for ARF in the emergency
department. 1 In the grey zone (BNP between 100 and 500 pg/ml), which represents less than a quarter of patients, further
investigations are needed, and ER physicians should consider massive PE, CHE, severe exacerbation of COPD or severe
pneumonia as possible diagnoses. 2 Physicians should keep in mind that half of elderly patients with ARF has more than one
diagnosis, i.e. a BNP greater than 500 pg/ml strongly suggests CHF, but other diagnosis that could have precipitated CHF.
CXR: chest X-ray; EKG: electrocardiogram; ABG: arterial blood gas analysis; CHF: congestive heart failure; ACS: acute coronary
syndrome; CT: computed tomography; IV: intravenous; NIV: non-invasive ventilation including continuous positive airway
pressure; ACEi: angiotensin converting enzyme inhibitor; EC: echocardiography.

an elderly patient to an ICU should be based on the patients’ 1 in the supplementary data on the journal’s website
co-morbidities, acuity of illness, pre-hospital functional status http://www.ageing.oxfordjournals.org) [35].
and the patient’s preferences [2].

How could we improve outcomes of ARF Role of B-type natriuretic peptides

in elderly patients?
Studies suggested that an inappropriate diagnosis and
treatment were associated with an increased mortality rate
[Figure 1(b)] [3, 18]. Usual tools used to differentiate CHF
from respiratory disorders are not very accurate, even the
chest X-ray (CXR) in CHF [31] or the classical hypocapnia in
PE [32]. Thus valid diagnostic tools for differentiating CHF
from other etiologies of ARF could aid clinicians.
Usefulness of transthoracic echocardiography
Echocardiography (EC) should be encouraged because
the diagnosis of systolic CHF can be easily confirmed
by the emergency physician [33, 34]. However non-systolic
CHF is more difficult to evaluate by EC, and needs
Doppler and myocardial tissue imaging (see Appendix
BNP is a polypeptide, released by ventricular myocytes
directly proportional to wall tension, for lowering renin-
angiotensin-aldosterone activation. In the blood, the
cleavage of a precursor protein produces BNP and the
biologically inactive NT-proBNP. For diagnosing CHF,
both BNP and NT-proBNP have similar accuracy [36, 37]
(see Appendix 1 in the supplementary data on the journal’s
website http://www.ageing.oxfordjournals.org). However,
threshold values are higher than in middle-aged population.
A study demonstrated that the use of BNP in patients
>70 years early in the ED reduced the time to discharge,
total treatment cost, and 30-day mortality. Figure 2 shows a
diagnostic strategy based on BNP in elderly patients admitted
for ARF in the ED [38, 39]

254

Inflammatory markers
Diagnosing CAP is difficult and urgent because it requires
prompt antibiotics [40]. Thus, biological markers such as C-
reactive protein (CRP) and procalcitonin (PCT) may be useful
to suggest bacterial infection [41]. PCT seems to be more
sensitive and specific than CRP, with an additional prognostic
value [42]. Several studies suggested that, in a middle-aged
population with suspected CAP or COPD exacerbation, PCT
guidance of antibiotherapy reduced antibiotic use without
adverse effect [43]. However, in elderly patients Strucker
et al. have found that it had a low sensitivity (24%) for
infection [44].
Potential usefulness of thoracic imaging
When PE is suspected, throcacic computed tomography
(CT) is now one of the first line investigations (see Appendix
2 in the supplementary data on the journal’s website
http://www.ageing.oxfordjournals.org, Figure 2) [45]. Fur-
thermore, thoracic CT is useful in determining alternate
diagnoses (pneumonia or CHF missed on CXR). In case of
unknown ARF, we recommend to begin with parenchymal
windows to diagnose obvious CHF or pneumonia, following
by contrast injection to rule in PE if the parenchymal win-
dows do not explain the clinical picture [46, 47]. However,
physicians should be aware of the risks taken in performing
helical CT scan. [48].
Lung ultrasound could also be useful, but needs further
evaluation [49, 50].
Treatment of ARF
Medical and social aspect
Most emergency physicians do not have the expertise to
comprehensively address the myriad of needs of elderly
patients with complex chronic illnesses (for example, in the
EPIDASA study, 45% of the patients had previous cardiac
disease and 26% chronic respiratory disease [3]) and daily
treatments (in one study, the average number of drugs taken
by elderly patient was 4.2 [51]). Furthermore, polymedication
may affect the respiratory and cardiac systems (for example,
ß-blockers prescribed for hypertension have an effect on
lung function). A multi-disciplinary care model, involving
emergency physicians, gerontologist physicians, nurses,
clinicial pharmacist, social worker, family doctor should
be encouraged [26].
Oxygen therapy
Hypoxaemic patients with ARF need oxygen supplemen-
tation as the first stage of treatment. However, studies
suggested that injudicious use of oxygen therapy is asso-
ciated with increased hypercapnia in COPD patients [52].
Thus, it is important that, emergency physicians aim at pro-
viding an oxygen saturation >90%, and check blood gases
30 min after starting oxygen in COPD patients [53].
ARF in the elderly: diagnosis and prognosis
Management of pneumonia in the elderly
Previous studies showed the important role of silent
aspiration and the low prevalence of Legionella sp., Chlamydia
and Mycoplasma pneumoniae in CAP [9] Streptococcus pneumoniae
is the most common cause of CAP in the elderly.
Conversely, gram-negative bacilli (Klebsiella, Proteus sp,
Escherichia coli, and others) account for half of all the
culture-diagnosed pneumonias in nursing-home acquired
pneumonia. Recommendations for anti-microbial drug
use depend on the suspected specific organism, and
guidelines [54, 55]. The main objective is to start antibiotics
as early as possible since antibiotic administration within
4 h of hospital arrival is associated with a lower 30-day
mortality [56]. Recently, it was suggested that the SOAR
score (based on systolic blood pressure, oxygenation, age
and respiratory rate) was an alternative criteria for a
better identification of severe CAP in advanced age where
both raised urea level above 7 mmol/l and confusion are
common [57].
Pharmalogical treatment of CHF
Classically, medical treatments of CHF consisted of diuretics,
and morphine, based on the ‘inappropriate’ concept that
CHF is caused by fluid accumulation rather than fluid
redistribution. Nitrate conveys both venodilatation (reducing
right and left ventricular preload and reducing pulmonary
venous pressure directly) and arteriodilatation (reducing
the afterload mismatch and therefore increasing cardac
index). Cotter et al. [58] demonstrated that boluses of high-
dose isosorbide dinitrate improved outcome compared to
repeated high-doses furosemide [58]. Sacchetti et al. [59]
demonstrated that morphine sulfate use in the ED was
associated with an increased ICU admission and endotracheal
intubation, whereas captopril sublingual use was associated
with a decreased ICU admissions, and a decreased need for
endotracheal intubation. Considering the fact that 50% of
the elderly with CHF have preserved systolic function [60]
and that nearly two thirds present with hypertension, nitrate
should be preferred [61]. Rapid determination of whether
there is a systolic or non-systolic CHF is important because
the etiologies and pharmalogical treatment are different (see
Appendix 1 in the supplementary data on the journal’s
website http://www.ageing.oxfordjournals.org) [62].
Potential role of non-invasive ventilation by a face
mask
In acute COPD exacerbations, non-invasive positive-
pressure ventilation (NPPV) decreases PaCO2 by unloading
the respiratory muscles and supplementing alveolar venti-
lation. Several trials and meta-analysis support the use of
NPPV by reducing ventilator associated pneumonia, intuba-
tion, duration of ICU stay, and mortality [13]. The few studies
on NPPV suggest that the response of middle-aged patients
with acidotic COPD exacerbations to NPPV may extend to
the geriatric population. In CHF, NPPV improves oxygena-
tion, reduces work of breathing, and may prevent intubation,
255
S. Delerme and P. Ray
and decrease mortality [63]. One study demonstrated that,
compared to medical treatment, continuous positive air-
way pressure (CPAP) decreased respiratory rate, decreased
PaCO2 , and improved oxygenation compared with baseline
in elderly patients with hypoxaemic CHF [64]. However, the
in-hospital mortality (28% versus 30%) was not different.
There is no difference in outcome between NPPV and CPAP
for CHF [65].
Conclusion
CHF is the most common cause of ARF in the elderly
but half of the patients had more than two diagnoses.
As inappropriate treatment is associated with increased
morbidity and mortality, accurate diagnostic tools, such
as BNP, should be available in an ED 24 h a day. We
should consider non-invasive ventilation (NIV) in elderly
patients hospitalised with acidotic COPD exacerbations or
CHF who do not improve with medical treatment. ICU
admission decisions should not be based on age alone but
on factors such as the patient’s baseline level of function and
co-morbidities, severity of illness, and preferences for life
support.
Key points
• Causes of ARF in the elderly are often difficult to diagnose.
• A misdiagnosis in the ED is associated with increased
morbidity and mortality.
• Use of BNP or NT-proBNP for suspected CHF improves
diagnostic accuracy and outcome.
• NIV should be an option for severe CHF or COPD
exacerbation.
Ackowledgements
The authors would like to thank the physicians and
nursing staff working in the emergency department of Pitié-
Salpêtrière Hospital for their co-operation and support. We
also would like to thank Dr Joanne Ho (Internal Medicine,
Toronto, Canada) for the review of the manuscript.
Conflict of interest
None
Supplementary data
Supplementary data for this article are available online at
http://ageing.oxfordjournals.org.
References
(Due to the large number of references, only 40 are listed below and
are represented by boldtype throughout the text. The full list can
be found in the supplementary data online, on the journal website
http://www.ageing.oxfordjournals.org as Appendix 3.)
256
1. Aminzadeh F, Dalziel WB. Older adults in the emergency
department: a systematic review of patterns of use, adverse
outcomes, and effectiveness of interventions. Ann Emerg Med
2002; 39: 238–47.
2. Marik PE. Management of the critically ill geriatric patient. Crit
Care Med 2006; 34: S176–82.
3. Ray P, Birolleau S, Lefort Y et al. Acute respiratory failure in
the elderly: etiology, emergency diagnosis and prognosis. Crit
Care 2006; 10: R82.
4. Rossi A, Ganassini A, Tantucci C et al. Aging and the respiratory
system. Aging (Milano) 1996; 8: 143–61.
6. Guenard H, Marthan R. Pulmonary gas exchange in elderly
subjects. Eur Respir J 1996; 9: 2573–7.
7. Banerji A, Clark S, Afilalo M et al. Prospective multicenter study
of acute asthma in younger versus older adults presenting to
the emergency department. J Am Geriatr Soc 2006; 54: 48–55.
8. Polkey MI, Harris ML, Hughes PD et al. The contractile
properties of the elderly human diaphragm. Am J Respir
Crit Care Med 1997; 155: 1560–4.
9. Marrie TJ. Community-acquired pneumonia in the elderly. Clin
Infect Dis 2000; 31: 1066–78.
10. Miyatake K, Okamoto M, Kinoshita N et al. Augmentation
of atrial contribution to left ventricular inflow with aging as
assessed by intracardiac Doppler flowmetry. Am J Cardiol
1984; 53: 586–9.
11. Roussos C, Koutsoukou A. Respiratory failure. Eur Respir J
Suppl 2003; 47: 3s–14s.
12. Bordin P, Da Col PG, Peruzzo P et al. Causes of death and
clinical diagnostic errors in extreme aged hospitalized people:
a retrospective clinical-necropsy survey. J Gerontol A Biol Sci
Med Sci 1999; 54: M554–9.
13. Ely EW, Wheeler AP, Thompson BT et al. Recovery rate and
prognosis in older persons who develop acute lung injury and
the acute respiratory distress syndrome. Ann Intern Med 2002;
136: 25–36.
14. Riquelme R, Torres A, el-Ebiary M et al. Community-acquired
pneumonia in the elderly. Clinical and nutritional aspects. Am
J Respir Crit Care Med 1997; 156: 1908–14.
15. Gehlbach BK, Geppert E. The pulmonary manifestations of
left heart failure. Chest 2004; 125: 669–82.
16. Jorge S, Becquemin MH, Delerme S et al. Cardiac asthma in
elderly patients: incidence, clinical presentation and outcome.
BMC Cardiovasc Disord 2007; 7: 16.
20. Couturaud F, Parent F, Meyer G et al. Effect of age
on the performance of a diagnostic strategy based on
clinical probability, spiral computed tomography and venous
compression ultrasonography: the ESSEP study. Thromb
Haemost 2005; 93: 605–9.
21. Masotti L, Landini G, Cappelli R et al. Doubts and certainness
in diagnosis of pulmonary embolism in the elderly. Int J Cardiol
2006; 112: 375–7.
22. Righini M, Le Gal G, Perrier A et al. The challenge of diagnosing
pulmonary embolism in elderly patients: influence of age on
commonly used diagnostic tests and strategies. J Am Geriatr
Soc 2005; 53: 1039–45.
26. Vinson JM, Rich MW, Sperry JC et al. Early readmission of
elderly patients with congestive heart failure. J Am Geriatr Soc
1990; 38: 1290–5.
29. Kaarlola A, Tallgren M, Pettila V. Long-term survival, quality
of life, and quality-adjusted life-years among critically ill elderly
patients. Crit Care Med 2006; 34: 2120–6.

31. Herman PG, Khan A, Kallman CE et al. Limited correlation
of left ventricular end-diastolic pressure with radiographic
assessment of pulmonary hemodynamics. Radiology 1990;
174: 721–4.
34. Randazzo MR, Snoey ER, Levitt MA et al. Accuracy of
emergency physician assessment of left ventricular ejection
fraction and central venous pressure using echocardiography.
Acad Emerg Med 2003; 10: 973–7.
35. Arques S, Roux E, Sbragia P et al. Accuracy of tissue
Doppler echocardiography in the emergency diagnosis of
decompensated heart failure with preserved left ventricular
systolic function: comparison with B-type natriuretic peptide
measurement. Echocardiography 2005; 22: 657–64.
36. Ray P, Arthaud M, Lefort Y et al. Usefulness of B-type
natriuretic peptide in elderly patients with acute dyspnea.
Intensive Care Med 2004; 30: 2230–6.
38. Mueller C, Laule-Kilian K, Frana B et al. The use of B-type
natriuretic peptide in the management of elderly patients with
acute dyspnoea. J Intern Med 2005; 258: 77–85.
40. Metlay JP, Schulz R, Li YH et al. Influence of age on
symptoms at presentation in patients with community-acquired
pneumonia. Arch Intern Med 1997; 157: 1453–9.
41. Hausfater P, Juillien G, Madonna-Py B et al. Serum
procalcitonin measurement as diagnostic and prognostic
marker in febrile adult patients presenting to the emergency
department. Crit Care 2007; 11: R60.
43. Christ-Crain M, Jaccard-Stolz D, Bingisser R et al. Effect of
procalcitonin-guided treatment on antibiotic use and outcome
in lower respiratory tract infections: cluster-randomised, single-
blinded intervention trial. Lancet 2004; 363: 600–7.
45. Perrier A, Roy PM, Sanchez O et al. Multidetector-row
computed tomography in suspected pulmonary embolism.
N Engl J Med 2005; 352: 1760–8.
47. Webb WR, Müller NL, Naidich DP. High-resolution CT of
the Lung. Philadelphia, PA Lippincott Williams Wilkins, 2000.
51. Hohl CM, Dankoff J, Colacone A et al. Polypharmacy, adverse
drug-related events, and potential adverse drug interactions in
elderly patients presenting to an emergency department. Ann
Emerg Med 2001; 38: 666–71.
ARF in the elderly: diagnosis and prognosis
52. Joosten SA, Koh MS, Bu X et al. The effects of oxygen
therapy in patients presenting to an emergency department
with exacerbation of chronic obstructive pulmonary disease.
Med J Aust 2007; 186: 235–8.
53. Pauwels RA, Buist AS, Calverley PM et al. Global
strategy for the diagnosis, management, and prevention of
chronic obstructive pulmonary disease. NHLBI/WHO Global
Initiative for Chronic Obstructive Lung Disease (GOLD)
Workshop summary. Am J Respir Crit Care Med 2001; 163:
1256–76.
56. Meehan TP, Fine MJ, Krumholz HM et al. Quality of care,
process, and outcomes in elderly patients with pneumonia.
JAMA 1997; 278: 2080–4.
58. Cotter G, Metzkor E, Kaluski E et al. Randomised trial of high-
dose isosorbide dinitrate plus low-dose furosemide versus
high-dose furosemide plus low-dose isosorbide dinitrate in
severe pulmonary oedema. Lancet 1998; 351: 389–93.
59. Sacchetti A, Ramoska E, Moakes ME et al. Effect of ED
management on ICU use in acute pulmonary edema. Am J
Emerg Med 1999; 17: 571–4.
62. Ahmed A. American College of Cardiology/American
Heart Association Chronic Heart Failure Evaluation and
Management guidelines: relevance to the geriatric practice.
J Am Geriatr Soc 2003; 51: 123–6.
63. Peter JV, Moran JL, Phillips-Hughes J et al. Effect of non-
invasive positive pressure ventilation (NIPPV) on mortality in
patients with acute cardiogenic pulmonary oedema: a meta-
analysis. Lancet 2006; 367: 1155–63.
64. L’Her E, Duquesne F, Girou E et al. Noninvasive continuous
positive airway pressure in elderly cardiogenic pulmonary
edema patients. Intensive Care Med 2004; 30: 882–8.
65. Mehta S, Jay GD, Woolard RH et al. Randomized, prospective
trial of bilevel versus continuous positive airway pressure in
acute pulmonary edema. Crit Care Med 1997; 25: 620–8.
Received 12 April 2007; accepted in revised form 7 November
2007
257