Aging of the population is a critical worldwide trend. The proportion of individuals older than 60 years has tripled over the last 50 years and will triple again before 2050. This aging has major consequences on the health system, including the intensive care unit (ICU). In the USA, almost half (48.7%) of the patients admitted to an ICU are aged 65 years or older, and patients aged 85 years or older account for 7 to 25% of the admission rate (1, 2). The rate of pneumonia increases rapidly with age. Approximately 19% of adults hospitalized with pneumonia have an ICU admission, including 60.7% of patients aged 65 years or older (3). Pneumonia in older patients can lead to cardiopulmonary failure, sepsis, and even systemic multiple organ failure, and they have a high mortality rate (4). Older people with pneumonia are at risk for a longer hospital stay, extended antibiotic therapy, and higher healthcare costs (5, 6). Therefore, an appropriate treatment protocol for pneumonia in older patients needs to be determined.

Because of age-related changes in the body, comorbidity, and malnutrition, the onset of pneumonia is insidious, rapid, and critical, and clinical treatment is difficult in older patients (2, 7, 8). Lung physiotherapy plays an important role in treatment of older patients with pneumonia (2, 7, 8). Lung physiotherapy can help patients in reducing the accumulation of airway secretion, clearing the respiratory tract, preventing a collapsed lung, improving lung compliance, and reducing comorbidities (9, 10). Nurses are responsible for most respiratory treatment in China. However, there is little evidence for the effect of nurse-led GDLPT on the prognosis of pneumonia in older patients with sepsis. In a previous study, we found that nurse-led GDLPT improved the outcomes in patients with sepsis and pneumonia (11). In this study, we carried out a retrospective analysis of older patients (age ≥ 65 years) with sepsis and pneumonia to evaluate whether GDLPT affects the clinical outcome.

Pneumonia is frequently encountered in older patients admitted to the ICU, with an incidence rate of >60% in those with sepsis (6). In numerous clinical studies, lung physiotherapy was analyzed in patients with various critical diseases (12, 13, 19). However, little is known about nurses providing lung physiotherapy to older patients with sepsis and pneumonia. Furthermore, the effect of lung physiotherapy on the prognosis of these patients is unclear. In this study, we found that nurse-led GLDPT was associated with shorter ventilation days, and reduced ICU mortality and 28 day mortality rates.

With aging, there are significant changes in the anatomical and physiological function of the lungs. Older people are more likely to develop pulmonary complications and underlying diseases, including COPD, aspiration, pneumonia, tumor, heart failure, chronic renal failure, and have a poor prognosis (14). The GDLPT protocol has several advantages over conventional physiotherapy. One advantage is that the frequency of oral care is determined by the Beck Oral Assessment Scale score and mucosal-plaque score. Another advantage is that enhancement of airway drainage is conducted every 4 h for 20 to 30 min each time, with a vibration frequency of 20 to 30 Hz. Additionally, the cough strength is evaluated every 6 h. Older people with a weak cough are more likely to have nosocomial pneumonia and aspiration pneumonia (15). In the USA, the incidence of aspiration pneumonia in older patients is 30.9 cases per 10,000 people, which is twice that in patients aged <65 years (16). A further advantage is that airway humidification is evaluated regularly to maintain humidification at degree II (17). For patients with specific pulmonary consolidation, goal-directed patient positioning is actively used. The frequency of turning over is adjusted, and a lung recruitment maneuver is also performed through mechanical ventilation or a manual resuscitator. Therefore, as a non-invasive intervention strategy, nurse-led GDLPT is useful for older patients with pneumonia.

In this nurse-led GDLPT study, pain assessment, delirium assessment, and active early activities were carried out every 6 h by nurses. Delirium varies from 11 to 42% in older patients and has adverse outcomes and high health care costs (18). Up to 60% of delirious patients were unrecognized unless actively screened, and sedative medications and deeper sedation are associated with the development of delirium (20). According to the patient's delirium status, early activities were carried out, such as sitting at the wheel and early walking. Frailty in older patients is also a risk of a longer ICU stay, prolonged ventilation duration, and increased mortality. Early exercise is the most effective intervention for debilitating syndrome and significantly improves muscle strength. In this nurse-led GDLPT study, old patients without delirium were able to get out of bed into a wheelchair early or walk early after therapy. Additionally, patients with intermittent delirium were able to perform bedside wheelchair activity, and patients with continuous delirium were able to receive passive movement in bed or sitting upon the bed. The nurse-led GDLPT protocol was formulated in the critical clinical setting and designed using more than 20 years of clinical experience, with specific items and strong operability. This therapy enabled good management of older patients.

In this study, nurse-led GDLPT significantly shortened the duration of ventilation. Prolonged mechanical ventilation might result in an increased incidence of ventilator-associated pneumonia, which is clinically meaningful, especially for older patients with pneumonia. A high frequency of antibiotic use and antibiotic resistance in patients is caused by ventilator-associated pneumonia. The prevalence of multidrug resistance is increasing, and ventilator-associated pneumonia caused by multidrug resistance is often fatal in the ICU (21). Several factors such as the CPIS score, and the APACHE II score contribute to a high percentage of multidrug resistance in the ICU and are important reasons for the poor prognosis of older patients with sepsis and pneumonia (22).

At present, older patients with a critical illness are frequently admitted in the ICU. However, data on older patients with pneumonia are relatively rare, and there have been few evidence-based medical reports (23). This study was a retrospective analysis based on data from a previous nurse-led GDLPT study. All collected data, including vital signs, ventilatory parameters, and laboratory indicators, were obtained from electronic information systems. Data were double checked to minimize the risk of data entry errors and there were missing data. Therefore, prospective, randomized, controlled trials are required to further investigate the role of nurse-led GDLPT on older patients with pneumonia. The nurse-led GDLPT study was a prospective, before-and-after study in a single center. Therefore, a multicenter study needs to be performed to further examine the details of GDLPT and validate its wide applicability in older patients with pneumonia.

Managing pneumonia in critically ill older patients is a complex issue. Aging, comorbidities, frailty, and other factors in older patients significantly increase the management requirements and risks for those with critical illness. Nurse-led GDLPT significantly shortens the duration of ventilation and improves the 28 day mortality rate in older patients with sepsis and pneumonia. Nurse-led GDLPT is a new clinical intervention for the refined management of older patients with pneumonia, and it promotes the recovery of older patients with severe pneumonia.

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.

The studies involving human participants were reviewed and approved by the Institutional Review Board of Peking Union Medical College Hospital (No. JS-1170). The study was registered at chictr.org.cn (identifier: ChiCTR1900025850). The patients/participants provided their written informed consent to participate in this study.

NC, QL, HW, and JS contributed to the conception of the study, data interpretation, and drafted the manuscript. WH, HL, and MZ contributed to the data collection and data analysis. WC and ZL contributed to data collection and interpretation and critically revised the manuscript for important intellectual content. All authors approved the final version of the manuscript.

The work was supported by National Natural Science Foundation of China (No. 82072226), Beijing Municipal Science and Technology Commission (No. Z201100005520049), Fundamental Research Funds for the Central Universities (No. 3332021018), Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (No. 2019XK320040), Tibet Natural Science Foundation (No. XZ2019ZR-ZY12(Z)), and Excellence Program of Key Clinical Specialty of Beijing in 2020 (No. ZK128001).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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