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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Rose L, Messer B. Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy. Crit Care Clin 2024; 40:409-427. [PMID: 38432703 DOI: 10.1016/j.ccc.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK; Department of Critical Care and Lane Fox Unit, Guy's & St Thomas' NHS Foundation Trust, King's College London, 57 Waterloo Road, London SE1 8WA, UK.
| | - Ben Messer
- Royal Victoria Infirmary, Newcastle-Upon-Tyne NHS Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Michels JD, Meis J, Sturm N, Bornitz F, von Schumann S, Weis A, Neetz B, Bentner M, Forstner J, Litke N, Wensing M, Erdmann S, Grobe T, Frerk T, Kempa A, Neurohr C, Schneider A, Müller M, Herth FJF, Szecsenyi J, Trudzinski FC. Prevention of invasive ventilation (PRiVENT)-a prospective, mixed-methods interventional, multicentre study with a parallel comparison group: study protocol. BMC Health Serv Res 2023; 23:305. [PMID: 36998047 PMCID: PMC10061400 DOI: 10.1186/s12913-023-09283-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/14/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) is a standard therapy for intensive care patients with respiratory failure. With increasing population age and multimorbidity, the number of patients who cannot be weaned from IMV increases, resulting in impaired quality of life and high costs. In addition, human resources are tied up in the care of these patients. METHODS The PRiVENT intervention is a prospective, mixed-methods interventional, multicentre study with a parallel comparison group selected from insurance claims data of the health insurer Allgemeine Ortskrankenkasse Baden-Württemberg (AOK-BW) conducted in Baden-Württemberg, Germany, over 24 months. Four weaning centres supervise 40 intensive care units (ICUs), that are responsible for patient recruitment. The primary outcome, successful weaning from IMV, will be evaluated using a mixed logistic regression model. Secondary outcomes will be evaluated using mixed regression models. DISCUSSION The overall objective of the PRiVENT project is the evaluation of strategies to prevent long-term IMV. Additional objectives aim to improve weaning expertise in and cooperation with the adjacent Intensive Care Units. TRIAL REGISTRATION This study is registered at ClinicalTrials.gov (NCT05260853).
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Affiliation(s)
- Julia D Michels
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany.
- Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Röntgenstrasse 1, Heidelberg, D-69126, Germany.
| | - Jan Meis
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Noemi Sturm
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Bornitz
- Asklepios Hospital Barmbek, Pneumology and Internal Intensive Care Medicine, Hamburg, Germany
| | - Selina von Schumann
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Aline Weis
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Neetz
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
| | - Martina Bentner
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Johanna Forstner
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicola Litke
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Stella Erdmann
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Thomas Grobe
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Timm Frerk
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Axel Kempa
- Department of Pneumology and Critical Care, SLK-Klinik Löwenstein, Löwenstein, Germany
| | - Claus Neurohr
- Department of Pneumology and Respiratory Medicine, Robert-Bosch-Krankenhaus Klinik Schillerhöhe, Gerlingen, Germany
| | - Armin Schneider
- Department of Anaesthesia and Intensive Care Medicine Waldburg-Zeil Kliniken, Wangen Im Allgäu, Germany
| | - Michael Müller
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
| | - Felix J F Herth
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Franziska C Trudzinski
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
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The Survival Outcomes of Patients Requiring Prolonged Mechanical Ventilation. Medicina (B Aires) 2023; 59:medicina59030614. [PMID: 36984615 PMCID: PMC10057588 DOI: 10.3390/medicina59030614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/10/2023] [Accepted: 03/17/2023] [Indexed: 03/22/2023] Open
Abstract
Background and objectives: Patients who require prolonged mechanical ventilation typically experience poor long-term survival outcomes. However, there have been few studies conducted to investigate the five-year survival rate of these patients. This study aims to determine the factors that affect the five-year survival rate of patients who require prolonged mechanical ventilation, with the goal of improving their survival outcomes. Materials and Methods: The current retrospective, single-center study included all patients who required prolonged mechanical ventilation over a period of six years. We collected data on their age, sex, causes of acute respiratory failure leading to prolonged mechanical ventilation, comorbidities, receipt of a tracheostomy or not, weaning status, discharge conditions, and long-term outcomes. Results: The study examined the long-term outcomes of 403 patients who required prolonged mechanical ventilation until December 2018. Of the study population, 157 patients were successfully weaned from prolonged mechanical ventilation and discharged, 186 patients passed away in the hospital, and 60 patients remained ventilator-dependent. For all 403 patients receiving prolonged mechanical ventilation, the one-year and five-year survival rates were 24.3% and 14.6%, respectively. Among the 243 patients who were successfully weaned from prolonged mechanical ventilation, the corresponding rates were 32.6% and 21.0%. For the 157 discharged prolonged mechanical ventilation patients, the one-year and five-year survival rates were 50.3% and 32.6%, respectively. For the 60 ventilator-dependent patients, the one-year and five-year survival rates were 31.7% and 13.2%, respectively. The study revealed that successfully weaned from invasive mechanical ventilation and the receipt of a tracheostomy were influential factors in the five-year survival rate of patients requiring prolonged mechanical ventilation. Conclusions: Patients requiring prolonged mechanical ventilation may experience poor survival outcomes. Nevertheless, two key factors that can improve their long-term survival are successfully weaned from invasive mechanical ventilation and receipt of a tracheostomy.
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Löfroth M, Petersson JE, Uusijärvi J, Hårdemark Cedborg AI, Sundman E. Outcomes of prolonged intensive care and rehabilitation at a specialized multidisciplinary center in Sweden. Acta Anaesthesiol Scand 2022; 66:232-239. [PMID: 34778943 DOI: 10.1111/aas.13998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/12/2021] [Accepted: 10/29/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Specialized clinics may improve the outcome for patients with prolonged intensive care stays. Admission may depend on diagnosis, need of respiratory support and more. We report the results from a Swedish specialized center with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation regardless of patients' primary diagnosis or ventilator need. METHODS All patients admitted and discharged from 2015 to 2018 were included. Demographics, diagnoses, ventilatory support requirement, discharge destination and survival were retrieved from the center´s quality registry. RESULTS A total of 181 patients, mean age 61 ± 16 years, 64% men, were analyzed. A neurological diagnosis was the cause for hospitalization in 46% of patients. Of the 55 patients admitted to the center for weaning from mechanical ventilation, 89% were successfully weaned within a median of 25 (interquartile range (IQR) 16-45) days. Decannulation was intended in 117 patients of which 90% were successful within a median of 25 (IQR 13-43) days. Readmission to intensive care was 4%. Most patients were discharged to their home or to rehabilitation clinics with a lower level of care. In-clinic mortality was 3%. Survival beyond 1 and 2 years after discharge was 79% and 70%, respectively. CONCLUSION Patients with prolonged intensive care and complex medical needs treated at a specialized center in Sweden had weaning and decannulation rates comparable to or better than previously reported. Mortality was low, and most patients were discharged home or for further rehabilitation. This was achieved with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation.
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Affiliation(s)
- Mathias Löfroth
- The Remeo Clinic, Remeo Stockholm Sweden
- The Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | - Jenny E. Petersson
- The Remeo Clinic, Remeo Stockholm Sweden
- The Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | | | | | - Eva Sundman
- The Remeo Clinic, Remeo Stockholm Sweden
- The Department of Medicine Solna Karolinska Institutet Stockholm Sweden
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6
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Cheng MCF, Murphy PB, Hart N, Evans MRB, Spillane JE, Howard RS. Prolonged Ventilatory Support for Patients Recovering From Guillain-Barré Syndrome. Neurol Clin Pract 2021; 11:18-24. [PMID: 33968468 PMCID: PMC8101308 DOI: 10.1212/cpj.0000000000000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/28/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recovery from Guillain-Barré syndrome (GBS) may be protracted, and patients may need prolonged ventilatory support. We present clinical data from a tertiary referral weaning center managing patients with GBS requiring prolonged ventilatory support. METHODS A retrospective review of patients managed in a 34-bed specialist ventilator weaning facility in London, United Kingdom, between 2006 and 2017. Data including demographics, initial presentation, and ventilatory support were collected. Functional recovery and outcome data were collected between 12 months and 3 years following disease onset. RESULTS Twenty-nine patients with severe GBS requiring prolonged ventilation were included. In several patients, coexisting conditions or complications affected the course. Seventy-six percent (n = 22) were successfully weaned from invasive ventilation with a median time to tracheostomy decannulation of 193 days (range: 49-527 days). Use of noninvasive ventilation (NIV), as part of the weaning program, was applied in 59% (13/22), with 14% (3/22) requiring long-term nocturnal NIV. Twenty-four percent (7/29) were not decannulated, with 14% (4/29) supported on long-term invasive ventilation. Forty-five percent (10/22) weaned from invasive ventilation were able to achieve short distance-assisted ambulation. Mortality at 36 months was 17% (5/29), with 3 of these deaths occurring in patients invasively ventilated during their acute admission. CONCLUSIONS GBS with severe respiratory muscle weakness and bulbar dysfunction may require prolonged invasive ventilation. However, there is potential for complete weaning from invasive mechanical ventilatory support with associated function recovery. These data highlight the importance of maintaining ongoing support and rehabilitation for patients with GBS requiring prolonged ventilation.
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Affiliation(s)
- Michael C F Cheng
- Lane Fox Respiratory Service (MCFC, NH, MRBE, JES, RSH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Lane Fox Clinical Respiratory Physiology Research Centre (MCFC, PBM, NH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Department of Neurology (MRBE, JES), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust, London, United Kingdom; and Central Clinical School (MCFC), Faculty of Medicine and Health, University of Sydney, Australia
| | - Patrick B Murphy
- Lane Fox Respiratory Service (MCFC, NH, MRBE, JES, RSH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Lane Fox Clinical Respiratory Physiology Research Centre (MCFC, PBM, NH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Department of Neurology (MRBE, JES), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust, London, United Kingdom; and Central Clinical School (MCFC), Faculty of Medicine and Health, University of Sydney, Australia
| | - Nicholas Hart
- Lane Fox Respiratory Service (MCFC, NH, MRBE, JES, RSH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Lane Fox Clinical Respiratory Physiology Research Centre (MCFC, PBM, NH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Department of Neurology (MRBE, JES), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust, London, United Kingdom; and Central Clinical School (MCFC), Faculty of Medicine and Health, University of Sydney, Australia
| | - Matthew R B Evans
- Lane Fox Respiratory Service (MCFC, NH, MRBE, JES, RSH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Lane Fox Clinical Respiratory Physiology Research Centre (MCFC, PBM, NH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Department of Neurology (MRBE, JES), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust, London, United Kingdom; and Central Clinical School (MCFC), Faculty of Medicine and Health, University of Sydney, Australia
| | - Jennifer E Spillane
- Lane Fox Respiratory Service (MCFC, NH, MRBE, JES, RSH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Lane Fox Clinical Respiratory Physiology Research Centre (MCFC, PBM, NH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Department of Neurology (MRBE, JES), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust, London, United Kingdom; and Central Clinical School (MCFC), Faculty of Medicine and Health, University of Sydney, Australia
| | - Robin S Howard
- Lane Fox Respiratory Service (MCFC, NH, MRBE, JES, RSH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Lane Fox Clinical Respiratory Physiology Research Centre (MCFC, PBM, NH), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust; Department of Neurology (MRBE, JES), St. Thomas' Hospital, Guy's & St. Thomas' NHS (Foundation) Trust, London, United Kingdom; and Central Clinical School (MCFC), Faculty of Medicine and Health, University of Sydney, Australia
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Khan I, Maredza M, Dritsaki M, Mistry D, Lall R, Lamb SE, Couper K, Gates S, Perkins GD, Petrou S. Is Protocolised Weaning that Includes Early Extubation Onto Non-Invasive Ventilation More Cost Effective Than Protocolised Weaning Without Non-Invasive Ventilation? Findings from the Breathe Study. PHARMACOECONOMICS - OPEN 2020; 4:697-710. [PMID: 32240532 PMCID: PMC7223248 DOI: 10.1007/s41669-020-00210-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Optimising techniques to wean patients from invasive mechanical ventilation (IMV) remains a key goal of intensive care practice. The use of non-invasive ventilation (NIV) as a weaning strategy (transitioning patients who are difficult to wean to early NIV) may reduce mortality, ventilator-associated pneumonia and intensive care unit (ICU) length of stay. OBJECTIVES Our objectives were to determine the cost effectiveness of protocolised weaning, including early extubation onto NIV, compared with weaning without NIV in a UK National Health Service setting. METHODS We conducted an economic evaluation alongside a multicentre randomised controlled trial. Patients were randomised to either protocol-directed weaning from mechanical ventilation or ongoing IMV with daily spontaneous breathing trials. The primary efficacy outcome was time to liberation from ventilation. Bivariate regression of costs and quality-adjusted life-years (QALYs) provided estimates of the incremental cost per QALY and incremental net monetary benefit (INMB) overall and for subgroups [presence/absence of chronic obstructive pulmonary disease (COPD) and operative status]. Long-term cost effectiveness was determined through extrapolation of survival curves using flexible parametric modelling. RESULTS NIV was associated with a mean INMB of £620 ($US885) (cost-effectiveness threshold of £20,000 per QALY) with a corresponding probability of 58% that NIV is cost effective. The probability that NIV is cost effective was higher for those with COPD (84%). NIV was cost effective over 5 years, with an estimated incremental cost-effectiveness ratio of £4618 ($US6594 per QALY gained). CONCLUSIONS The probability of NIV being cost effective relative to weaning without NIV ranged between 57 and 59% overall and between 82 and 87% for the COPD subgroup.
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Affiliation(s)
- Iftekhar Khan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, OX3 9DU UK
| | - Mandy Maredza
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Melina Dritsaki
- Centre for Statistics in Medicine, University of Oxford, Oxford, OX3 9DU UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Sarah E. Lamb
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Keith Couper
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Simon Gates
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
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Warnke C, Heine A, Müller-Heinrich A, Knaak C, Friesecke S, Obst A, Bollmann T, Desole S, Boesche M, Stubbe B, Ewert R. Predictors of survival after prolonged weaning from mechanical ventilation. J Crit Care 2020; 60:212-217. [PMID: 32871419 DOI: 10.1016/j.jcrc.2020.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Weaning from mechanical ventilation is a key component of intensive care treatment; however, this process may be prolonged as some patients require care at specialised centres. Current data indicate that weaning from invasive mechanical ventilation is successful in approximately 65% of patients; however, data on long-term survival after discharge from a weaning centre are limited. MATERIALS AND METHODS We analysed predictors of survival among 597 patients (392 men, mean age 68 ± 11) post-discharge from a specialised German weaning centre. RESULTS Complete weaning from mechanical ventilation was achieved in 407 (57.8%) patients, and 106 patients (15.1%) were discharged with non-invasive ventilation; thus, prolonged weaning was successful in 72.9% of the patients. The one-year and five-year survival rates post-discharge were 66.5% and 37.1%, respectively. Age, duration of mechanical ventilation, certain clusters of comorbidities, and discharged with mechanical ventilation significantly influenced survival (p < .001). Completely weaned patients who were discharged with a tracheostomy had a significantly reduced survival rate than did those who were completely weaned and discharged with a closed tracheostomy (p = .004). CONCLUSIONS The identified predictors of survival after prolonged weaning could support therapeutic strategies during patients' intensive care unit stay. Patients should be closely monitored after discharge from a weaning centre.
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Affiliation(s)
- Christian Warnke
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Alexander Heine
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Annegret Müller-Heinrich
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Christine Knaak
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Sigrun Friesecke
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Anne Obst
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Tom Bollmann
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Susanna Desole
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Michael Boesche
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
| | - Beate Stubbe
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany.
| | - Ralf Ewert
- University Hospital Greifswald, Department of Internal Medicine B, Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine, F.-Sauerbruchstr, D-17475 Greifswald, Germany
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9
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Windisch W, Dellweg D, Geiseler J, Westhoff M, Pfeifer M, Suchi S, Schönhofer B. Prolonged Weaning from Mechanical Ventilation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:197-204. [PMID: 32343653 PMCID: PMC7194302 DOI: 10.3238/arztebl.2020.0197] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 05/31/2019] [Accepted: 12/17/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND To accommodate the increasing number of patients requiring prolonged weaning from mechanical ventilation, specialized weaning centers have been established for patients in whom weaning on the intensive care unit (ICU) was unsuccessful. METHODS This study aimed to determine both the outcome of treatment and the factors associated with prolonged weaning in patients who were transferred from the ICU to specialized weaning centers in Germany during the period 2011 to 2015, based on a nationwide registry covering all specialized weaning centers currently going through the process of accreditation by the German Respiratory Society. RESULTS Of 11 424 patients, 7346 (64.3%) were successfully weaned, of whom 2236 were switched to long-term non-invasive ventilation; 1658 (14.5%) died in the weaning unit; and 2420 (21.2%) could not be weaned. The duration of weaning decreased significantly from 22 to 18 days between 2011 and 2015 (p <0.0001). Multivariate analysis revealed that the factor most strongly associated with in-hospital mortality was advanced age (odds ratio [OR] 11.07, 95% confidence interval [6.51; 18.82], p <0.0001). The need to continue with invasive ventilation was most strongly associated with the duration mechanical ventilation prior to transfer from the ICU (OR 4.73 [3.25; 6.89]), followed by a low body mass index (OR 0.38 [0.26; 0.58]), pre-existing neuromuscular disorders (OR 2.98 [1.88; 4.73]), and advanced age (OR 2.96 [1.87; 4.69]) (each p <0.0001). CONCLUSION Weaning duration has decreased over time, but prolonged weaning is still unsuccessful in one third of patients.Overall, the results warrant the establishment of specialized weaning centers. Variables associated with death and weaningfailure can be integrated into ICU decision-making processes.
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Affiliation(s)
- Wolfram Windisch
- Department of Respiratory Medicine, Cologne Merheim Hospital, Witten/Herdecke University
| | - Dominic Dellweg
- Kloster Grafschaft Hospital GmbH, Academic Teaching Hospital of Marburg University, Schmallenberg-Grafschaft
| | - Jens Geiseler
- Vest Hospital, Department of Internal Medicine IV: Respiratory, Ventilation, and Sleep Medicine, Academic Teaching Hospital of Bochum University, Marl
| | - Michael Westhoff
- Department of Respiratory Medicine, Hemer Lung Hospital, Witten/Herdecke University
| | - Michael Pfeifer
- Department of Respiratory Medicine, Donaustauf Hospital, Regensburg University
| | - Stefan Suchi
- Data-quest GmbH – Statistics and Data Management, Göttingen
| | - Bernd Schönhofer
- Department of Respiratory, Intensive Care, and Sleep Medicine, Siloah Hospital, Hanover
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10
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Dale CM, Carbone S, Istanboulian L, Fraser I, Cameron JI, Herridge MS, Rose L. Support needs and health-related quality of life of family caregivers of patients requiring prolonged mechanical ventilation and admission to a specialised weaning centre: A qualitative longitudinal interview study. Intensive Crit Care Nurs 2020; 58:102808. [PMID: 32115334 DOI: 10.1016/j.iccn.2020.102808] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/02/2019] [Accepted: 01/22/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Family caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre. RESEARCH METHODOLOGY/DESIGN A longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis. SETTING A 6-bed specialised weaning centre in Toronto, Canada. FINDINGS Eighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight. CONCLUSIONS Deficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
| | | | - Ian Fraser
- Division of Respirology, Department of Medicine, Michael Garron Hospital & University of Toronto, Toronto, Canada
| | - Jill I Cameron
- Department of Occupational Science & Occupational Therapy, University of Toronto, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada; Toronto General Hospital Research Institute, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Division of Respirology, Department of Medicine, Michael Garron Hospital & University of Toronto, Toronto, Canada; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, United Kingdom
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11
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Varon DS, Varon J. On Being a Good Pulmonary Practitioner. CURRENT RESPIRATORY MEDICINE REVIEWS 2020. [DOI: 10.2174/1573398x1504191218115026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | - Joseph Varon
- The University of Texas Health Science Center at Houston Chief of Staff and Chief of Critical Care Services United Memorial Medical Center Houston, Texas, United States
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12
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Dawson A, Grigonis A. Comment on: The Clinical Course after Long-term Acute Care Hospital Admission among Older Medicare Beneficiaries. J Am Geriatr Soc 2020; 68:666-667. [PMID: 31903544 DOI: 10.1111/jgs.16320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Amanda Dawson
- Select Medical, Research Unit, Inpatient Hospital Division, Mechanicsburg, Pennsylvania
| | - Antony Grigonis
- Select Medical, Quality and Healthcare Analytics Department, Inpatient Hospital Division, Mechanicsburg, Pennsylvania
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13
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Karagiannidis C, Strassmann S, Schwarz S, Merten M, Fan E, Beck J, Sinderby C, Windisch W. Control of respiratory drive by extracorporeal CO 2 removal in acute exacerbation of COPD breathing on non-invasive NAVA. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:135. [PMID: 31014366 PMCID: PMC6480839 DOI: 10.1186/s13054-019-2404-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/21/2019] [Indexed: 01/19/2023]
Abstract
Background Veno-venous extracorporeal CO2 removal (vv-ECCO2R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. Methods A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. Results Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO2R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO2R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO2R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 μV vs. 56 ± 20 μV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO2 and pH values stable. Edi was the best predictor for vv-ECCO2R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. Conclusions This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO2R and NIV-NAVA. The Edi during vv-ECCO2R weaning was found to be the best predictor of tolerance to removing vv-ECCO2R. Electronic supplementary material The online version of this article (10.1186/s13054-019-2404-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Sarah Schwarz
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Michaela Merten
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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14
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Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: a narrative review. Multidiscip Respir Med 2018; 13:6. [PMID: 29507719 PMCID: PMC5831532 DOI: 10.1186/s40248-018-0118-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/07/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Progress in management has improved hospital mortality of patients admitted to the intensive care units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients, caregivers and health services, as well as high human and financial resources consumption, despite poor long-term outcomes. An effort should be made to improve the management of these patients. This narrative review summarizes the main concepts in this field. MAIN BODY There is great variability in terminology and definitions of prolonged mechanical ventilation.There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of protocols, early mobilisation and physiotherapy, specialised weaning units.There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival of these patients.Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised controlled trials on this critical issue. End of life decisions should result from appropriate communication among professionals, patients and surrogates and national legislations should give clear indications. CONCLUSION Present medical training of clinicians and locations like traditional intensive care units do not appear enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects of management are needed.
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Affiliation(s)
- Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, 27040 Montescano, PV Italy
| | - Michele Vitacca
- Istituti Clinici Scientifici Maugeri, IRCCS, Respiratory Unit, Istituto Scientifico di Lumezzane, Lumezzane, BS Italy
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