Quality of life in survivors of prolonged mechanical ventilatory support

Survival and Quality of Life after Prolonged Intensive Care Unit Stay

There are few data on long-term outcomes in mixed groups of intensive care unit (ICU) patients with prolonged stays. We evaluated the relationship between length of stay in the ICU and long-term outcome in all patients admitted to our 31-bed department of medico-surgical intensive care over a one-year period who stayed in the department for more than 10 days (n=189, 7% of all ICU admissions). Mortality increased with length of stay from 1 to 10 days (1 day 5%, 5 days 15%, 9 days 24%, 10 days 33%) but remained stable at about 35% for longer ICU stays. In the long-stay patients, the most common reasons for ICU admission were intracranial bleeding (23%), polytrauma (14%), respiratory failure (13%) and septic shock (11%). The main reasons for prolonged ICU stay were ventilator dependency (40%), infectious complications (23%) and coma (16%). Long-stay patients had a 65% ICU survival, 55% hospital survival and 37% one-year survival. At one-year follow-up, 73% of surviving patients reported no or minor persistent physical complaints compared to before the acute illness; 27% had a major functional impairment, including 8% who required daily assistance. In conclusion, in ICU patients, mortality increases with length of stay up to 10 days. Patients staying in the ICU for more than 10 days have a relatively good long-term survival. Most survivors have an acceptable quality of life.

Long-Term Quality of Life After Extracorporeal Membrane Oxygenation in ARDS Survivors: Systematic Review and Meta-Analysis

PURPOSE

Extracorporeal membrane oxygenation (ECMO) is an increasingly prevalent treatment for acute respiratory failure (ARF). To evaluate the impact of ECMO support on long-term outcomes for critically ill adults with ARF.

METHODS

We searched electronic databases 1948 through to November 30 2016; selected controlled trials or observational studies of critically ill adults with acute respiratory distress syndrome, examining long-term morbidity specifically health-related quality of life (HRQL); 2 authors independently selected studies, extracted data, and assessed methodological quality.

ANALYSIS

Of the 633 citations, 1 randomized controlled trial and 5 observational studies met the selection criteria. Overall quality of observational studies was moderate to high (mean score on Newcastle-Ottawa scale, 7.2/9; range, 6-8). In 3 studies (n = 245), greater decrements in HRQL were seen for survivors of ECMO when compared to survivors of conventional mechanical ventilation (CMV) as measured by the Short Form 36 (SF-36) scores ([ECMO-CMV]: 5.40 [95% confidence interval, CI, 4.11 to 6.68]). As compared to CMV survivors, those who received ECMO experienced significantly less psychological morbidity (2 studies; n = 217 [ECMO-CMV]: mean weighted difference [MWD], -1.31 [95% CI, -1.98 to -0.64] for depression and MWD, -1.60 [95% CI, -1.80 to -1.39] for anxiety).

CONCLUSIONS

Further studies are required to confirm findings and determine prognostic factors associated with more favorable outcomes in survivors of ECMO.

Assessing Outcomes in Critical Care

The need to assess a range of outcomes in intensive care is increasingly important as more patients survive episodes of acute, severe illness. In this article, we discuss the relevance of commonly studied outcomes and the strengths and weaknesses of the techniques used to measure them. Short-term mortality is no longer the only important consideration in the evaluation of a therapy. The assessment of longer-term mortality, morbidity, and patient-centered outcomes is necessary. Randomized, controlled trials (RCTs) are frequently adapted to incorporate outcome measures that include cost and quality of life. In addition, observational studies have become more sophisticated and are being used to evaluate issues not amenable to study by RCTs. These developments will provide more comprehensive assessments of critical care interventions and will ultimately enhance the health of the patients we serve.

Health-related quality of life and nursing-sensitive outcomes in mechanically ventilated patients in an Intensive Care Unit: a study protocol

BACKGROUND

Mechanical ventilation (MV) is one of the most utilised techniques in the intensive care unit (ICU), but it can cause sequelae that can negatively influence the patient's health-related quality of life (HRQL). Nursing-sensitive outcomes (NSOs) can also influence the HRQL. Assessing the HRQL of mechanically ventilated patients admitted to an ICU and its relation to nurse-sensitive outcomes will give healthcare professionals with valuable information to improve patient care.

METHODS

Prospective longitudinal cohort study in which all patients admitted to the ICU at Hospital Universitari Vall d'Hebron who undergo MV for more than 48 h will be included. The study will last 12 consecutive months. HRQL will be assessed by the completion of the SF-36 and the Saint Georges Respiratory Questionnaire. Pre-admission HRQL assessment will be performed by the main caregiver, and after ICU discharge, the assessment will be performed by the patient him/herself. The same questionnaires will also be completed one year after ICU discharge. Other variables (sociodemographic and those related to reason for ICU admission, ICU length of stay, MV, ICU stressors and NSO) will be included in a multiple regression model to assess their relation to the patient's HRQL.

DISCUSSION

This study will show the relationship between the HRQL perceived by patients and their main caregiver, what the HRQL is one year after discharge from ICU, and what the impact of MV, NSO and ICU stressors and other clinical outcomes on the patient's HRQL is. Determining mechanically ventilated patients' HRQL and its relation to NSO and ICU stressors as well as other clinical variables will enable early nursing interventions to try to minimise possible sequelae and improve the patient's welfare.

TRIAL REGISTRATION

ClinicalTrials.gov ID:NCT02636660Registration Date: 17th December 2015.

Six-month quality-of-life and functional status of acute respiratory distress syndrome survivors compared to patients at risk: a population-based study

Introduction

The long-term attributable burden related to acute respiratory distress syndrome (ARDS) is not fully investigated. The aim of this study is to evaluate the quality of life (QOL) and functional status at 6 months after hospitalization in patients at risk for ARDS who did and did not develop the syndrome.

Method

This is a population-based prospective cohort study of adult patients from Olmsted County, Minnesota, with or at risk for ARDS hospitalized from October 2008 to July 2011. The primary outcomes were changes in QOL and functional status, measured through 12-Item Short Form Survey (SF-12) and Barthel Index (BI) respectively, from baseline to 6 months, compared between survivors who did and did not develop ARDS.

Results

Of 410 patients with or at risk for ARDS, 98 had baseline surveys collected and 67 responded to a 6-month survey (26 ARDS, 41 non-ARDS). Both ARDS and non-ARDS groups had lower physical component of SF-12 at baseline compared to general population (P < 0.001 for both). ARDS patients had poorer baseline functional status compared to non-ARDS (mean BI 80 ± 25 vs. 88 ± 22, P = 0.03). No significant differences were observed for the change between 6 months and baseline BI (delta 2.3 for ARDS vs. 2.0 for non-ARDS, P = 0.5), or mental (delta 2.7 vs. 2.4, P = 0.9) or physical (delta –3 vs. –3.3, P = 0.9) component of SF-12 between survivors with and without ARDS.

Conclusion

In this population-based study, decreased QOL and functional status 6 months after hospitalization were largely explained by baseline condition, with similar recovery in survivors who did and did not develop ARDS.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1062-y) contains supplementary material, which is available to authorized users.

Risk factors for hospitalization and medical intensive care unit (MICU) admission among HIV-infected Veterans

OBJECTIVE

With improved survival of HIV-infected persons on antiretroviral therapy and growing prevalence of non-AIDS diseases, we asked whether the VACS Index, a composite measure of HIV-associated and general organ dysfunction predictive of all-cause mortality, predicts hospitalization and medical intensive care unit (MICU) admission. We also asked whether AIDS and non-AIDS conditions increased risk after accounting for VACS Index score.

METHODS

We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV-infected Veterans receiving care between 2002 and 2008. Data were obtained from the electronic medical record, VA administrative databases, and patient questionnaires and were used to identify comorbidities and calculate baseline VACS Index scores. The primary outcome was first hospitalization within 2 years of VACS enrollment. We used multivariable Cox regression to determine risk factors associated with hospitalization and logistic regression to determine risk factors for MICU admission, given hospitalization.

RESULTS

Of 3410 patients, 1141 were hospitalized within 2 years; 203 (17.8%)/1141 patients included an MICU admission. Median VACS Index scores were 25 (no hospitalization), 34 (hospitalization only), and 51 (MICU). In adjusted analyses, a 5-point increment in VACS Index score was associated with 10% higher risk of hospitalization and MICU admission. In addition to VACS Index score, Hispanic ethnicity, current smoking, hazardous alcohol use, chronic obstructive pulmonary disease, hypertension, diabetes, and prior AIDS-defining event predicted hospitalization. Among those hospitalized, VACS Index score, cardiac disease, and prior cancer predicted MICU admission.

CONCLUSIONS

The VACS Index predicted hospitalization and MICU admission as did current smoking, hazardous alcohol use, and AIDS and certain non-AIDS diagnoses.

Neglect of quality-of-life considerations in intensive care unit family meetings for long-stay intensive care unit patients

OBJECTIVE

To examine the frequency with which quality of life and treatment limitation were discussed in formal family meetings for long-stay intensive care unit patients with high risk for mortality and morbidity.

DESIGN

Descriptive observational study.

SETTING

Five intensive care units.

PATIENTS

One hundred sixteen family surrogate decisionmakers of long-stay intensive care unit patients who participated in an intensive communication system that aimed to provide weekly meetings with family decisionmakers. The structure of each meeting was to address medical update, patient preferences, treatment plan, and milestones for evaluating the treatment plan.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We audiotaped initial family meetings for 116 family decisionmakers for a total of 180 meetings. On average, meetings were 24 mins long with a majority of time being devoted to nonemotional speech and little (12%) spent discussing patient preferences. Quality of life was discussed in 45% and treatment limitation in 23% of all meetings. Quality-of-life discussions were more likely to occur when patients were admitted to a medical intensive care unit (odds ratio [OR] 5.9; p = .005), have a family decisionmaker who is a spouse (OR 9.4; p = .0001), were older (OR 1.04; p = 01), have a shorter length of stay (OR 0.93; p = .001), and have a family decisionmaker who was a spouse (OR 5.1; p = .002). For those with a treatment limitation discussion, 67% had a do-not-resuscitate order, 40% were admitted to a medical intensive care unit, 56% had a family decisionmaker who had been their caregiver, and 48% of their family decisionmakers were their children.

CONCLUSIONS

To guide discussion with families of the subset of intensive care unit patients with high risk of mortality and long-term morbidity, quality of life was not consistently addressed. Continued efforts to assist clinicians in routinely including discussions of quality-of-life outcomes is needed.

Lung function and quality of life in survivors of the acute respiratory distress syndrome (ARDS)

Recent studies have begun to describe the long-term outcomes of acute respiratory distress syndrome (ARDS) survivors. These patients experience a number of physical, mental and psychological morbidities that significantly impair their health-related quality of life (HRQL). The trajectory of pulmonary recovery in survivors of ARDS, as it relates to lung function, structure and health-related quality of life (HRQL), is predictable and often persists years after hospital discharge. True pulmonary parenchymal morbidity is uncommon and when present, persistent restrictive disease is likely related to diaphragmatic weakness with a mild reduction in diffusion capacity (DLCO). Future research should focus on identifying patients at risk for long-term functional limitations and the design of rehabilitation interventions tailored to individual patient needs.

Critical illness in HIV-infected patients in the era of combination antiretroviral therapy

As HIV-infected persons on combination antiretroviral therapy (ART) are living longer and rates of opportunistic infections have declined, serious non-AIDS-related diseases account for an increasing proportion of deaths. Consistent with these changes, non-AIDS-related illnesses account for the majority of ICU admissions in more recent studies, in contrast to earlier eras of the AIDS epidemic. Although mortality after ICU admission has improved significantly since the earliest HIV era, it remains substantial. In this article, we discuss the current state of knowledge regarding the impact of ART on incidence, etiology, and outcomes of critical illness among HIV-infected patients. In addition, we consider issues related to administration of ART in the ICU and identify important areas of future research.

Use of the Functional Independence Measure in people for whom weaning from mechanical ventilation is difficult

BACKGROUND

The Functional Independence Measure (FIM) has been proposed as an outcome measure for people receiving pulmonary rehabilitation after an acute exacerbation of chronic obstructive pulmonary disease. Objective The purpose of this study was to examine the clinical utility of the FIM after a weaning program in people for whom weaning from mechanical ventilation is difficult. Design This was a retrospective observational study.

METHODS

People who had had a tracheostomy, for whom weaning from mechanical ventilation was difficult, and who were participating in a weaning program (WP group) were retrospectively evaluated. People receiving pulmonary rehabilitation after an acute exacerbation of chronic obstructive pulmonary disease (PR group) were included as a validated control group. The scores on the FIM questionnaire and the Medical Research Council dyspnea scores were assessed at admission to and at discharge from the programs.

RESULTS

Admission and discharge data from 56 participants in the WP group and 63 participants in the PR group were compared. At admission, according to the FIM, 5 participants in the WP group (7.7%) were defined as functionally independent, 34 (52.3%) were defined as partially dependent, and 26 (40.0%) were defined as completely dependent. At discharge, the mean FIM global score was significantly improved, from 47.9 (SD=22.8) to 62.6 (SD=30.0). For participants in the WP group, changes in the FIM score were significantly inversely related to the admission Acute Physiology and Chronic Health Evaluation (R=-.286) and Simplified Acute Physiology (R=-.293) scores and directly related to the admission FIM score (R=.355). At admission, 46 participants in the PR group (67.7%) were defined as functionally independent, 19 (27.9%) were defined as partially dependent, and 3 (4.4%) were defined as completely dependent. After pulmonary rehabilitation, the mean FIM global score was significantly improved, from 97.4 (SD=27.5) to 102.5 (SD=25.7). Limitations The study was not randomized and involved a relatively small sample size.

CONCLUSIONS

The FIM can be used as a functional status outcome measure in people for whom weaning from mechanical ventilation is difficult.

Quality of life, pulmonary function, and tomographic scan abnormalities after ARDS

BACKGROUND

ARDS can produce a loss of lung function with persistent sequelae. This study aimed to evaluate health-related quality of life (HRQL) in survivors of ARDS compared with a healthy reference population and to determine the middle/long-term radiographic abnormalities and functional status, as well as their relation to observed HRQL, in these patients.

METHODS

This was a prospective study carried out in three ICUs. HRQL in patients was determined with the Nottingham Health Profile immediately after ARDS diagnosis and 6 months after diagnosis. Patients underwent complete respiratory function testing, chest CT scan study, and the 6-min walk test.

RESULTS

Follow-up was conducted in 38 patients with ARDS. Survivors of ARDS presented a poorer overall HRQL vs the general population, mainly because of lower scores in the dimensions related to mobility, energy, and social isolation. Limitations in daily life activities were documented in 40%. Respiratory function was altered in 67%, with a restrictive respiratory pattern in 58%. Radiologic study disclosed alterations in 76% (mainly reticular pattern). Patients were able to cover only 366 m (318-411 m) in the 6-min walk test and had a minimum pulse oximetry of 93% (90%-94%). A significant correlation was documented between the overall quality of life at first and at 6 months (r = 0.68, P < .01).

CONCLUSIONS

Survivors of ARDS after 6 months had a poorer HRQL than the healthy population and showed mild radiographic and functional involvement. Early HRQL study in these patients enabled early detection of those who would present more long-term HRQL morbidity.

Measurement of quality of life using EQ-5D in patients on prolonged mechanical ventilation: comparison of patients, family caregivers, and nurses

PURPOSE

This study reports how QOL (quality of life) assessments differ between patients on prolonged mechanical ventilation (PMV) and their proxies (family caregivers and nurses).

METHODS

We enrolled consecutive subjects on PMV for more than 21 days from five institutions. We conducted QOL assessments using the Taiwanese version of the EQ-5D in face-to-face interviews. Direct caregivers (family members and nurses) also completed the EQ-5D from the patient's point of view.

RESULTS

For 55 of the 142 enrolled patients who were able to assess their QOL, we recruited 44 patient-family caregiver pairs, 53 patient-nurse pairs, and 42 family caregiver-nurse pairs. There were 81 family caregiver-nurse pairs out of 87 patients with poor cognition. The agreement between patient-family caregiver pairs was generally higher than that of patient-nurse pairs. As the proportions of exact agreement between family caregivers and nurses for patients with poor cognition were 98-99% for observable dimensions of mobility, self-care, and usual activities, they lead to a minimal difference in the final values.

CONCLUSIONS

QOL assessments from family caregivers agreed more closely with patients than did those from nurses using EQ-5D evaluations for patients with clear cognition, but either proxy was acceptable for rating PMV patients with poor cognition.

Legacy of intensive care unit-acquired weakness

Loss of muscle mass, nerve dysfunction, and resultant weakness and functional disability represent important and lasting morbidities of an episode of critical illness. As investigators increasingly incorporate long-term functional, neuropsychological, and quality-of-life outcomes into their studies, more data are accruing that support the existence of often devastating and irreversible sequelae of severe illness and treatment in an intensive care unit. This review highlights early quality-of-life literature that supports significant physical dysfunction after intensive care unit treatment and more recent longitudinal studies up to 5 yrs after intensive care unit discharge, which clearly implicate nerve and muscle dysfunction as contributors to this reported disability. Additional follow-up work is needed to understand the pathophysiology of this injury, the spectrum of physical disability, and its associated risk factors. These data are crucial to inform risk-stratification and future rehabilitation interventions, both during the intensive care unit admission and after hospital discharge as patients reintegrate within their community and workplace.

[Outcome for adults with acute respiratory distress syndrome]

Acute respiratory distress syndrome in adults (ARDS) is a relatively frequent disease, the mortality of which has diminished considerably in recent years. The long-term outcome of patients who have survived ARDS has been studied extensively and should in the future be taken into account in assessing new treatment modalities. The long-term respiratory sequelae are generally minimal and moderately disabling. Secondary deterioration of respiratory function is not part of the natural history of ARDS and should suggest other diagnoses. The various studies find a clear diminution in quality of life after ARDS (compared with the general population), essentially related to neuromuscular deficiencies associated with the neuromyopathies of resuscitation or to neuropsychological damage combining cognitive disorders and symptoms of posttraumatic stress. These symptoms are not at all specific to ARDS. They are found in varying degrees in patients who have survived intensive care or resuscitation. Appropriate management for these symptoms remains to be determined. Critical care units must now work at preventing the onset of these disorders, by limiting the treatments at risk when possible and by identifying these disorders before discharge to prepare for optimal subsequent management. Patients with ARDS are only a subgroup of more severe illness among all patients in critical care departments.

Chronically Critically Ill Patients: Health-Related Quality of Life and Resource Use After a Disease Management Intervention

Background Chronically critically ill patients often have high costs of care and poor outcomes and thus might benefit from a disease management program.

Objectives To evaluate how adding a disease management program to the usual care system affects outcomes after discharge from the hospital (mortality, health-related quality of life, resource use) in chronically critically ill patients.

Methods In a prospective experimental design, 335 intensive care patients who received more than 3 days of mechanical ventilation at a university medical center were recruited. For 8 weeks after discharge, advanced practice nurses provided an intervention that focused on case management and interdisciplinary communication to patients in the experimental group.

Results A total of 74.0% of the patients survived and completed the study. Significant predictors of death were age (P = .001), duration of mechanical ventilation (P = .001), and history of diabetes (P = .04). The disease management program did not have a significant impact on health-related quality of life; however, a greater percentage of patients in the experimental group than in the control group had “improved” physical health-related quality of life at the end of the intervention period (P = .02). The only significant effect of the intervention was a reduction in the number of days of hospital readmission and thus a reduction in charges associated with readmission.

Conclusion The intervention was not associated with significant changes in any outcomes other than duration of readmission, but the supportive care coordination program could be provided without increasing overall charges.

The long and difficult road to better evaluation of outcomes of prolonged mechanical ventilation: not yet a highway to heaven

The study conducted by Cox and coworkers included in this issue of Critical Care demonstrates that prolonged mechanical ventilation (MV; defined as MV for 21 days or longer) is more specific than Diagnosis Related Group 541/542 as a marker of resource utilization, hospital costs and potentially ineffective care. These patients also had greater 1-year mortality and lower functional ability than patients who had received MV for 48 to 96 hours, despite having better baseline functional status. However, predictors of mortality and long-term functional outcomes that are reliable and accurate at the level of the individual patient remain to be identified.

Weaning units: lessons from North America?

In the United Kingdom over 5% of critical care beds are occupied by stable patients weaning from mechanical ventilation. In North America, diagnosis related groups (DRGs) were introduced over a decade ago. These provided an economic impetus to develop more cost effective regional weaning centres. The imminent introduction of Payment By Results may encourage similar developments in the UK. The evidence for weaning centres is reviewed and detailed organisational and outcome data from two North American centres presented. These units differ from UK critical care units in terms of nurse : patient ratios and types and numbers of ancillary staff. Limited data, mostly from North America, suggest that weaning centres may be better at improving outcome in ventilator-dependent patients compared with standard critical care. The existing evidence is not conclusive and highlights the need for UK-based studies on organisational approaches to the provision of weaning and longer term critical care.

Characteristics associated with discharge to home following prolonged mechanical ventilation: a signal detection analysis

The objective of study was to identify characteristics associated with being home at 6 months in 80 patients on prolonged mechanical ventilation (PMV) (> or =7 days). At 6 months, 47.5% were home, 13.8% institutionalized, and 38.8% deceased and classified "not home." Using signal detection methodology (SDM), four mutually exclusive groups at high and low probability of being home were identified. The best outcome (94.4% home) was achieved by patients with an admission Charlson Comorbidity Score < or =3 and an Acute Physiology Score (APS) < or =21 and the worst outcome (23.4% home) by patients with an admission Charlson Comorbidity Score >3 and Health Assessment Questionnaire score >2.7. SDM provided an effective means of identifying subgroups likely to be discharged home using available information.

Quality of life, emotional abnormalities, and cognitive dysfunction in survivors of acute lung injury/acute respiratory distress syndrome

This article provides a brief discussion of the recent literature linking quality-of-life impairment to physical dysfunction after acute lung injury/acute respiratory distress syndrome. Its main focus is a review of the current knowledge concerning cognitive and emotional outcomes after lung injury and their impact on long-term quality of life.

Functional Status One Year After Heart Transplant

PURPOSE

Although heart transplantation (HT) increases survival of heart failure patients, many patients still experience problems afterward that affect functioning.

PURPOSES

(1) to compare the functional status of HT patients before transplant versus 1 year after transplant, (2) to identify functional problems 1 year post-transplant, and (3) to identify which variables predicted worse functional status 1 year later.

METHODS

The sample was 237 adult HT recipients who completed the 1-year post-transplant study booklet. Functional ability was assessed by the Sickness Impact Profile. Paired t tests compared Sickness Impact Profile scores before and after transplant. Medical and demographic data plus patient questionnaire data on Sickness Impact Profile, symptoms, stressors, and compliance were used in the regression.

RESULTS

Sickness Impact Profile functional scores improved significantly from pre-transplant (23.0%) to post-transplant (13.4%); however, many HT recipients still reported problems in 12 functional areas 1 year after surgery. Major problem areas were the following: work (90% of patients), eating (due to dietary restrictions, 87%), social interaction (70%), recreation (63%), home management (62%), and ambulation (54%). Only 26% were working 1 year after transplant; 59% of those working reported health-related problems performing their job. Predictors of worse functional status were greater symptom distress, more stressors, more neurologic problems, depression, female sex, older age, and lower left ventricular ejection fraction (worse cardiac function).

CONCLUSIONS

Many HT recipients were still having functional problems and had not reached their full rehabilitation potential by the 1-year anniversary after transplant.

Outcomes of prolonged mechanical ventilation

PURPOSE OF REVIEW

Patients requiring prolonged mechanical ventilation consume a disproportionate amount of healthcare resources and clinician time. Measurement and knowledge of their outcomes will guide efforts to improve their care.

RECENT FINDINGS

The number of patients requiring prolonged mechanical ventilation after acute illness is increasing. Their long-term outcome is poor and has not improved significantly over the past 20 years. The symptom burden for patients is considerable, and family members often suffer from significant physical and emotional strain. Long-term survivors report lasting physical limitations, but their emotional health is generally good. Care for many patients requiring prolonged mechanical ventilation is shifting to post-intensive care unit settings. While this trend has resulted in cost savings for hospitals and payers, it has not had a major impact on patient outcomes.

SUMMARY

The long-term outcomes of patients requiring prolonged mechanical ventilation are poor for the majority of patients, especially the elderly. Continued research is needed to identify the highest-risk patients, and to improve outcomes during hospitalization and in the immediate postdischarge period.

Quality of life after acute respiratory distress syndrome: a meta-analysis

OBJECTIVE

To summarize long-term quality of life (QOL) and the degree of variation in QOL estimates across studies of acute respiratory distress (ARDS) survivors.

DESIGN

A systematic review of studies evaluating QOL in ARDS survivors was conducted. Medline, EMBASE, CINAHL, pre-CINAHL, and the Cochrane Library were searched, and reference lists from relevant articles were evaluated. Two authors independently selected studies reporting QOL in adult survivors of ARDS or acute lung injury at least 30 days after intensive care unit discharge and extracted data on study design, patient characteristics, methods, and results.

MEASUREMENTS AND RESULTS

Thirteen independent observational studies (557 patients) met inclusion criteria. Eight of these studies used eight different QOL instruments, allowing only qualitative synthesis of results. The five remaining studies (330 patients) measured QOL using the Medical Outcomes Study 36-Item Short Form survey (SF-36). Mean QOL scores were similar across these studies, falling within a range of 20 points for all domains. Pooled domain-specific QOL scores in ARDS survivors 6 months or later after discharge ranged from 45 (role physical) to 66 (social functioning), or 15-26 points lower than population norms, in all domains except mental health (11 points) and role physical (39 points). Corresponding confidence intervals were no wider than +/-9 points. Six studies all found stable or improved QOL over time, but only one found significant improvement beyond 6 months after discharge.

CONCLUSIONS

ARDS survivors in different clinical settings experience similar decrements in QOL. The precise magnitude of these decrements helps clarify the long-term prognosis for ARDS survivors.

Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference

Patients requiring prolonged mechanical ventilation (PMV) are rapidly increasing in number, as improved ICU care has resulted in many patients surviving acute respiratory failure only to then require prolonged mechanical ventilatory assistance during convalescence. This patient population has clearly different needs and resource consumption patterns than patients in acute ICUs, and specialized venues, management strategies, and reimbursement schemes for them are rapidly emerging. To address these issues in a comprehensive way, a conference on the epidemiology, care, and overall management of patients requiring PMV was held. The goal was to not only review existing practices but to also develop recommendations on a variety of assessment, management, and reimbursement issues associated with patients requiring PMV. Formal presentations were made on a variety of topics, and writing groups were formed to address three specific areas: epidemiology and outcomes, management and care settings, and reimbursement. Each group was charged with summarizing current data and practice along with formulation of recommendations. A working draft of the products of these three groups was then created and circulated among all participants. The document was reworked with input from all concerned until a final product with consensus recommendations on 12 specific issues was achieved.

Preferences for Mechanical Ventilation Among Survivors of Prolonged Mechanical Ventilation and Tracheostomy

• Background Among survivors of prolonged mechanical ventilation, preferences for this treatment have rarely been explored.

• Objectives To elicit preferences of survivors of prolonged mechanical ventilation (≥7 days) and factors influencing these preferences.

• Methods A descriptive, cross-sectional survey design was used. Subjects were recruited from intensive care units in a tertiary care hospital and from long-term care facilities. Each subject (n = 30) was asked to reflect on the decision to use mechanical ventilation; rate current health, pain/discomfort in the intensive care unit and from mechanical ventilation, perceived family financial burden, and emotional/physical stress related to mechanical ventilation; identify changes that would influence preference for mechanical ventilation; and answer questions about quality of life, functional status, depressive symptoms, and communication.

• Results Most subjects (75.9%) would have chosen mechanical ventilation. Median days of mechanical ventilation and tracheostomy were greater for subjects who would have chosen mechanical ventilation (98.5 vs 70), as were median days of tracheostomy (102 vs 64). Patients who would not have chosen mechanical ventilation had more depressive symptoms and were more likely to be insured by Medicare. No other variables differed between groups. Patients who preferred mechanical ventilation would change their preference on the basis of their families’ emotional/physical stress and financial burden. Patients who did not prefer mechanical ventilation would change their preference if the family financial burden and emotional/physical stress were reduced and current health improved.

• Conclusions Most patients would have chosen mechanical ventilation. Survivors’ preferences were influenced by their current health and families’ financial burden and stress.

Trial of a disease management program to reduce hospital readmissions of the chronically critically ill

BACKGROUND

Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. They are prone to continued morbidity and mortality after hospital discharge and are at high risk for hospital readmission. Disease management (DM) programs have been shown to be effective in improving both coordination and efficiency of care after hospital discharge for populations with single-disease diagnoses, but have not been tested with patients with multiple-disease diagnoses, such as the chronically critically ill.

STUDY OBJECTIVES

To test the effect of a DM program on hospital readmission patterns of chronically critically ill patients during the first 2 months after hospital discharge and to estimate the cost-effectiveness of the DM program.

DESIGN

Randomized, controlled trial.

SETTING

Academic medical center, extended care facilities, and participant homes.

PARTICIPANTS

Three hundred thirty-four consenting adults from one academic medical center who underwent > 3 days of mechanical ventilation and survived to hospital discharge.

INTERVENTION

Two hundred thirty-one patients in the experimental group received care coordination, family support, teaching, and monitoring of therapies from a team of advanced-practice nurses, a geriatrician, and a pulmonologist for 2 months post-hospital discharge.

MEASUREMENTS

Rehospitalization rate, time-to-first rehospitalization, duration of rehospitalization, mortality during rehospitalization, and associated costs.

RESULTS

Patients who received DM services had significantly fewer mean days of rehospitalization (11.4; 95% confidence interval [CI], 9.3 to 12.6) compared with the control group (16.7 days; 95% CI, 12.5 to 21.0; p = 0.03). There were no other significant differences between experimental and control groups, although all measures of rehospitalization risk for the experimental group were in a positive direction. Total cost savings associated with the intervention were approximately $481,811 for the 93 subjects who were readmitted to the hospital.

CONCLUSIONS

Chronic critical illness may have a natural trajectory of continued morbidity following hospital discharge that is not affected by the provision of additional care coordination services. Nevertheless, given the high cost of rehospitalization and the additional burden it imposes on patients and families, interventions that can reduce the duration of rehospitalization are cost-effective and merit continued testing.

Health-related quality of life in patients with chronic respiratory failure after long-term mechanical ventilation

STUDY OBJECTIVES

This study was aimed at assessing health-related quality of life (HRQL) in patients with chronic respiratory failure (CRF) and long-term survival following prolonged intensive care mechanical ventilation.

DESIGN

Observational cohort study.

SETTING

Patients with CRF who had been transferred to our specialized weaning centre due to prolonged mechanical ventilation (>14 days) and weaning failure.

PATIENTS AND PARTICIPANTS

Out of 87 long-term survivors (>6 months), 73 patients (mean age: 60.3+/-13.6 years, chronic obstructive pulmonary disease (COPD, 43%), thoraco-restrictive (21%) or neuromuscular disorders (15%), various chronic diseases (22%)) returned the MOS 36-Item Short-Form Health Status Survey (SF-36) and the St. George's respiratory questionnaire (SGRQ).

MEASUREMENTS AND RESULTS

The total ventilation time was 38.7+/-45.9 days. The time between discharge from ICU and HRQL assessment was 31.0+/-22.2 months. Physical health was markedly reduced compared to general population norm, but mental health was mildly impaired. HRQL was comparable to patients with stable CRF receiving non-invasive ventilation who did not need prolonged invasive MV. In addition, general HRQL was better in patients with restrictive respiratory disease compared to patients with neuromuscular diseases (P<0.05). Physiological parameters such as blood gases or lung function parameters were not correlated to any HRQL measurements.

CONCLUSIONS

In patients with CRF surviving prolonged ventilation on ICU, the presence of CRF itself is the major determinant of HRQL. Here, the underlying cause of CRF is the major factor which determines the degree of HRQL impairment with patients suffering from restrictive ventilatory disorders reporting the best HRQL when compared to patients with COPD or neuromuscular diseases. Despite severe physical handicaps due to CRF mental health is only mildly compromised.

Hospital and long-term outcome after tracheostomy for respiratory failure

OBJECTIVE

To determine the patient characteristics, hospital course, hospital cost, posthospital survival, and functional outcome in a group of patients with tracheostomy for respiratory failure.

DESIGN

Retrospective chart review combined with prospective evaluation of functional status.

SETTING

An urban, tertiary-care medical center.

PATIENTS

Adult patients with tracheostomy for respiratory failure between January 1, 1998, and December 31, 2000.

METHODS

Retrospective chart review and prospective administration of the Short Form-36 (SF-36) for health status outcome.

RESULTS

Four hundred twenty-nine patients were studied. Hospital mortality was 19%. Only 57% of survivors were liberated from mechanical ventilation. At 100 days, 6 months, 1 year, and 2 years after discharge, 24%, 30%, 36%, and 42% of hospital survivors had died, respectively. Patients liberated from mechanical ventilation and having their tracheostomy tubes decannulated had the lowest mortality (8% at 1 year); the mortality of ventilator-dependent patients was highest (57%). Sixty-six patients completed the SF-36 for functional status. While emotional health was generally good, physical function was quite limited. Median hospital direct variable cost was $29,340.

CONCLUSION

Overall survival and functional status are poor in patients with tracheostomy for respiratory failure. Patients who are liberated from mechanical ventilation and have their tracheostomy tubes removed have the best survival; however, it comes at a higher hospital cost and longer length of stay.

Quality of life and dialysis decisions in critically ill patients with acute renal failure

OBJECTIVE

To determine whether health-related quality of life (HRQL) in survivors of acute renal failure (ARF) occurring in intensive care is predictable from data available at the time of acute illness.

DESIGN AND SETTING

Prospective pilot study in academic intensive care units.

PATIENTS AND METHODS

Patients requiring renal replacement therapy for ARF while in intensive care over a 6-month enrollment period were included. The primary outcome measure was HRQL among survivors 6 months following hospital discharge, as assessed by the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), and its association with Acute Physiology and Chronic Health Evaluation (APACHE) III score. We also asked survivors whether, in retrospect, they would choose to have dialysis again and what factors influenced this decision.

RESULTS

Ninety-two percent (12/13) of participants surviving 6 months completed the follow-up interview. The mean mental and physical components of the SF-36 were comparable to and slightly lower than the age-matched general population, respectively. There was no correlation between APACHE III score at the time of dialysis initiation and SF-36 score at 6 months. Almost all patients, regardless of their HRQL, stated they would choose dialysis again.

CONCLUSIONS

HRQL may not be predictable from data available at the time of dialysis initiation in this population. In retrospect, surviving patients agree with the decision to accept dialysis, even when their HRQL is poor.

Survival and quality of life: short-term versus long-term ventilator patients

OBJECTIVE

Examine postdischarge mortality, quality of life, and charges for care for short-term (>24 and <or=96 hrs of ventilation) and long-term (>96 hrs) ventilator patients.

DESIGN

Prospective longitudinal descriptive study.

SETTING

Posthospital discharge follow-up in homes, nursing homes, and rehabilitation centers.

PATIENTS

Intensive care unit patients who required >24 hrs of continuous in-hospital mechanical ventilation were enrolled from February 1997 through March 1999. Patients living to hospital discharge were followed for 1 yr postdischarge.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

A total of 538 patients were studied. In-hospital mortality was 47.4%, with a 1-yr mortality rate of 64.7%; survival analysis showed that the different survival risks for short-term and long-term ventilator patients over time were not statistically significant. Long-term patients were more likely to be discharged to a nursing home (45.2%). Short-term ventilator patients had better overall quality of life at all points postdischarge. Charges to produce a long-term survivor were significantly higher than for short-term patients; on average $86,360 more charges were required to produce a long-term ventilator patient survivor for 1 yr postdischarge.

CONCLUSIONS

There were no significant demographic or clinical differences between short-term and long-term ventilator patients. Our results suggest that the likelihood of need for continued care in an extended-care facility for months and the risk of death during the first year postdischarge are sufficiently common features of this population and need to be included in discussions of treatment options with patients and their families.

The epidemiology and costs of chronic critical illness

CCI patients are patients who have suffered acute illness or injury and require life support or care in an ICU setting for periods of weeks or months. These patients account for between 5% and 10% of ICU admissions, and they appear to be increasing in number. Over half of the patients are over age 65. Patients with underlying premorbid conditions who suffer complications of acute illness are at highest risk for becoming CCI. These patients have poor short-term and long-term survival, although survival may be improving for some types of CCI patients as the medical system adapts to their specific needs. Long-term survival is associated with age and premorbid condition or functional status. Survivors have significant functional limitations, but their reported quality of life is generally good. CCI patients consume a disproportionate share of ICU and hospital resources, and significant additional resources are required for continued recovery or care after discharge. Specialized units have been evolving to manage these patients at lower costs than in acute ICUs, and with similar outcomes. Further refinement of the definition of CCI is an important objective, and should pave the way to better design of outcomes studies. Efforts should continue to learn how to identify patients at high risk for CCI and poor outcome so that expensive resources can be managed effectively, and patient-provider decision making can be better informed.

Liberation from prolonged mechanical ventilation

After weaning from PMV, patients are usually far from ready to resume normal activities. A prolonged recovery period after catastrophic illness is the rule, with multidisciplinary rehabilitation and discharge planning efforts. Following such efforts, reports of success of restorative care are institutional and population specific. That all PMV patients are not "chronically critically ill" introduces selection factors that make comparisons between institutions even more difficult. Half of the authors' patients were able to go home in past years [14], although more recently, with patients admitted more debilitated and more ill, the percent returning home has gradually declined to the low 20% range. Bagley et al [11] report discharge to home in 31% of patients weaned. Gracey et al [6,133], treating younger, postsurgical patients, have reported the highest discharge to home rate, 57%; over 70% were eventually discharged to home after first being transferred to a rehabilitation unit. On the other hand, the few reports of survival 1 or more years after discharge are in the 50% range at best (Table 2). Carson and colleagues [9] report a 23% 1-year survival in 133 PMV patients. Their premorbid functional status and age analysis showed younger and more independent patients having a better mortality (56%), and older and more dependent patients having a 95% mortality at 1 year. Nasraway et al [25] report a 1-year mortality of 50.5% in 97 patients transferred from five ICUs to multiple ECFs. Most of these patients would probably meet criteria for PMV, with median time mechanically ventilated 33 days, and 71 ventilator dependent at the time of ICU discharge. A report from 25 Vencor Hospitals [134] not included in Table 2 because weaning outcome was not reported, examines mortality and cost in patients > 65 years of age primarily referred for failure to wean from mechanical ventilation (91% of the cohort of 1619 patients.) There was a 58% in-hospital mortality by day 102 (28 days in the acute care hospital before referral, 74 days in the LTAC afterward), and a 67% mortality in postdischarge follow-up to day 180. Results of functional status studies and quality-of-life (QQL) measures, some using validated instruments, are now being reported in small series of PMV patients. These will merit consideration as important as weaning outcome, disposition, and survival data, as they accumulate to round out the treatment results in this population. Using a proprietary instrument, Carson et al [9] found 42% of 1-year survivors, that is, 8% of study patients, functionally independent at 1 year after discharge. Nasraway [25], using a single-question QQL assessment, and a validated functionality measurement, found 11.5% of his original cohort at home, breathing independently, with a "fair or better" QOL and good physical functionality. In a preliminary report from Dr. Criner's VRU, objective physical improvement was demonstrated in rehabilitation after PMV, using a functional independence measure scale [89]. A full report from the same unit, using a Sickness Impact Profile score makes it clear that PMV had no independent adverse effect on QOL several years later [135]. The 46 patients (25 of whom, with mean age 59 years, responded to the follow-up questionnaire), followed for 24 months after the catastrophic episode, scored their QOL based on their underlying chronic diseases, if any. The older patients, status postsurgical illness, predominantly cardiac surgery, rated their QOL better than younger patients with acute or chronic diseases. Similar findings have been reported in a recent ICU study, reporting QOL after prolonged intensive care [136]. Those who work to liberate PMV patients from mechanical ventilation, a satisfying end in many ways, have demonstrated that this post-ICU critical care activity is usually safe, and successful, although only in observational studies. Will multicenter studies in PMV patients liberated from mechanical ventilation yield facility benchmark, weaning outcome, and survival data that warrant continuation of these activities on a cost-per-outcome basis? That remains to be seen. Assessing and interpreting QOL and functionality findings in these patients, many with underlying chronic diseases resulting in long convalescence and rehabilitation, is a particularly important challenge. The authors are participating in a multicenter study that will yield some of these data; no doubt others will also address these questions. In the mean time, "No one in our society is willing to put Grandma out on an iceberg because she's no longer contributing. Someone needs to take care of these people" [137].