Patient characteristics and outcomes of a provincial prolonged-ventilation weaning centre: a retrospective cohort study

A historical cohort study on predictors for successful weaning from prolonged mechanical ventilation and up to 3-year survival follow-up in a rehabilitation center

BACKGROUND

We followed prolonged mechanically ventilated (PMV) patients for weaning attempts and explored factors associated with successful weaning and long-term survival.

METHODS

This historical cohort study included all adult PMV patients admitted to a single rehabilitation hospital during 2015-2018 and followed for survival according to weaning success up to 3 years or the end of 2021.

RESULTS

The study included 223 PMV patients. Of them, 124 (55.6 %) underwent weaning attempts, with 69 (55.6 %) successfully weaned, 55 (44.4 %) unsuccessfully weaned, and 99 patients with no weaning attempts. The mean age was 67 ± 20 years, with 39 % female patients. Age, sex distributions and albumin levels at admission were not significantly different among the groups. The successful weaning group had a 6 % higher proportion of conscious patients than the failed weaning group (55 % vs. 49 %, respectively, p = 0.45). Patients successfully weaned were less frequently treated with antibiotics for 5 days or more than those unsuccessfully weaned (74 % vs 80 %, respectively, p = 0.07). They also had a lower proportion of time from intubation to tracheostomy greater than 14 days (45 % vs 66 %, p = 0.02). The age, sex, antibiotic treatment, time to tracheostomy exceeding 14 days and time from admission to first weaning attempt adjusted one-year mortality risk of successful vs. failed weaning was somewhat lower, HR = 0.75, 95%CI: 0.33-1.60, p = 0.45, with the same trend by the end of 3 years, HR = 0.77, 95%CI: 0.42-1.39, p = 0.38.

CONCLUSION

Successful weaning from PMV may be associated with better survival and allows chronically ventilated patients to become independent on a ventilator. A larger study is needed to further validate our findings.

Clinician-perceived barriers and facilitators for the provision of actionable processes of care important for persistent or chronic critical illness

AIM

To explore clinician-perceived barriers to and facilitators for the provision of actionable processes of care important for patients with persistent or chronic critical illness.

DESIGN

Qualitative descriptive interview study.

METHODS

Secondary analysis of semi-structured telephone interviews (December 2018 - February 2019) with professionally diverse clinicians working with adults experiencing persistent or chronic critical illness in Canadian intensive care units. We used deductive content analysis informed by the Social-Ecological Model.

RESULTS

We recruited 31 participants from intensive care units across nine Canadian provinces. Reported intrapersonal level barriers to the provision of actionable processes of care included lack of training, negative emotions and challenges prioritizing these patients. Facilitators included establishment of positive relations and trust with patients and family. Interpersonal barriers included communication difficulties, limited access to physicians and conflict. Facilitators included communication support, time spent with the patient/family and conflict management. Institutional barriers comprised inappropriate care processes, inadequate resources and disruptive environmental conditions. Facilitators were regular team rounds, appropriate staffing and employment of a primary care (nurse and/or physician) model. Community-level barriers included inappropriate care location and insufficient transition support. Facilitators were accessed to alternate care sites/teams and to formalized transition support. Public policy-level barriers included inadequacy of formal education programs for the care of these patients; knowledge implementation for patient management was identified as a facilitator.

CONCLUSION

Our results highlighted multilevel barriers and facilitators to the delivery of actionable processes important for quality care for patient/family experiencing persistent or chronic critical illness.

IMPACT

Using the Social-Ecological Model, the results of this study provide intra and interpersonal, institutional, community and policy-level barriers to address and facilitators to harness to improve the care of patients/family experiencing persistent or chronic critical illness.

REPORTING METHOD

Consolidated criteria for reporting qualitative studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Epidemiology of Tracheostomized Adult Patients Admitted to Specialized Weaning Centers After Acute COVID-19

BACKGROUND

Epidemiological data on patients with COVID-19 referred to specialized weaning centers (SWCs) are sparse, particularly in low- and middle-income countries. Our aim was to describe clinical features, epidemiology, and outcomes of subjects admitted to SWCs in Argentina.

METHODS

We conducted a prospective, multi-center, observational study between July 2020-December 2021 in 12 SWCs. We collected demographic characteristics, laboratory results, pulmonary function, and dependence on mechanical ventilation at admission, decannulation, weaning from mechanical ventilation, and status at discharge. A multiple logistic model was built to predict home discharge.

RESULTS

We enrolled 568 tracheostomized adult subjects after the acute COVID-19 phase who were transferred to SWCs. Age was 62 [52-71], males 70%, Charlson comorbidity index was 2 [0-3], and length of stay in ICU was 42 [32-56] d. Of the 315 ventilator-dependent subjects, 72.4% were weaned, 427 (75.2%) were decannulated, and 366 subjects (64.5%) were discharged home. The mortality rate was 6.0%. In multivariate analysis, age (odds ratio 0.30 [95% CI 0.16-0.56], P < .001), Charlson comorbidity index (odds ratio 0.43 [95% CI 0.22-0.84], P < .01), mechanical ventilation duration in ICU (odds ratio 0.80 [95% CI 0.72-0.89], P < .001), renal failure (odds ratio 0.40 [95% CI 0.22-0.73], P = .003), and expiratory muscle weakness (odds ratio 0.35 [95% CI 0.19-0.62], P < .001) were independently associated with home discharge.

CONCLUSIONS

Most subjects with COVID-19 transferred to SWCs were weaned, achieved decannulation, and were discharged to home. Age, high-comorbidity burden, prolonged mechanical ventilation in ICU, renal failure at admission, and expiratory muscle weakness were inversely associated with home discharge.

The Survival Outcomes of Patients Requiring Prolonged Mechanical Ventilation

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.

Five years follow up of patient receiving prolonged mechanical ventilation: Data for a single center in Taiwan

Background

The National Association for Medical Direction of Respiratory Care recommended tracking 1-year survival rates (the most relevant outcome) in patients treated with prolonged mechanical ventilation. However, patients treated with prolonged mechanical ventilation had higher mortality rates within the first 2 years after weaning. More knowledge regarding long-term mortality would help patients, families, and clinicians choose appropriate interventions and make end-of-life decisions. In this investigation, we attempted to determine the rates of long-term mortality for all patients treated with prolonged mechanical ventilation over a period of 10 years.

Objective

The purpose of this investigation was to enhance the overall survival outcomes for patients receiving prolonged mechanical ventilation by identifying the factors affecting the 5-year mortality rates for these patients.

Design

Retrospective observational study.

Materials and methods

In this retrospective study, we explored the influential factors related to the overall survival outcomes of all patients treated with prolonged mechanical ventilation. We enrolled every individual admitted to the weaning unit between January 1, 2012, and December 31, 2016. The length of survival for each patient was estimated from admission to the weaning unit until death or December 31, 2021, whichever came first. We analyzed the data to investigate the survival time, mortality rates, and survival curves in these patients.

Results

Long-term follow-up information was gathered for 296 patients who received prolonged mechanical ventilation. There was better mean survival times in patients treated with prolonged mechanical ventilation with the following characteristics (in order): no comorbidities, tracheostomies, and intracranial hemorrhage. Successful weaning, receipt of tracheostomy, an age less than 75 years, and no comorbidities were associated with better long-term overall survival outcomes.

Conclusion

Prolonged mechanical ventilation patients had abysmal overall survival outcomes. Even though prolonged mechanical ventilation patients’ long-term survival outcomes are tragic, medical professionals should never give up on the dream of enhancing long-term outcomes.

Mortality, Health Care Use, and Costs of Weaning Center Survivors and Matched Prolonged ICU Stay Controls

BACKGROUND

Quantification of long-term survival, health care utilization, and costs of prolonged ventilator dependence informs patient/family decision-making, health care policy, and understanding of specialized weaning centers (SWCs) as alternate care models. Our objective was to compare survival trajectory, health care utilization, and costs of SWC survivors with a matched cohort of ≥ 21-d-stay ICU patients.

METHODS

This was a retrospective longitudinal (12 y) case-control study linking to health administrative databases with matching on age, sex, Charlson comorbidity index, income quintiles, and days in ICU and hospital in preceding 12 months.

RESULTS

We matched 201 SWC subjects to 201 prolonged ICU survivors (402-subject cohort); 42% had a Charlson score of > 4. Risk of death at 12 months was lower in SWC subjects (hazard ratio [HR] 0.70 [95% CI 0.54-0.91]) adjusting for length of hospital admission (HR 1.02 [95% CI 1.00-1.04]) and number of care location transfers (HR 0.84 [95% CI 0.75-0.93]). By follow-up end, more SWC subjects died, 149 (73%) versus 127 (62%). We found no difference in discharge to home. At 12 months, acute health care utilization was comparable for the entire cohort, except hospital readmission rates (median interquartile range [IQR] 2 [1-3) vs 1 [1-2] d). Median (IQR) cost 12 months after unit discharge was CAD $68,165 ($19,894-$153,475). 12-month costs were higher in the SWC survivors (CAD $82,874 [$29,942-$224,965] vs CAD $55,574 [$6,572-$128,962], P < .001). SWC survivors had higher community health care utilization. Regression modeling demonstrated cost was associated with stay and care transfers but not SWC admission. Over 12-y follow-up, health care utilization and costs were higher in SWC survivors.

CONCLUSIONS

SWC admission may confer some medium-term survival advantage; however, this may be influenced by selection bias associated with admission criteria.

The Long-Term Survival of Successfully Weaned Prolonged Mechanical Ventilation Patients

Background

There are rare articles in the literature that addressed long-term survival in successfully weaned prolonged mechanical ventilation patients. How are the long-term outcomes of these successfully weaned prolonged mechanical ventilation patients? Our objective is to explore this issue in depth in this study and serve as the basis for us to provide suggestions for patients in long-term care of the successfully weaned prolonged mechanical ventilation patients.

Methods

We investigated the clinical variables, long-term survival, cause of death, receipt or not of tracheostomy and analyzed the factors association with survival in successfully weaned prolonged mechanical ventilation patients.

Results

We can further gather long-term follow-up data on successfully weaned prolonged mechanical ventilation patients, 243 patients. The 1-, 2-, 3-, 4- and 5-year survival rates of successfully weaned PMV patients were 32.5%, 28.0%, 24.9%, 23.9%, and 21.3%, respectively. The factors between successfully weaned prolonged mechanical ventilation patients who died in the ward and those who were discharged from the hospital revealed the poorer survival of patients who died in the ward was due to a higher percentage of end-stage renal disease comorbidity, a higher percentage of ≥4 comorbidities and a lower percentage of undergoing tracheostomy. The factors between successfully weaned discharged prolonged mechanical ventilation patients who survived <1 year and those who survived ≥1 year revealed the poorer survival of patients who survived <1 year was due to older age, a higher percentage of ≥4 comorbidities, and a lower percentage of undergoing tracheostomy.

Conclusion

The receipt or not of tracheostomy is the key influential factor of long-term survival of successfully weaned prolonged mechanical ventilation patients. Tracheostomy should be attempted in suitable patients for improving long-term outcomes in successfully weaned prolonged mechanical ventilation patients.

Mortality outcomes of patients on chronic mechanical ventilation in different care settings: A systematic review

Objectives

To determine the outcomes of chronically ventilated patients outside the setting of intensive care units.

Design

Systematic review.

Setting and participants

Studies evaluating patients on chronic invasive mechanical ventilation in different care settings.

Methods

A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion.

Results

Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death.

Conclusions and implications

Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources.

Predictors of survival after prolonged weaning from mechanical ventilation

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.

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

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.

Validation of the Multi-INdependence Dimensions (MIND) questionnaire for prolonged mechanically ventilated subjects

Background

Evaluating severity of illness of patients with prolonged mechanical ventilation (PMV) is important to adopt the best appropriate care management for each individual. Yet, no severity-of-illness scoring system has been specifically designed for this type of patients. The aim of this study was to develop and validate a new instrument, the Multi-INdependence Dimensions (MIND) questionnaire designed to comprehensively measure the severity of illness of patients under PMV.

Methods

The validation of the MIND questionnaire was performed during a longitudinal observational study conducted with PMV subjects in weaning facilities in three countries (Argentina, Colombia and Germany). The questionnaire validity was tested in 3 stages: 1) Specification of components, with description of item responses, inter-item and Cronbach alpha correlations; 2) Creation of the composite scores; 3) Measurement properties determination including test-retest reliability after 30 days, clinical validity (Medical Research Council (MRC) muscle strength score, Sepsis-related Organ Failure Assessment (SOFA), Glasgow Coma Scale (GCS), Dependence Nursing Scale and EuroQol-5 Dimension evaluated at inclusion), and ability to detect change.

Results

A total of 128 subjects participated in the validation study. Eleven component scores and four composite scores were created. MIND scores significantly correlated with MRC muscle strength, SOFA, DNS, GCS and EQ-5D, supporting the validity of the new scores. Intraclass Correlation Coefficient greater than 0.82 were observed for all composite scores, indicating good test-retest reliability. MIND scores were able to detect improvement in subject severity of illness.

Conclusion

The MIND questionnaire is a valid and reliable instrument for measuring comprehensively the multiple dimensions characterizing the severity of illness of PMV patients.

Trial registration

NCT02255058.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0870-2) contains supplementary material, which is available to authorized users.

Variation in mortality rates after admission to long-term acute care hospitals for ventilator weaning

PURPOSE

We sought to examine variation in long-term acute care hospital (LTACH) quality based on 90-day in-hospital mortality for patients admitted for weaning from mechanical ventilation.

METHODS

We developed an administrative risk-adjustment model using data from Medicare claims. We validated the administrative model against a clinical model using data from LTACHs participating in a 2002 to 2003 clinical registry. We then used our validated administrative model to assess national variation in 90-day in-hospital mortality rates in LTACHs from 2013.

RESULTS

The administrative risk-adjustment model was derived using data from 9447 patients admitted to 221 LTACHs in 2003. The model had good discrimination (C statistic=0.72) and calibration. Compared to a clinically derived model using data from 1163 patients admitted to 14 LTACHs, the administrative model generated similar performance estimates. National variation in risk-adjusted mortality was assessed using data from 20,453 patients admitted to 380 LTACHs in 2013. LTACH-specific risk-adjusted mortality rates varied from 8.4% to 48.1% (median: 24.2%, interquartile range: 19.7%-30.7%).

CONCLUSIONS

LTACHs vary widely in mortality rates, underscoring the need to better understand the sources of this variation and improve the quality of care for patients requiring long-term ventilator weaning.

APACHE II score cannot predict successful weaning from prolonged mechanical ventilation

At least 5% of all intensive care unit patients require prolonged respiratory support. Multiple factors have been suggested as possible predictors of successful respiratory weaning so far. We sought to verify whether the Acute Physiology and Chronic Health Evaluation II (APACHE II) can predict freedom from prolonged mechanical ventilation (PMV) in patients treated in a regional weaning centre. The study group comprised 130 consecutive patients (age; median (interquartile range): 71 (62–77) years), hospitalized between 1 January 2012, and 31 December 2013. APACHE II score was assessed based on the worst values taken during the first 24 hours after admission. Glasgow coma scale was excluded from calculations due to the likely influence of sedative agents. The outcome was defined as freedom from mechanical ventilation, with or without tracheostomy on discharge. Among survivors (n = 115), 88.2% were successfully liberated from mechanical ventilation and 60.9% from tracheostomy. APACHE II failed to predict freedom from mechanical ventilation (area under the receiver–operating characteristic curve [AUROC] = 0.534; 95% confidence interval [CI]: 0.439–0.628; p = 0.65) and tracheostomy tube removal (AUROC = 0.527; 95% CI: 0.431–0.621; p = 0.63). Weaning outcome was unrelated to the aetiology of respiratory failure on admission (p = 0.41). APACHE II cannot predict weaning outcome in patients requiring PMV.

Clinical factors associated with weaning failure in patients requiring prolonged mechanical ventilation

BACKGROUND

For patients requiring prolonged mechanical ventilation (PMV), weaning is difficult and mortality is very high. PMV has been defined recently, by consensus, as constituting ≥21 consecutive days of mechanical ventilation (MV) for ≥6 hours per day. This study aimed to evaluate the clinical factors predicting weaning failure in patients undergoing PMV in medical intensive care unit (ICU).

METHODS

We retrospectively reviewed the clinical and laboratory characteristics of 127 patients who received MV for more than 21 days in the medical ICU at Chonnam National University Hospital in South Korea between January 2005 and December 2014. Patients who underwent surgery or experienced trauma were excluded from this study.

RESULTS

Among the 127 patients requiring PMV, 41 (32.3%) were successfully weaned from MV. The median age of the weaning failure group was higher than that of the weaning success group (74.0 vs. 70.0 years; P=0.003). The proportion of male patients was 58.5% in the weaning success group and 72.1% in the weaning failure group, respectively. The most common reasons for ICU admission were respiratory causes (66.1%) followed by cardiovascular causes (16.5%) in both groups. ICU mortality and in-hospital mortality rates were 55.1% and 55.9%, respectively. In the multivariate analysis, respiratory causes of ICU admission [odds ratio (OR), 3.98; 95% confidence interval (CI), 1.29-12.30; P=0.016] and a high sequential organ failure assessment (SOFA) score on day 21 of MV (OR, 1.47; 95% CI, 1.17-1.85; P=0.001) were significantly associated with weaning failure in patients requiring PMV. The area under the receiver operating characteristic (ROC) curve of the SOFA score on day 21 of MV for predicting weaning failure was 0.77 (95% CI, 0.67-0.87; P=0.000).

CONCLUSIONS

Respiratory causes of ICU admission and a high SOFA score on day 21 of MV could be predictive of weaning failure in patients requiring PMV.

Does the APACHE II score predict performance of activities of daily living in patients discharged from a weaning center?

INTRODUCTION

Data regarding the functional status of patients after prolonged mechanical ventilation are scarce, and little is known about its clinical predictors.

AIM

To investigate whether the Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission may predict performance in activities of daily living on discharge from a weaning center.

MATERIAL AND METHODS

All consecutive patients admitted between January 1, 2012 and December 31, 2013 were enrolled (n = 130). During this period, 15 subjects died, and 115 were successfully discharged (34 women; 81 men). APACHE II was calculated based on the worst values taken during the first 24 hours after admission. On discharge, the Barthel Index (BI) and its extended version, the Early Rehabilitation Barthel Index (ERBI), were assessed.

RESULTS

Median BI was 20 points (IQR 5; 40), and ERBI was 20 points (-50; 40). There was no correlation between APACHE II and either BI (R = -0.07; p = 0.47) or ERBI (R = -0.07; p = 0.44). APACHE II predicted the need for assistance with bathing (AUROC = 0.833; p < 0.001), grooming (AUROC = 0.823; p < 0.001), toilet use (AUROC = 0.887; p < 0.001), and urination (AUROC = 0.658; p = 0.04). APACHE II had no impact on any ERBI items associated with ventilator weaning, including the need of further mechanical ventilation (AUROC = 0.534; p = 0.65) or tracheostomy (AUROC = 0.544; p = 0.42).

CONCLUSIONS

Although APACHE II cannot predict the overall functional status in patients discharged from a weaning center, it helps identify subjects who will need support with bathing, grooming, and toilet use. The APACHE II score is inadequate to predict performance in activities associated with further respiratory support.

Noninvasive ventilation during the weaning process in chronically critically ill patients

Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process.

We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h.

231 chronically critically ill patients were included in the study. 198 (85.71%) patients achieved weaning success (mean weaning time 25.45±16.71 days), of whom 40 (21.4%) needed NIV during the weaning process. The variable which predicted the need for NIV was arterial carbon dioxide tension at respiratory care unit admission (OR 1.08 (95% CI 1.01–1.15), p=0.013), with a cut-off point of 45.5 mmHg (sensitivity 0.76, specificity 0.67, positive predictive value 0.76, negative predictive value 0.97).

NIV is a useful tool during weaning in chronically critically ill patients. Hypercapnia despite mechanical ventilation at respiratory care unit admission is the main predictor of the need for NIV during weaning.

NIV is a useful tool during weaning in chronic critically ill patients independent of their premorbid conditionhttp://ow.ly/j4Av304sEoJ

Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5)

Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.

The Care-Integrated Concentration Meditation Program for Patients With Weaning Difficulty: A Pilot Study

Because of the multifaceted process of weaning patients with prolonged mechanical ventilation, enhancing weaning success remains a challenge. The Care-Integrated Concentration Meditation Program was developed on the basis of Buddhist philosophy and implemented to determine its procedural feasibility. A qualitative case study with 3 participants was conducted, and the process and initial outcomes were evaluated.

Elevated Red Cell Distribution Width Is Associated With Decreased Ventilator-Free Days in Critically Ill Patients

INTRODUCTION

Elevated red cell distribution width (RDW) is associated with mortality in a variety of respiratory conditions. Recent data also suggest that RDW is associated with mortality in intensive care unit (ICU) patients. Although respiratory failure is common in the ICU, the relationship between RDW and pulmonary outcomes in the ICU has not been previously explored. Therefore, our goal was to investigate the association of admission RDW with 30-day ventilator-free days (VFDs) in ICU patients.

METHODS

We performed a retrospective analysis from an ongoing prospective, observational study. Patients were recruited from medical and surgical ICUs of a large teaching hospital in Boston, Massachusetts. The RDW was assessed within 1 hour of ICU admission. Poisson regression analysis was used to investigate the association of RDW (normal: 11.5%-14.5% vs elevated: >14.5%) with 30-day VFD, while controlling for age, sex, race, body mass index, Nutrition Risk in the Critically Ill score, the presence of chronic lung disease, Pao₂/Fio₂ ratio, and admission levels of hemoglobin, mean corpuscular volume, phosphate, albumin, C-reactive protein, and creatinine.

RESULTS

A total of 637 patients comprised the analytic cohort. Mean RDW was 15 (standard deviation 4%), with 53% of patients in the normal range and 47% with elevated levels. Median VFD was 16 (interquartile range: 6-25) days. Poisson regression analysis demonstrated that ICU patients with elevated admission RDW were likely to have 32% lower 30-day VFDs compared to their counterparts with RDW in the normal range (incidence rate ratio: 0.68; 95% confidence interval: 0.55-0.83: P < .001).

CONCLUSIONS

We observed an inverse association of RDW and 30-day VFD, despite controlling for demographics, nutritional factors, and severity of illness. This supports the need for future studies to validate our findings, understand the physiologic processes that lead to elevated RDW in patients with respiratory failure, and determine whether changes in RDW may be used to support clinical decision-making.

Prospective observational cohort study of patients with weaning failure admitted to a specialist weaning, rehabilitation and home mechanical ventilation centre

OBJECTIVES

According to National Health Service England (NHSE) specialist respiratory commissioning specification for complex home ventilation, patients with weaning failure should be referred to a specialist centre. However, there are limited data reporting the clinical outcomes from such centres.

SETTING

Prospective observational cohort study of patients admitted to a UK specialist weaning, rehabilitation and home mechanical ventilation centre between February 2005 and July 2013.

PARTICIPANTS

262 patients admitted with a median age of 64.2 years (IQR 52.6-73.2 years). 59.9% were male.

RESULTS

39.7% of patients had neuromuscular and/or chest wall disease, 21% were postsurgical, 19.5% had chronic obstructive pulmonary disease (COPD), 5.3% had obesity-related respiratory failure and 14.5% had other diagnoses. 64.1% of patients were successfully weaned, with 38.2% weaned fully from ventilation, 24% weaned to nocturnal non-invasive ventilation (NIV), 1.9% weaned to nocturnal NIV with intermittent NIV during the daytime. 21.4% of patients were discharged on long-term tracheostomy ventilation. The obesity-related respiratory failure group were most likely to wean (relative risk (RR) for weaning success=1.48, 95% CI 1.35 to 1.77; p<0.001), but otherwise weaning success rates did not significantly vary by diagnostic group. The median time-to-wean was 19 days (IQR 9-33) and the median duration of stay was 31 days (IQR 16-50), with no difference observed between the groups. Weaning centre mortality was 14.5%, highest in the COPD group (RR=2.15, 95% CI 1.19 to 3.91, p=0.012) and lowest in the neuromuscular and/or chest wall disease group (RR=0.34, 95% CI 0.16 to 0.75, p=0.007). Of all patients discharged alive, survival was 71.7% at 6 months and 61.8% at 12 months postdischarge.

CONCLUSIONS

Following NHSE guidance, patients with weaning delay and failure should be considered for transfer to a specialist centre where available, which can demonstrate favourable short-term and long-term clinical outcomes.

Institutional care for long-term mechanical ventilation in Canada: A national survey

INTRODUCTION

No national Canadian data define resource requirements and care delivery for ventilator-assisted individuals (VAIs) requiring long-term institutional care. Such data will assist in planning health care services to this population.

OBJECTIVE

To describe institutional and patient characteristics, prevalence, equipment used, care elements and admission barriers for VAIs requiring long-term institutional care.

METHODS

Centres were identified from a national inventory and snowball referrals. The survey weblink was provided from December 2012 to April 2013. Weekly reminders were sent for six weeks.

RESULTS

The response rate was 84% (54 of 64), with 44 adult and 10 pediatric centres providing data for 428 VAIs (301 invasive ventilation; 127 noninvasive ventilation [NIV]), equivalent to 1.3 VAIs per 100,000 population. An additional 106 VAIs were on wait lists in 18 centres. More VAIs with progressive neuromuscular disease received invasive ventilation than NIV (P<0.001); more VAIs with chronic obstructive pulmonary disease (P<0.001), obesity hypoventilation syndrome (P<0.001) and central hypoventilation syndrome (P=0.02) required NIV. All centres used positive pressure ventilators, 21% diaphragmatic pacing, 15% negative pressure and 13% phrenic nerve stimulation. Most centres used lung volume recruitment (55%), manually (71%) and mechanically assisted cough (55%). Lack of beds and provincial funding were common admission barriers.CONCLUSIONS: Variable models and care practices exist for institutionalized care of Canadian VAIs. Patient prevalence was 1.3 per 100,000 Canadians.

Patient transitions relevant to individuals requiring ongoing ventilatory assistance: a Delphi study

BACKGROUND

Various terms, including 'prolonged mechanical ventilation' (PMV) and 'long-term mechanical ventilation' (LTMV), are used interchangeably to distinguish patient cohorts requiring ventilation, making comparisons and timing of clinical decision making problematic.

OBJECTIVE

To develop expert, consensus-based criteria associated with care transitions to distinguish cohorts of ventilated patients.

METHODS

A four-round (R), web-based Delphi study with consensus defined as >70% was performed. In R1, participants listed, using free text, criteria perceived to should and should not define seven transitions. Transitions comprised: T1 - acute ventilation to PMV; T2 - PMV to LTMV; T3 - PMV or LTMV to acute ventilation (reverse transition); T4 - institutional to community care; T5 - no ventilation to requiring LTMV; T6 - pediatric to adult LTMV; and T7 - active treatment to end-of-life care. Subsequent Rs sought consensus.

RESULTS

Experts from intensive care (n=14), long-term care (n=14) and home ventilation (n=10), representing a variety of professional groups and geographical areas, completed all Rs. Consensus was reached on 14 of 20 statements defining T1 and 21 of 25 for T2. 'Physiological stability' had the highest consensus (97% and 100%, respectively). 'Duration of ventilation' did not achieve consensus. Consensus was achieved on 13 of 18 statements for T3 and 23 of 25 statements for T4. T4 statements reaching 100% consensus included: 'informed choice', 'patient stability', 'informal caregiver support', 'caregiver knowledge', 'environment modification', 'supportive network' and 'access to interprofessional care'. Consensus was achieved for 15 of 17 T5, 16 of 20 T6 and 21 of 24 T7 items.

CONCLUSION

Criteria to consider during key care transitions for ventilator-assisted individuals were identified. Such information will assist in furthering the consistency of clinical care plans, research trials and health care resource allocation.