Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center

A Case of Complicated Traumatic Generalized Surgical Emphysema, Pneumomediastinum, Pneumopericardium, Pneumothorax, and Pneumoperitoneum Due to Accidental Dislodgement of Tracheostomy Tube

A tracheostomy tube (TT) is usually taken out in a well-planned and coordinated manner after the underlying condition that necessitated the procedure is resolved. The inadvertent removal or dislodgement of the TT from the stroma is known as accidental extubation or decannulation. This event may prove fatal in a stable patient. Like other respiratory procedures, tracheostomy with the long-term placement of tracheal tube comes with several risks, including scarring of the trachea, pneumothorax, tracheal rupture, and tracheoesophageal fistula. Other complications may include pneumomediastinum (PM) or the escape of air into the surrounding tissue. This may be attributed to several reasons, including mispositioning of the tracheal tube, barotrauma, or tracheal rupture. In some cases, PM presents with free air into cavities such as the thorax, peritoneum, or subcutaneous tissue. Although not fatal, it may require complex treatments such as ventilator management, high-flow oxygen, or, in some cases, surgical intervention. In this article, we describe a rare case of PM and generalized surgical emphysema due to mispositioning of the tracheal tube.

Clinical outcomes of difficult-to-wean patients with ventilator dependency at intensive care unit discharge

Background

Ventilator-dependent patients in the intensive care unit (ICU) who are difficult to wean from invasive mechanical ventilation (IMV) have been increasing in number. However, data on the clinical outcomes of difficult-to-wean patients are lacking. We aimed to evaluate clinical outcomes in patients discharged from the ICU with tracheostomy and ventilator dependency.

Methods

We retrospectively investigated clinical course and survival in patients requiring home mechanical ventilation (HMV) with a tracheostomy and difficulty weaning from IMV during medical ICU admission from September 2013 through August 2016 at Severance Hospital, Yonsei University, Seoul, Korea.

Results

Of 84 difficult-to-wean patients who were started on HMV in the medical ICU, 72 survived, were discharged from the ICU, and were included in this analysis. HMV was initiated after a median of 23 days of IMV, and the successful weaning rate was 46% (n=33). In-hospital mortality rate was significantly lower in the successfully weaned group than the unsuccessfully weaned group (0% vs. 23.1%, respectively; P=0.010). Weaning rates were similar according to primary diagnosis, but high body mass index (BMI), low Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at ICU admission, and absence of neuromuscular disease were associated with weaning success. After a median follow-up of 4.6 months (range, 1–27 months) for survivors, 3-month (n=64) and 6-month (n=59) survival rates were 82.5% and 72.2%, respectively. Survival rates were higher in the successfully weaned group than the unsuccessfully weaned group at 3 months (96.4% vs. 69.0%; P=0.017) and 6 months (84.0% vs. 62.1%; P=0.136) following ICU discharge.

Conclusions

In summary, 46% of patients who started HMV were successfully weaned from the ventilator in general wards. High BMI, low APACHE II score, and absence of neuromuscular disease were factors associated with weaning success.

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.

How prolonged mechanical ventilation is a neglected disease in chest medicine: a study of prolonged mechanical ventilation based on 6 years of experience in Taiwan

Background:

An increasing number of patients require prolonged mechanical ventilation (PMV) to survive recovery from critical care. It should be emphasized that PMV is a neglected disease in chest medicine. We investigated 6 years of clinical outcomes and long-term survival rates of patients who required PMV.

Methods:

We analyzed retrospectively data from patients in respiratory care center (RCC) to investigate the main causes of respiratory failure leading patients to require PMV. We also studied the factors that influence the ventilator weaned rate, factors that influence the long-term ventilator dependence of patients who require PMV, as well as patients’ hospital mortality and long-term survival rates.

Results:

A total of 574 patients were admitted to RCC during the 6 years. Of these, 428 patients (74.6%) were older than 65 years. A total of 391 patients (68.1%) were successfully weaned from the ventilator while 83 patients (14.4%) were unsuccessfully weaned. A total of 95 patients (16.6%) died during RCC hospitalization. The most common cause of acute respiratory failure leading to patients requiring PMV was pneumonia. The factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Our hospital mortality rate was 32.4%; the 1-year survival rate was 24.3%. There was a strong correlation between higher patient age and higher hospital mortality rate and poor 1-year survival rate. Patients with no comorbidity demonstrated good 1-year survival rates. Patients with four comorbidities and patients with end-stage renal disease requiring hemodialysis comorbidity showed poor 1-year survival rates.

Conclusions:

The factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Older patients, patients with renal failure requiring hemodialysis, and those with numerous comorbidities demonstrated poor long-term survival.

The reviews of this paper are available via the supplemental material section.

Prolonged Weaning from Mechanical Ventilation

BACKGROUND

To accommodate the increasing number of patients requiring prolonged weaning from mechanical ventilation, specialized weaning centers have been established for patients in whom weaning on the intensive care unit (ICU) was unsuccessful.

METHODS

This study aimed to determine both the outcome of treatment and the factors associated with prolonged weaning in patients who were transferred from the ICU to specialized weaning centers in Germany during the period 2011 to 2015, based on a nationwide registry covering all specialized weaning centers currently going through the process of accreditation by the German Respiratory Society.

RESULTS

Of 11 424 patients, 7346 (64.3%) were successfully weaned, of whom 2236 were switched to long-term non-invasive ventilation; 1658 (14.5%) died in the weaning unit; and 2420 (21.2%) could not be weaned. The duration of weaning decreased significantly from 22 to 18 days between 2011 and 2015 (p <0.0001). Multivariate analysis revealed that the factor most strongly associated with in-hospital mortality was advanced age (odds ratio [OR] 11.07, 95% confidence interval [6.51; 18.82], p <0.0001). The need to continue with invasive ventilation was most strongly associated with the duration mechanical ventilation prior to transfer from the ICU (OR 4.73 [3.25; 6.89]), followed by a low body mass index (OR 0.38 [0.26; 0.58]), pre-existing neuromuscular disorders (OR 2.98 [1.88; 4.73]), and advanced age (OR 2.96 [1.87; 4.69]) (each p <0.0001).

CONCLUSION

Weaning duration has decreased over time, but prolonged weaning is still unsuccessful in one third of patients.Overall, the results warrant the establishment of specialized weaning centers. Variables associated with death and weaningfailure can be integrated into ICU decision-making processes.

An Unusual Cause of Failed Tracheal Decannulation—A Case Report

Failure of decannulation may occur due to unexpected upper airway problems. However, the presence of a membrane in between the vocal cords is usually rare. We report a case of a 46-year-old female, who presented with focal seizures and progressed to status epilepticus. She was put on a mechanical ventilator because of hypoxic arrest. As she required prolonged ventilatory support, tracheostomy and gradual weaning from ventilator support to T-piece was done. Following stable hemodynamics, decannulation trial was attempted which failed. Subsequently, bronchoscopy was done to assess the upper airway. It revealed a thick membrane in between the vocal cords. Further examination with an indirect laryngoscope under general anesthesia confirmed the findings, and the membrance was excised. Decannulation was successful the very following day and the patient was discharged with stable hemodynamics.

Resource use, characteristics and outcomes of prolonged non-invasive ventilation: a single-centre observational study in China

OBJECTIVE

To report the resource use, characteristics and outcomes of patients with prolonged non-invasive ventilation (NIV).

DESIGN

A single-centre observational study.

SETTING

An intensive care unit of a teaching hospital.

PARTICIPANTS

Patients who only received NIV because of acute respiratory failure were enrolled. Prolonged NIV was defined as subjects who received NIV ≥14 days. A total of 1539 subjects were enrolled in this study; 69 (4.5%) underwent prolonged NIV.

MAIN OUTCOME MEASURES

Predictors of prolonged NIV and hospital mortality.

RESULTS

The rate of do-not-intubate (DNI) orders was 9.1% (140/1539). At the beginning of NIV, a DNI order (OR 3.95, 95% CI 2.25 to 6.95) and pH ≥7.35 (2.20, 1.27 to 3.82) were independently associated with prolonged NIV. At days 1 and 7 of NIV, heart rate (1.01 (1.00 to 1.03) and 1.02 (1.00 to 1.03], respectively) and PaO₂/FiO₂<150 (2.19 (1.25 to 3.85) and 2.05 (1.04 to 4.04], respectively) were other independent risk factors for prolonged NIV. When patients who died after starting NIV but prior to 14 days were excluded, the association was strengthened. Regarding resource use, 77.1% of subjects received NIV<7 days and only accounted for 47.0% of NIV-days. However, 18.4% of subjects received NIV 7-13.9 days and accounted for 33.4% of NIV-days, 2.9% of subjects received NIV 14-20.9 days and accounted for 9.5% of NIV-days, and 1.6% of subjects received NIV≥21 days and accounted for 10.1% of NIV-days.

CONCLUSIONS

Our results indicate the resource use, characteristics and outcomes of a prolonged NIV population with a relatively high proportion of DNI orders. Subjects with prolonged NIV make up a high proportion of NIV-days and are at high risk for in-hospital mortality.

Factors influencing weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation patients

BACKGROUND

Studies analyzing risk factors of weaning failure in neurological and neurosurgical early rehabilitation (NNER) patients are rare.

AIM

The aim of this study was to identify clinical factors influencing the weaning of NNER patients.

DESIGN

An observational, retrospective data analysis of a German multicenter study was performed.

SETTING

German neurological early rehabilitation centers.

POPULATION

Inpatient ventilated NNER patients (N.=192) were enrolled in the study.

METHODS

Demographical data, main diagnosis, medical devices, special medical care and assessment instruments of functional abilities, consciousness and independence in activities of daily living were accrued and compared between patients with and without successful weaning. The prognostic power of factors associated with weaning success/failure was analyzed using binary logistic regression.

RESULTS

In total, 75% of the patients were successfully weaned. Colonization with multi-drug resistant bacteria and the need for dialysis were independent predictors of weaning failure. Successfully weaned patients had a shorter length of stay, better functional outcome, and lower mortality than non-successfully weaned patients.

CONCLUSIONS

Successfully weaned patients differ from patients with weaning failure in several clinical variables. All these variables are associated with the morbidity of the patient, indicating that the weaning process is strongly influenced by disease burden.

CLINICAL REHABILITATION IMPACT

Functional abilities, level of consciousness, independence in activities of daily living, colonization with multi-drug resistant bacteria, need for dialysis and disease duration might help to predict the weaning process of NNER.

[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

Weaning from long-term mechanical ventilation

As many as 5% of patients who need mechanical ventilation will require prolonged mechanical ventilation (PMV). The cost of their care and its associated morbidity is alarming; however, good outcomes can be achieved when their care is specialized and delivered in a programmatic manner. In this article, we review some of the common and potentially reversible reasons why patients fail successfully liberation from mechanical ventilation. We examine the outcomes of patients requiring PMV and present evidence that supports the development of specialized units where patients can be cohorted and may produce better outcomes than would be likely if these patients remained in the ICU.

Preadmission tracheostomy is associated with better outcomes in patients with prolonged mechanical ventilation in the postintensive care respiratory care setting

BACKGROUND/PURPOSE

Prolonged mechanical ventilation (PMV) is the most common situation where tracheostomy is indicated for intensive care unit (ICU) patients. However, it is unknown if this procedure confers survival benefits on PMV patients in a post-ICU setting.

METHODS

Patients who were admitted to the specialized weaning unit from 2005 to 2008 and received PMV were included in this study. On admission, data pertaining to patient characteristics, physiologic status, and type of artificial airway (tracheostomy vs. no tracheostomy) were obtained. Outcomes of tracheostomized and nontracheostomized patients were evaluated using multivariate Cox proportional hazards and propensity score-matching models. The primary outcome of interest was 1-year survival.

RESULTS

A total of 401 patients (mean age 74.4 years, 204 male) were identified. In multivariate analyses, higher Acute Physiology and Chronic Health Evaluation II score [hazard ratio (HR) = 1.061, 95% confidence interval (CI) = 1.016-1.107] and presence of comorbidities, including congestive heart failure (HR = 1.562, 95% CI = 1.119-2.181), malignancy (HR = 1.942, 95% CI = 1.306-2.885), and liver cirrhosis (HR = 2.373, 95% CI = 1.015-5.544), were independently associated with 1-year mortality. An association between having tracheostomy and a better 1-year outcome was observed (HR = 0.625, 95% CI = 0.453-0.863). The matched cohort study also demonstrated a favorable 1-year survival for tracheostomized patients, and these patients had significantly lower in-hospital mortality (24% vs. 36%, p = 0.049) and risk of ventilator-associated pneumonia (10% vs. 20%, p = 0.030) than nontracheostomized ones.

CONCLUSION

Preadmission tracheostomy may be associated with better outcomes of PMV patients in a post-ICU respiratory care setting. The findings suggest that this procedure should be recommended before PMV patients are transferred to specialized weaning units.

Benefits and Challenges in Developing a Program of Research

The ultimate goals of nursing research are knowledge generation and improvement in nursing practice. Designing studies that provide the evidence needed for practice change and that have clear implications for immediate application to current practice environments is particularly challenging. Research programs that consist of sequential studies, each building on and expanding on the results of the previous work, offer the greatest promise for generating understanding of the human phenomenon relevant to nursing practice. The authors review their experience with a series of studies of inpatient and postdischarge needs and interventions associated with chronic critical illness to illustrate the benefits of developing a longitudinal research program as well as the importance of strategies that will foster application of results. Recommendations for developing such a program are discussed.

Relationship of the Duration of Ventilator Support to Successful Weaning and Other Clinical Outcomes in 437 Prolonged Mechanical Ventilation Patients

OBJECTIVE

To investigate the relationships between durations of ventilator support and weaning outcomes of prolonged mechanical ventilation (PMV) patients.

METHODS

Cohort study of 957 PMV patients sequentially admitted to a long-term acute care hospital (LTACH). The study population was 437 PMV patients who underwent weaning, having achieved ≥4 hours of sustained spontaneous breathing. They were divided into tertiles of mechanical ventilation (MV) durations and compared for differences (tertile A: 21-58 days, n = 146; tertile B: 59-103 days, n = 147; and tertile C: ≥104 days, n = 144).

RESULTS

Tertiles showed comparable weaning success rates and survival. As MV durations increased, LTACH postweaning days became progressively greater, whereas decannulations and discharge physical function diminished, and home discharges decreased while nursing facility discharges increased (all P < .001). Patients with lower physical function before critical illness or greater burdens of comorbidities were least likely to be weaned (all P < .001). Younger ages, lower comorbidity burdens, neurological diagnoses, higher admission prealbumin levels, and successful weaning, each independently reduced the risk of death (all P < .01).

CONCLUSION

Durations of MV did not affect weaning success or survival, although deleterious effects were found in discharges, decannulations, LTACH postweaning days, and discharge physical function. Durations of MV alone should not guide transfer decisions for subsequent continuing care.

Clinical verification of a clinical decision support system for ventilator weaning

Background

Weaning is typically regarded as a process of discontinuing mechanical ventilation in the daily practice of an intensive care unit (ICU). Among the ICU patients, 39%-40% need mechanical ventilator for sustaining their lives. The predictive rate of successful weaning achieved only 35-60% for decisions made by physicians. Clinical decision support systems (CDSSs) are promising in enhancing diagnostic performance and improve healthcare quality in clinical setting. To our knowledge, a prospective study has never been conducted to verify the effectiveness of the CDSS in ventilator weaning before. In this study, the CDSS capable of predicting weaning outcome and reducing duration of ventilator support for patients has been verified.

Methods

A total of 380 patients admitted to the respiratory care center of the hospital were randomly assigned to either control or study group. In the control group, patients were weaned with traditional weaning method, while in the study group, patients were weaned with CDSS monitored by physicians. After excluding the patients who transferred to other hospitals, refused further treatments, or expired the admission period, data of 168 and 144 patients in the study and control groups, respectively, were used for analysis.

Results

The results show that a sensitivity of 87.7% has been achieved, which is significantly higher (p<0.01) than the weaning determined by physicians (sensitivity: 61.4%). Furthermore, the days using mechanical ventilator for the study group (38.41 ± 3.35) is significantly (p<0.001) shorter than the control group (43.69 ± 14.89), with a decrease of 5.2 days in average, resulting in a saving of healthcare cost of NT$45,000 (US$1,500) per patient in the current Taiwanese National Health Insurance setting.

Conclusions

The CDSS is demonstrated to be effective in identifying the earliest time of ventilator weaning for patients to resume and sustain spontaneous breathing, thereby avoiding unnecessary prolonged ventilator use and decreasing healthcare cost.

[Weaning from prolonged mechanical ventilation in neurological weaning units: an evaluation of the German Working Group for early Neurorehabilitation]

BACKGROUND

A significant proportion of patients with long-term mechanical ventilation (MV) and difficult or prolonged weaning suffer from primary or secondary neurological conditions and concomitant functional disorders, in addition to respiratory problems. Therefore, these patients are treated in neurological weaning departments.

MATERIAL AND METHODS

Using a questionnaire members of the German Working Group for early neurorehabilitation were interviewed with respect to the structure of weaning facilities, weaning strategies, patient characteristics and treatment outcome of patients admitted for weaning in 2009.

RESULTS

In the year 2009 a total of 1,486 patients were admitted to 7 participating neurological weaning units. The primary diagnosis was a neurological condition in 97.5% of the patients. In 62.9% of the patients the neurological condition was considered to be primarily responsible for the MV, 22.8% demonstrated pulmonary factors and for 3.0% a cardiac condition was determined to be decisive. In 5.0% of the patients it was not possible to ascertain a single cause or factor. Weaning was successful in 69.8% of all cases, 64.9% (965 patients) were released from the facility without MV, 274 patients (18.4%) were released with MV, 61.3% of these (168 patients) were referred to other rehabilitation facilities or into the care of the family physician and 38.7% (106 patients) were transferred to other hospitals due to special medical problems. The total mortality rate was 16.6% (247 patients deceased).

CONCLUSIONS

In this first comprehensive evaluation of German neurological weaning centers for patients with long-term MV, structures and treatment outcomes were compared with recent results from the literature.

Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial

IMPORTANCE

Patients requiring prolonged mechanical ventilation (>21 days) are commonly weaned at long-term acute care hospitals (LTACHs). The most effective method of weaning such patients has not been investigated.

OBJECTIVE

To compare weaning duration with pressure support vs unassisted breathing through a tracheostomy collar in patients transferred to an LTACH for weaning from prolonged ventilation.

DESIGN, SETTING, AND PARTICIPANTS

Between 2000 and 2010, a randomized study was conducted in tracheotomized patients transferred to a single LTACH for weaning from prolonged ventilation. Of 500 patients who underwent a 5-day screening procedure, 316 did not tolerate the procedure and were randomly assigned to receive weaning with pressure support (n = 155) or a tracheostomy collar (n = 161). Survival at 6- and 12-month time points was also determined.

MAIN OUTCOME MEASURE

Primary outcome was weaning duration. Secondary outcome was survival at 6 and 12 months after enrollment.

RESULTS

Of 316 patients, 4 were withdrawn and not included in analysis. Of 152 patients in the pressure-support group, 68 (44.7%) were weaned; 22 (14.5%) died. Of 160 patients in the tracheostomy collar group, 85 (53.1%) were weaned; 16 (10.0%) died. Median weaning time was shorter with tracheostomy collar use (15 days; interquartile range [IQR], 8-25) than with pressure support (19 days; IQR, 12-31), P = .004. The hazard ratio (HR) for successful weaning rate was higher with tracheostomy collar use than with pressure support (HR, 1.43; 95% CI, 1.03-1.98; P = .033) after adjusting for baseline clinical covariates. Use of the tracheostomy collar achieved faster weaning than did pressure support among patients who did not tolerate the screening procedure between 12 and 120 hours (HR, 3.33; 95% CI, 1.44-7.70; P = .005), whereas weaning time was equivalent with the 2 methods in patients who did not tolerate the screening procedure within 0 to 12 hours. Mortality was equivalent in the pressure-support and tracheostomy collar groups at 6 months (55.92% vs 51.25%; 4.67% difference, 95% CI, -6.4% to 15.7%) and at 12 months (66.45% vs 60.00%; 6.45% difference, 95% CI, -4.2% to 17.1%).

CONCLUSION AND RELEVANCE

Among patients requiring prolonged mechanical ventilation and treated at a single long-term care facility, unassisted breathing through a tracheostomy, compared with pressure support, resulted in shorter median weaning time, although weaning mode had no effect on survival at 6 and 12 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01541462.

Reinstitution of mechanical ventilation within 14 days as a poor predictor in prolonged mechanical ventilation patients following successful weaning

Although many parameters were investigated about weaning and mortality in critical patients in intensive units, no studies have yet investigated predictors in prolonged mechanical ventilation (PMV) patients following successful weaning. A cohort of 142 consecutive PMV patients with successful weaning in our respiratory care center was enrolled in this study. Successful weaning is defined as a patient having smooth respiration for more than 5 days after weaning. The results showed as follows: twenty-seven patients (19%) had the reinstitution within 14 days, and 115 patients (81%) had the reinstitution beyond 14 days. Renal disease RIFLE-LE was associated with the reinstitution within 14 days (P = 0.006). One year mortality rates showed significant difference between the two groups (85.2% in the reinstitution within 14 days group versus 53.1% in the reinstitution beyond 14 days; P < 0.001). Kaplan-Meier analysis showed that age ≥70 years (P = 0.04), ESRD (P = 0.02), and the reinstitution within 14 days (P < 0.001) were associated with one-year mortality. Cox proportional hazards regression model showed that only the reinstitution within 14 days was the independent predictor for mortality (P < 0.001). In conclusion, the reinstitution within 14 days was a poor predictor for PMV patients after successful weaning.

Testing the prognostic value of the rapid shallow breathing index in predicting successful weaning in patients requiring prolonged mechanical ventilation

OBJECTIVE

The study objective was to assess the prognostic value of the rapid shallow breathing index (RSBI) in predicting successful weaning of patients from prolonged mechanical ventilation (PMV) in long-term acute care (LTAC) facilities. The RSBI predicts successful ventilator weaning in acutely ill patients. However, its value in PMV is unclear.

METHODS

A retrospective cohort study of patients receiving PMV in LTAC facilities was performed. RSBI was measured daily, with weaning per protocol. Initial, mean, and final RSBI; RSBI ≤ 105; rate of change; and variability were assessed.

RESULTS

Twenty-five of 52 patients were weaned from PMV. Only the mean RSBI and the RSBI on the last day of weaning predicted success (78.7 ± 14.2 vs 99.3 ± 30.2, P = .007; 71.7 ± 31.2 vs 123.3 ± 92.5, P = .005, respectively). RSBI variability and rate of change were different between groups (coefficient of variation, .37 ± .12 vs .51 ± .30, P = .02, rate of change: -3.40 ± 9.40 vs 4.40 ± 11.1 RSBI points/day, P = .005, weaned vs failed).

CONCLUSION

Although isolated RSBI measurements do not predict successful weaning from PMV, RSBI trends may have prognostic value.

A comparison of seriously ill patients with or without AIDS requiring prolonged mechanical ventilation

PURPOSE

The aim of this study was to compare differences in underlying diagnoses, weaning outcomes, discharge disposition, and survival in prolonged mechanical ventilator (PMV)-dependent patients with and without AIDS.

METHODS

Ninety consecutive AIDS patients requiring PMV were retrospectively matched with 90 clinically similar non-AIDS patients to form matched cohorts to determine differences in their outcomes.

RESULTS

AIDS patients had more acute diagnoses requiring PMV, whereas non-AIDS patients had more chronic diagnoses (P < .001). Weaning outcomes were alike with 31 (35%) AIDS and 37 (41%) non-AIDS patients successfully weaned. More AIDS patients went home, and fewer, to nursing facilities (P = .04). In each cohort, successfully weaned patients had significantly longer survival than their unweaned counterparts (all P < .001). Successful weaning reduced the risk of death in AIDS and non-AIDS patients (hazard ratios, 0.29 and 0.20; 95% confidence intervals, 0.17-0.50 and 0.11-0.36, respectively; all P < .001).

CONCLUSIONS

AIDS had little effect on weaning success or survival. Successful weaning increased survival regardless of a diagnosis of AIDS. The AIDS patients had more home discharges and fewer to nursing facilities, which likely resulted from the AIDS patients having more acute illnesses leading to PMV than the non-AIDS patients.

Outcomes of prolonged mechanic ventilation: a discrimination model based on longitudinal health insurance and death certificate data

BACKGROUND

This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factors associated with survival after PMV, and (3) the number of days alive free of hospital stays requiring mechanical ventilation (MV) care after PMV.

METHODS

This is a retrospective cohort study based on secondary analysis of prospectively collected data in the national health insurance system and governmental data on death registry in Taiwan. It used data for a nationally representative sample of 25,482 patients becoming under PMV (> = 21 days) during 1998-2003. We calculated survival rates for the 4 years after PMV, and adopted logistic regression to construct prediction models for 3-month, 6-month, 1-year, and 2-year survival, with data of 1998-2002 for model estimation and the 2003 data for examination of model performance. We estimated the number of days alive free of hospital stays requiring MV care in the immediate 4-year period after PMV, and contrasted patients who had low survival probability with all PMV patients.

RESULTS

Among these patients, the 3-month survival rate was 51.4%, and the 1-year survival rate was 31.9%. Common health conditions with significant associations with poor survival included neoplasm, acute and unspecific renal failure, chronic renal failure, non-alcoholic liver disease, shock and septicaemia (odd ratio < 0.7, p < 0.05). During a 4-year follow-up period for patients of year 2003, the mean number of days free of hospital stays requiring MV was 66.0 in those with a predicted 6-month survival rate < 10%, and 111.3 in those with a predicted 2-year survival rate < 10%. In contrast, the mean number of days was 256.9 in the whole sample of patients in 2003.

CONCLUSIONS

Neoplasm, acute and unspecific renal failure, shock, chronic renal failure, septicemia, and non-alcoholic liver disease are significantly associated with lower survival among PMV patients. Patients with anticipated death in a near future tend to spend most of the rest of their life staying in hospital using MV services. This calls for further research into assessing PMV care need among patients at different prognosis stages of diseases listed above.

Physical training is beneficial to functional status and survival in patients with prolonged mechanical ventilation

BACKGROUND/PURPOSE

Early physical training is necessary for severely deconditioned patients undergoing prolonged mechanical ventilation (PMV), because survivors often experience prolonged recovery. Long-term outcomes after physical training have not been measured; therefore, we investigated outcome during a 1-year period after physical training for the PMV patients.

METHODS

We conducted a prospective randomized control trial in a respiratory care center. Thirty-four patients were randomly assigned to the rehabilitation group (n = 18) and the control group (n = 16). The rehabilitation group participated in supervised physical therapy training for 6 weeks, and continued in an unsupervised maintenance program for 6 more weeks. The functional independence measurement (FIM) was used to assess functional status. Survival status during the year after enrollment, the number of survivors discharged, and the number free from ventilator support were collected. These outcome parameters were assessed at entry, immediately after the 6 weeks physical therapy training period, after 6 weeks unsupervised maintenance exercise program, and 6 months and 12 months after study entry.

RESULTS

The scores of total FIM, motor domain, cognitive domain, and some sub-items, except for the walking/wheelchair sub-item, increased significantly in the rehabilitation group at 6 months postenrollment, but remained unchanged for the control group. The eating, comprehension, expression, and social interaction subscales reached the 7-point complete independence level at 6 months in the rehabilitation group, but not in the control group. The 1-year survival rate for the rehabilitation group was 70%, which was significantly higher than that for the control group (25%), although the proportion of patients discharged and who were ventilator-free in the rehabilitation and control groups did not differ significantly.

CONCLUSION

Six weeks physical therapy training plus 6 weeks unsupervised maintenance exercise enhanced functional levels and increased survival for the PMV patients compared with those with no such intervention. Early physical therapy interventions are needed for the PMV patients in respiratory care centers.

Intrinsic apoptosis in mechanically ventilated human diaphragm: linkage to a novel Fos/FoxO1/Stat3-Bim axis

Mechanical ventilation (MV) is a life-saving measure in many critically ill patients. However, prolonged MV results in diaphragm dysfunction that contributes to the frequent difficulty in weaning patients from the ventilator. The molecular mechanisms underlying ventilator-induced diaphragm dysfunction (VIDD) remain poorly understood. We report here that MV induces myonuclear DNA fragmentation (3-fold increase; P<0.01) and selective activation of caspase 9 (P<0.05) and Bcl2-interacting mediator of cell death (Bim; 2- to 7-fold increase; P<0.05) in human diaphragm. MV also statistically significantly down-regulates mitochondrial gene expression and induces oxidative stress. In cultured muscle cells, we show that oxidative stress activates each of the catabolic pathways thought to underlie VIDD: apoptotic (P<0.05), proteasomal (P<0.05), and autophagic (P<0.01). Further, silencing Bim expression blocks (P<0.05) oxidative stress-induced apoptosis. Overlapping the gene expression profiles of MV human diaphragm and H₂O₂-treated muscle cells, we identify Fos, FoxO1, and Stat3 as regulators of Bim expression as well as of expression of the catabolic markers atrogin and LC3. We thus identify a novel Fos/FoxO1/Stat3-Bim intrinsic apoptotic pathway and establish the centrality of oxidative stress in the development of VIDD. This information may help in the design of specific drugs to prevent this condition.

Survival in Patients Receiving Prolonged Ventilation: Factors that Influence Outcome

Background:

Prolonged mechanical ventilation is increasingly common. It is expensive and associated with significant morbidity and mortality. Our objective is to comprehensively characterize patients admitted to a Ventilator Rehabilitation Unit (VRU) for weaning and identify characteristics associated with survival.

Methods:

182 consecutive patients over 3.5 years admitted to Temple University Hospital (TUH) VRU were characterized. Data were derived from comprehensive chart review and a prospectively collected computerized database. Survival was determined by hospital records and social security death index and mailed questionnaires.

Results:

Upon admission to the VRU, patients were hypoalbuminemic (albumin 2.3 ± 0.6 g/dL), anemic (hemoglobin 9.6 ± 1.4 g/dL), with moderate severity of illness (APACHE II score 10.7 + 4.1), and multiple comorbidities (Charlson index 4.3 + 2.3). In-hospital mortality (19%) was related to a higher Charlson Index score (P = 0.006; OR 1.08–1.6), and APACHE II score (P = 0.016; OR 1.03–1.29). In-hospital mortality was inversely related to admission albumin levels (P = 0.023; OR 0.17–0.9). The presence of COPD as a comorbid illness or primary determinant of respiratory failure and higher VRU admission APACHE II score predicted higher long-term mortality. Conversely, higher VRU admission hemoglobin was associated with better long term survival (OR 0.57–0.90; P = 0.0006).

Conclusion:

Patients receiving prolonged ventilation are hypoalbuminemic, anemic, have moderate severity of illness, and multiple comorbidities. Survival relates to these factors and the underlying illness precipitating respiratory failure, especially COPD.

The difficult-to-wean patient

Up to 20% of patients requiring mechanical ventilation will suffer from difficult weaning (the need of more than 7 days of weaning after the first spontaneous breathing trial), which may depend on several reversible causes: respiratory and/or cardiac load, neuromuscular and neuropsychological factors, and metabolic and endocrine disorders. Clinical consequences (and/or often causes) of prolonged mechanical ventilation comprise features such as myopathy, neuropathy, and body composition alterations and depression, which increase the costs, morbidity and mortality of this. These difficult-to-wean patients may be managed in two type of units: respiratory intermediate-care units and specialized regional weaning centers. Two weaning protocols are normally used: progressive reduction of ventilator support (which we usually use), or progressively longer periods of spontaneous breathing trials. Physiotherapy is an important component of weaning protocols. Weaning success depends strongly on patients&#x2019; complexity and comorbidities, hospital organization and personnel expertise, availability of early physiotherapy, use of weaning protocols, patients&#x2019; autonomy and families&#x2019; preparation for home discharge with mechanical ventilation.

Chronic critical illness: prevalence, profile, and pathophysiology

The syndrome of chronic critical illness has well-documented emotional, social, and financial burdens for individuals, caregivers, and the health care system. The purpose of this article is to provide experienced acute and critical care clinicians with essential information about the prevalence and profile of the chronically critically ill patient needed for comprehensive care. In addition, pathophysiology contributing to chronic critical illness is addressed, though the exact mechanism underlying the conversion of acute critical illness to chronic critical illness is unknown. Clinicians can use this information to identify at-risk intensive care unit patients and to institute proactive care to minimize burden and distress experienced by patients and their caregivers.

A proposal of a new model for long-term weaning: respiratory intensive care unit and weaning center

BACKGROUND

Respiratory intermediate care units (RICU) are hospital locations to treat acute and acute on chronic respiratory failure. Dedicated weaning centers (WC) are facilities for long-term weaning.

AIM

We propose and describe the initial results of a long-term weaning model consisting of sequential activity of a RICU and a WC.

METHODS

We retrospectively analysed characteristics and outcome of tracheostomised difficult-to wean patients admitted to a RICU and, when necessary, to a dedicated WC along a 18-month period.

RESULTS

Since February 2008 to November 2009, 49 tracheostomised difficult-to wean patients were transferred from ICUs to a University-Hospital RICU after a mean ICU length of stay (LOS) of 32.6 +/- 26.6 days. The weaning success rate in RICU was 67.3% with a mean LOS of 16.6 +/- 10.9 days. Five patients (10.2%) died either in the RICU or after being transferred to ICU, 10 (20.4%) failed weaning and were transferred to a dedicated WC where 6 of them (60%) were weaned. One of these patients was discharged from WC needing invasive mechanical ventilation for less than 12h, 2 died in the WC, 1 was transferred to a ICU. The overall weaning success rate of the model was 79.6%, with 16.3% and 4.8% in-hospital and 3-month mortality respectively. The model resulted in an overall 39 845 +/- 22 578 euro mean cost saving per patient compared to ICU.

CONCLUSION

The sequential activity of a RICU and a WC resulted in additive weaning success rate of difficult-to wean patients. The cost-benefit ratio of the program warrants prospective investigations.

Chronic critical illness

Although advances in intensive care have enabled more patients to survive an acute critical illness, they also have created a large and growing population of chronically critically ill patients with prolonged dependence on mechanical ventilation and other intensive care therapies. Chronic critical illness is a devastating condition: mortality exceeds that for most malignancies, and functional dependence persists for most survivors. Costs of treating the chronically critically ill in the United States already exceed $20 billion and are increasing. In this article, we describe the constellation of clinical features that characterize chronic critical illness. We discuss the outcomes of this condition including ventilator liberation, mortality, and physical and cognitive function, noting that comparisons among cohorts are complicated by variation in defining criteria and care settings. We also address burdens for families of the chronically critically ill and the difficulties they face in decision-making about continuation of intensive therapies. Epidemiology and resource utilization issues are reviewed to highlight the impact of chronic critical illness on our health care system. Finally, we summarize the best available evidence for managing chronic critical illness, including ventilator weaning, nutritional support, rehabilitation, and palliative care, and emphasize the importance of efforts to prevent the transition from acute to chronic critical illness. As steps forward for the field, we suggest a specific definition of chronic critical illness, advocate for the creation of a research network encompassing a broad range of venues for care, and highlight areas for future study of the comparative effectiveness of different treatment venues and approaches.

Outcomes of hemodialysis patients in a long-term care hospital setting: a single-center study

BACKGROUND

Long-term care hospitals (LTCHs) provide intermediary care after an acute-care hospitalization and usually furnish care to patients with complex medical problems. Outcomes of hemodialysis patients admitted to LTCHs, which includes patients with either end-stage renal disease (ESRD) or acute kidney injury (AKI) requiring dialysis therapy, are not known.

STUDY DESIGN

Observational study.

SETTING & PARTICIPANTS

All consecutive hemodialysis patients admitted to an LTCH.

PREDICTORS

Demographic characteristics, comorbid and laboratory variables, ESRD, and AKI status during LTCH stay.

OUTCOMES

Disposition from LTCHs was classified as discharge to home, nursing home, death in LTCH or hospice care, and re-admission to the hospital. In patients with AKI, renal recovery was defined as discontinuation of dialysis therapy before meeting disposition outcomes.

RESULTS

96 of 206 (46.6%) patients had ESRD, whereas 110 of 206 (53.3%) developed AKI requiring dialysis therapy during the acute-care hospitalization. 63 of 206 (31%) were discharged to home, 11 of 206 (5.4%) died or transferred to hospice, 81 of 206 (40%) went to a nursing home, and 49 of 206 (24%) were re-admitted to a hospital; mortality after re-admission was 32%. Older age (OR, 0.96; 95% CI, 0.93-0.98), diabetes mellitus (OR, 0.45; 95% CI, 0.23-0.94), number of re-admissions to the hospital (OR, 0.38; 95% CI, 0.18-0.78), aminoglycoside use (OR, 0.16; 95% CI, 0.04-0.64), and duration of hospitalization before LTCH admission (OR, 0.96; 95% CI, 0.94-0.99) were associated with lower odds of discharge to home. Of 110 patients with AKI requiring dialysis therapy, 30% (33 patients) discontinued dialysis therapy, whereas 70% were deemed to have ESRD on discharge.

LIMITATIONS

Retrospective observational study.

CONCLUSIONS

Most dialysis patients at LTCHs are either re-admitted to acute-care hospitals or require nursing home placement. Only 30% of patients with AKI recover sufficiently to discontinue dialysis therapy, whereas 70% are deemed to have ESRD.

Patients' characterization, hospital course and clinical outcomes in five Italian respiratory intensive care units

BACKGROUND

Respiratory intensive care units (RICU) dedicated to weaning could be suitable facilities for clinical management of "post-ICU" patients.

METHODS

We retrospectively analyzed the time course of patients' characteristics, clinical outcomes and medical staff utilization in five Italian RICUs by comparing three periods of 5 consecutive years (from 1991 to 2005).

RESULTS

A total of 3,106 patients (age 76 +/- 4 years; 72% males) were analyzed. The number of co-morbidities per patient (from 1.8 to 3.0, p = 0.05) and the previous intensive care unit (ICU) stay (from 25 to 32 days, p = 0.002) increased over time. The doctor-to-patient ratio significantly decreased over time (from 1:3 to 1:5, p < 0.01), whereas the physiotherapist-to-patient ratio mildly increased (from 1:6 to 1:4.5, p < 0.05). The overall weaning success rate decreased (from 87 to 66%, p < 0.001), and the discharge destination changed (p < 0.001) over time; fewer patients were discharged to home (from 22 to 10%), and more patients to nursing home (from 3 to 6%), acute hospitals (from 6 to 10%) and rehabilitative units (from 70 to 75%). The mortality rate increased over time (from 9 to 15%). Significant correlations between the doctor-to-patient ratio and the rates of weaning success (r = 0.679, p = 0.005), home discharge (r = 0.722, p = 0.002) and the RICU length of stay (LOS) (r = -0.683, p = 0.005) were observed.

CONCLUSIONS

The clinical outcomes of our units worsened over 15 years, likely as consequence of admitting more severely ill patients. The potential further negative influence of reduced medical staff availability on weaning success, home discharge and LOS warrants future prospective investigations.

Contradictions in end-of-life decisions for self and other, expressed by relatives of chronically ventilated patients

OBJECTIVES

In certain populations, social, legal, and religious factors may influence end-of-life decisions in ventilator-dependent patients. This study aims to evaluate attitudes of first-degree relatives of chronically ventilated patients in Israel, toward end-of-life decisions regarding their loved ones, themselves, and unrelated others.

MATERIALS AND METHODS

The study was conducted in a chronic ventilation unit. First-degree family members of chronically ventilated patients were interviewed about their end-of-life attitudes for patients with end-stage diseases. Distinctions were made between attitudes in the case of their ventilated relatives, themselves, and unrelated others; between conscious and unconscious patients; and between a variety of interventions.

RESULTS

Thirty-one family members of 25 patients were interviewed. Median length of ventilation at the time of the interview was 13.4 months. Most interviewees wanted further interventions for their ventilated relatives, yet, for themselves, only 21% and 18% supported chronic ventilation and resuscitation, respectively, and 48% would want to be disconnected from the ventilator. Interventions were more likely to be endorsed for others (vs self), for the conscious self (vs unconscious self), and for artificial feeding (vs chronic ventilation and resuscitation). Interviewees were reluctant to disconnect patients from a ventilator.

CONCLUSIONS

Family members often want escalation of treatment for their ventilated relatives; however, most would not wish to be chronically ventilated or resuscitated under similar circumstances. Advance directives may reconcile people's wishes at the end of their own lives with their reticence to make decisions regarding others.

Predictors of successful weaning from prolonged mechanical ventilation in Taiwan

BACKGROUND

For adult patients on prolonged mechanical ventilation (PMV, >/=21 days), successful weaning has been attributed to various factors. The purpose of this study was to describe patient outcomes, weaning rates and factors in successful weaning at a hospital-based respiratory care center (RCC) in Taiwan.

METHODS AND RESULTS

This was a retrospective observational study performed in a 24-bed RCC over six years. A total of 1307 patients on PMV were included in the study. The overall survival rate was 62%. Fifty-six percent of patients were successfully weaned. Unsuccessfully weaned patients had higher MICU transfer rates, higher Acute Physiology and Chronic Health Evaluation II scores, longer duration of RCC stay, higher rates of being bed-ridden prior to admission, increased hemodialysis rates, higher modified Glasgow Coma Scale scores, higher rapid shallow breathing index, lower inspiratory pressure at residual volume (PImax) and lower blood urea nitrogen (BUN) and creatinine levels. Factors found to be associated with unsuccessful weaning were length of RCC stay (OR=1.04, P<0.001), modified GCS score (OR=0.93, P<0.046), PImax (OR=0.97, P<0.001), serum albumin concentration (OR=0.62, P<0.023) and BUN level (OR=1.01, P<0.002).

CONCLUSION

High rates of ventilator independence can be achieved in an RCC setting as an alternative to ICU care. Factors associated with unsuccessful weaning included longer duration of RCC stay, elevated BUN levels and lower modified GCS scores, serum albumin and PImax levels.

The soaring mechanic ventilator utilization under a universal health insurance in Taiwan

OBJECTIVES

The use of mechanic ventilators (MVs) is increasing in many countries. Taiwan's Bureau of National Health Insurance (NHI) launched a new payment program in 2000 to encourage integrated care for mechanically ventilated patients and to reduce the heavy utilization of high-cost intensive care unit. This study examines the trend in MV usage in Taiwan.

METHODS

This study used nationally representative NHI claim data from 1997 to 2004 to examine the MV usage. Total inpatient days and MV usage days were analyzed by piece-wise regression model. We also analyzed the major diagnoses related to MV dependence.

RESULTS

While the total hospital inpatient days increased only 49.41%, MV usage rose 181.75% over the 8-year study period. The increase in number of MV patient-days in ICUs has not been curbed, besides there was an increase in respiratory care center/wards. Acute respiratory failure (ARF), pneumonia and diabetes mellitus were the leading diagnoses for mechanically ventilated patients.

CONCLUSIONS

The new NHI insurance payment program may have helped spark the increased trend in MV usage in Taiwan. The significant impact of insurance incentive on healthcare utilization is a critical issue for policymakers in developing healthcare programs.

Outcome of patients undergoing prolonged mechanical ventilation after critical illness

OBJECTIVE

To examine the longitudinal outcome of a cohort of mechanically ventilated patients admitted to an acute care respiratory unit after critical illness.

DESIGN, SETTING, AND PATIENTS

Prospective, observational study of 210 consecutive patients admitted to a respiratory unit of an acute, tertiary care university hospital, who had an acute critical illness with respiratory failure. The study was powered to develop multivariate regression models to investigate the relationship between patient characteristics and a) liberation from mechanical ventilation and b) survival.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The median time to liberation from mechanical ventilation after respiratory unit admission was 14 days (interquartile range, 6-51). A total of 146 patients (69%) were off mechanical ventilation at 6 months, and 123 patients (61%) were alive at 1 yr. Patients who did not come off mechanical ventilation in the respiratory unit were seven times more likely to die within a year than those who did (odds ratio, 6.55; 95% confidence intervals, 4.04-10.63; p < .001). At least 75% of deaths occurred by consensual withdrawal of life support. Patient activity of daily living scores (0-100 scale) increased progressively from hospital discharge (24 +/- 6) through 3 (54 +/- 21) and 6 months (64 +/- 22) (p < .001). The median cost of hospitalization for all study patients was $149,624 (interquartile range, $102,540-225,843).

CONCLUSIONS

The majority of patients requiring prolonged mechanical ventilation in a respiratory unit after acute critical illness are liberated from mechanical ventilation, survive, and have a steady improvement in the activity of daily living during the first 6 months after discharge. However, a substantial fraction of these patients does not wean from mechanical ventilation and dies from consensual withdrawal of life support after a prolonged and costly hospital stay.

Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study

STUDY OBJECTIVES

This multicenter study was undertaken to characterize the population of ventilator-dependent patients admitted to long-term care hospitals (LTCHs) with weaning programs, and to report treatments, complications, weaning outcome, discharge disposition, and survival in these patients.

DESIGN

Observational study with concurrent data collection.

SETTING

Twenty-three LTCHs in the United States.

PATIENTS

Consecutive ventilator-dependent patients admitted over a 1-year period: March 1, 2002, to February 28, 2003.

RESULTS

A total of 1,419 patients were enrolled in the Ventilation Outcomes Study. Median age of patients was 71.8 years (range, 18 to 97.7 years). Patients averaged 6.9 procedures and treatments during the LTCH hospitalization; median length of stay was 40 days (range, 1 to 365 days). Seven of the 10 most frequent complications treated at the LTCH were infections; congestive heart failure and diabetes mellitus were the most common comorbidities requiring treatment. Outcomes of weaning attempts, scored at LTCH discharge, were 54.1% weaned, 20.9% ventilator dependent, and 25.0% deceased. Median time to wean (n = 766) was 15 days (range, 7 to 30 days). Discharge disposition included 28.8% to home, 49.2% to rehabilitation and extended-care facilities, and 19.5% to short-stay acute hospitals. Nearly one third of patients were known to be alive 12 months after admission to the LTCH.

CONCLUSIONS

Patients admitted to LTCHs for weaning attempts were elderly, with acute-on-chronic diseases, and continued to require considerable medical interventions and treatments. The frequency and type of complications were not surprising following prolonged and aggressive ICU interventions. In the continuum of critical care medicine, more than half of ventilator-dependent survivors of catastrophic illness transferred from the ICU were successfully weaned from prolonged mechanical ventilation in the setting of an LTCH.

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.

An economic evaluation of prolonged mechanical ventilation

OBJECTIVE

Patients who receive prolonged mechanical ventilation have high resource utilization and relatively poor outcomes, especially the elderly, and are increasing in number. The economic implications of prolonged mechanical ventilation provision, however, are uncertain and would be helpful to providers and policymakers. Therefore, we aimed to determine the lifetime societal value of prolonged mechanical ventilation.

DESIGN AND PATIENTS

Adopting the perspective of a healthcare payor, we developed a Markov model to determine the cost effectiveness of providing mechanical ventilation for at least 21 days to a 65-yr-old critically ill base-case patient compared with the provision of comfort care resulting in withdrawal of ventilation. Input data were derived from the medical literature, Medicare, and a recent large cohort study of ventilated patients.

MEASUREMENTS AND MAIN RESULTS

We determined lifetime costs and survival, quality-adjusted life expectancy, and cost effectiveness as reflected by costs per quality-adjusted life-year gained. Providing prolonged mechanical ventilation to the base-case patient cost "dollars"55,460 per life-year gained and "dollars"82,411 per quality-adjusted life-year gained compared with withdrawal of ventilation. Cost-effectiveness ratios were most sensitive to variation in age, hospital costs, and probability of readmission, although less sensitive to postacute care-facility costs. Specifically, incremental costs per quality-adjusted life-year gained by prolonged mechanical ventilation provision exceeded "dollars"100,000 with age >or=68 and when predicted 1-yr mortality was >50%.

CONCLUSIONS

The cost effectiveness of prolonged mechanical ventilation provision varies dramatically based on age and likelihood of poor short- and long-term outcomes. Identifying patients likely to have unfavorable outcomes, lowering intensity of care for appropriate patients, and reducing costly readmissions should be future priorities in improving the value of prolonged mechanical ventilation.