Inpatient chronic assisted ventilatory care: a 15-year experience

Successful decannulation of patients with traumatic spinal cord injury: A scoping review

Context: Patients with spinal cord injury (SCI) often require tracheostomy as an immediate life-saving measure. Successful decannulation, or removal of the tracheostomy, improves patient quality of life, function, and physical appearance and is considered an important rehabilitative milestone for SCI patients.Objective: We sought to synthesize the existing published literature on SCI patients undergoing decannulation.Methods: Ovid MEDLINE, Embase, Web of Science, CINAHL, and Cochrane Central Register of Controlled Trials were systematically searched through July 2, 2019 using appropriate keywords and MeSH terms pertaining to tracheostomy and SCI. Searches were human-subject only without language restrictions. Published literature discussing the outcomes of SCI patients who underwent decannulation were screened using inclusion/exclusion criteria determined a priori and reviewed.Results: Twenty-six publications were eligible for review and synthesis out of 1,493 unique articles. Over half of the studies were retrospective case series or reports. The research was nearly all published within the fields of physical medicine and rehabilitation, neurology, and pulmonary/critical care. Three themes emerged from review: (1) interdisciplinary or multidisciplinary tracheostomy team management to optimize decannulation processes, (2) non-invasive intermittent positive-pressure ventilatory support instead of tracheostomy-based ventilator support, and (3) wide variation in the reporting of post-decannulation clinical outcomes.Conclusion: Published research lacks a consistent taxonomy for reporting post-decannulation outcomes in SCI patients. Non-invasive ventilation research could benefit many SCI patients but has been studied in depth primarily by a single authorship group. Further investigation into the socioeconomic and fiscal impact on tracheostomies on SCI patients is warranted.

Severe Protracted Hypophosphatemia in a Patient with Persistent Vegetative State on Long-Term Assisted Respiratory Support

BACKGROUND Phosphorous is an essential component of cell structure and physiology, and is required for energy conservation and expenditure. Severe hypophosphatemia can lead to profound dysfunction and injury affecting most organs and can be life-threatening. It can also compromise weaning of mechanically ventilated patients. Long-term assisted ventilatory care in ambulatory or inpatient settings is an expanding medical service for patients with various forms of persistent or progressive incapacitating diseases. Hypophosphatemia, caused by respiratory alkalosis, has been reported in critical-care settings, but its occurrence in medically stable patients requiring long-term respiratory support has not been thoroughly investigated. CASE REPORT We report the case of a ventilated patient in a chronic vegetative state displaying progressive hypophosphatemia spanning over 3 months, with plasma levels gradually declining to 0.8 mg/dL. Evaluation did not reveal conditions leading to diminished phosphate absorption or enhanced urinary phosphate excretion, but it identified respiratory alkalosis related to a recent increase in target minute-volume ventilation in the adaptive support ventilation (ASV) mode as the cause of hypophosphatemia. Despite the very low plasma phosphate level, the patient was asymptomatic, probably because this type of hypophosphatemia may not represent physiologically significant intracellular phosphate depletion. The respiratory alkalosis resolved upon decreasing the target minute-volume ventilation settings, and serum phosphate was normalized. CONCLUSIONS Since blood gases are not routinely monitored in respiratory and hemodynamically stable patients on long-term respiratory support, hypophosphatemia may herald the development of significant respiratory alkalosis. Assessment of acid-base balance is thus warranted in patients receiving long-term ventilation, especially in those developing hypophosphatemia.

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.

Inpatient pulmonary rehabilitation: does it make sense?

Among the nonpharmacological therapies, pulmonary rehabilitation (PR) is particularly appropriate for patients with chronic respiratory impairment who, despite any optimal drug management, are still symptomatic and experience restriction in every day activities. Pulmonary rehabilitation performed in inpatient, outpatient, or home settings demonstrates short–and long–term clinical efficacy. Although disease severity does not inherently dictate candidacy for exercise training, the degree of physiological and functional impairment may influence setting in which the training should occur. Therefore, inpatient rehabilitation is generally best–suited for the most sick and most disabled patients. The overall results from the literature confirm that the inpatient setting for a PR program is a feasible option and does not necessarily result in higher direct costs when balanced against duration and effectiveness in terms of improved 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.

Sleep, sleep disordered breathing, and nocturnal hypoventilation in children with neuromuscular diseases

Sleep disordered breathing (SDB) is now well recognized in children with neuromuscular diseases (NMD) and may lead to significant morbidity and increased mortality. Predisposing factors to SDB in children with NMD include reduced ventilatory responses, reduced activity of respiratory muscles during sleep and poor lung mechanics due to the underlying neuro-muscular disorder. SDB may present long before signs of respiratory failure emerge. When untreated, SDB may contribute to significant cardiovascular morbidities, neuro-cognitive deficits and premature death. One of the problems in detecting SDB in patients with NMD is the lack of correlation between lung function testing and daytime gas exchange. Polysomnography is the preferred method to evaluate for SDB in children with NMD. When the diagnosis of SDB is confirmed, treatment by non-invasive ventilation (NIV) is usually recommended. However, other modalities of mechanical ventilation do exist and may be indicated in combination with or without other supportive measures.

A systematic review of the experiences of adult ventilator-dependent patients

OBJECTIVES

The objective of this meta-synthesis study was to describe the nature of the experience of adult ventilator-dependent patients.

INCLUSION CRITERIA

This review considered studies utilized qualitative methods to examine the experience of adult with ventilator. The phenomena of interest were experiences of patients who were treated with ventilator for both short term and long term in ICU settings or home settings. The research was limited to studies published in Chinese or in English language.

SEARCH STRATEGY

The searching strategy sought to find both published and unpublished studies. The CINAHL, PubMed, MEDLINE, Cochrane Library, Chinese Periodicals Index and JIB website were used to search the articles. The preliminary keywords were drawn from the natural language terms of the topic, in the title, abstract and subject descriptors.

METHODOLOGICAL QUALITY

Each paper was assessed independently by two reviewers for methodological quality. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument were used to appraisal the methodological quality of the articles. Any disagreements that arose between the reviewers were resolved through discussion with a third reviewer.

DATA SYNTHESIS

Qualitative research findings were pooled and the data analysis process involved synthesizing findings to generate a set of statements that represent the nature of the experiences of ventilator-dependent adult patients. The categories and themes/meta-syntheses were emerged from the analysis process.

RESULTS

A total of 997 papers were identified from various database and hand searches. Nineteen papers were critically appraised and 15 met inclusion criteria. Four papers were excluded because they did not meet the inclusion criteria. Five themes/meta-syntheses emerged from the analysis: 1). The feelings of fear due to being dependent on ventilator and the loss of control of life, 2). Disconnection with reality, 3). Impaired embodiment (body image and body boundary), 4). Construction of coping patterns, 5). Trust and caring relationship.

CONCLUSION

The five themes/meta-syntheses derived from the review represent the patients' experiences in regarding the threatening of the integrity of self, self-other and self-environment relationships, the coping patterns and resilient resources to maintain their self-identify and the meaning of life. These findings also illustrate the resiliency factors for those patients to cope with this stressful situation.The implications to practice include enhancing the trust relationship with health professionals, as well as the nursing actions prior to suction, during the suction procedure and post suction in related to release their psychological distress and empower their resilience factors was suggested.Furthermore, the further research could focus on the development and implementation of support programs for the patients, families, and health professionals, as well as the research regarding the reduction of psychological distress and empower the coping patterns.

Outcome and attitudes toward home tracheostomy ventilation of consecutive patients: a 10-year experience

OBJECTIVES

To describe survival, predictors of long-term outcome and attitudes in patients treated at home by tracheostomy-intermittent positive-pressure ventilation (TIPPV) for respiratory failure during a 10-year period (1995-2004).

METHODS

Seventy-seven consecutive patients were treated by TIPPV at home. Patients were divided into three groups: neuromuscular, pulmonary, and non-pulmonary patients. Effects of TIPPV on survival, factors influencing outcome after TIPPV, and attitudes of patients and caregivers regarding mechanical ventilation were studied.

RESULTS

Forty-one patients (53%) were neuromuscular, 19 (25%) were affected by pulmonary diseases, and 17 (22%) by non-pulmonary diseases. The median survival time after TIPPV in the group was 49 months (range 3-149 months). There was statistically significant longer survival in neuromuscular compared to pulmonary patients (p=0.006), and a trend toward longer survival for non-pulmonary when compared to pulmonary patients (p=0.048). Chronic obstructive pulmonary disease (COPD) patients (n=14) showed the poorest outlook (median survival 26 months, range 3-45 months) and the highest number of emergency readmissions to hospital. The median survival in amyotrophic lateral sclerosis (ALS) patients was 49 months (range 30-61), lower than the whole group of neuromuscular patients. Major tracheostomy complications were low: 2.6%. Multivariate analysis showed that COPD and ALS patients had a three-fold higher risk of death than patients with other diagnoses. Lastly, 64 patients (83%) were pleased they had chosen TIPPV and 69 (90%) would choose it again. Forty-two caregivers (55%) were pleased the patients had chosen home ventilation, but 29 (38%) reported major burdens.

CONCLUSIONS

TIPPV is well-received by the patients, is safe, and provides survival for long periods of time. Underlying conditions (COPD and ALS) might represent important prognostic factors for survival.

A retrospective survey of outpatients with long-term tracheostomy

BACKGROUND

The Respiratory Unit (RU) at Danderyd University Hospital opened in 1982, with the expressed goal of supporting outpatients with long-term tracheostomy. The primary aim of this retrospective study in tracheostomized patients was to compare the need for hospital care in the 2-year period before and after the tracheostomy.

METHODS

Data were collected from patient medical records at the RU, from the National Board of Health and Welfare, Sweden and from the Official Statistics of Sweden. The subjects were RU patients in 1982 (Group 1, n = 27) and in 1997 (Group 2, n = 106) with long-term tracheostomy surviving at least 4 years after the tracheostomy.

RESULTS

Both groups had few and unchanged needs for hospital care after tracheostomy. They spent > or = 96% of their time out of hospital. In 1997, (group 2) the number of patients, diagnoses and need for home mechanical ventilation had increased. Life expectancy was assessed for patients in Group 1. Data showed that they lived as long as an age-matched and gender-adjusted control cohort.

CONCLUSIONS

Long-term tracheostomy may not increase the need for hospital care and does not reduce life expectancy. These clinical observations were made in a setting where patients had regular access to a dedicated outpatient unit.

Cardiopulmonary Rehabilitation and Cancer Rehabilitation. 2. Pulmonary Rehabilitation Review

Pulmonary rehabilitation includes the rehabilitation of not only patients with respiratory failure in need of ventilatory support but also patients with primary pulmonary disease. New advances in medical management now offer treatment to patients with end-stage emphysema, pulmonary hypertension, and interstitial disease, and the principles of rehabilitation can add both function and quality to the lives of these patients. New surgical approaches and better transplantation outcomes that restore pulmonary function have also been introduced. Rehabilitation professionals need to be aware of these advances and be able to incorporate this knowledge into the practice of rehabilitation medicine.

OVERALL ARTICLE OBJECTIVES

(a) To identify major categories of pulmonary disease seen in pulmonary rehabilitation, (b) to know appropriate interventions and support for patients with respiratory failure, (c) to describe the new interventions available for end-stage lung disease, and (d) to describe the appropriate pulmonary rehabilitation for people with pulmonary disease.