Chronic ventilator units

Ankrom reported a five-year experience in a 19-bed chronic ventilator unit located in a SNF, for which there were no predetermined requirements for VAI admission except that the patients do not require intensive monitoring, nursing, or technology (32). Patients had failed weaning trials over several weeks, had a tracheostomy and required LTMV. Of the 95 VAIs, 26 lived more than 12 months 15 patients were weaned, 13 elected to discontinue ventilator support, and 13 were still alive in the nursing home but required LTMV. The one-year survival in a SNF was similar to that of an ICU. Care of VAI in a SNF is less costly than at home (33). 

Ankrom MA, Barofsky L Georas SN, et al. AVhat happens to patients in a nursing home-based, chronic ventilator unit a five-year retrospective review of patients and outcomes. Ann Long-Term Care 1998 6(10) 309-314. 

The level of design complexity and engineering needed for the critical care ventilators is higher than the ventilators used for chronic treatment. However, many of the engineering concepts employed in designing critical care ventilators can also he applied in the simpler chronic care units. Therefore, this chapter focuses on the design of intensive care ventilators. Hence, the terms respirator, mechanical ventilator, or ventilator will be used from this point to refer to the intensive care unit respirators. 

Gracey DR, Viggiano RW, Naessens JM, et aL Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clin Proc 1992 67(2) 131—136. 

Gracey DR, Hardy DC, Koenig GE. The chronic ventilator-dependent unit a lower-cost alternative to intensive care. Mayo Clin Proc 2000 75(5) 445-449. 

Lindsay ME, Bijwadia JS, Schauer WW, et al. Shifting care of chronic ventilator-dependent patients from the intensive care unit to the nursing home. Jt Comm J Qual Saf 2004 30 257-265. 

In a report by Criner et al. (28) from another HCFA Chronic Ventilator Demonstration Project Clinical Unit of 77 patients, in which 74% had medical causes, the findings were similar to Gracey s. Ninety-three percent of patients were discharged, 82% were alive at 6 months, and 61% at 12 months. Eighty-six percent of the patients were completely weaned from mechanical ventilation, 11% required continuous ventilation, and 10% had nocturnal ventilation at the time of discharge. In those discharged, there was a signifrcant increase in functional status at 5 and 12 months. 

At our facility, the Temple University Hospital, which is one of four HCFA Chronic Ventilator-Demonstration sites, the complex and diverse problems of PMV patients are treated by a diverse team comprises pulmonologists, respiratory nurses, nutritionists, psychologists, physical therapists, speech therapists, and a social worker (Fig. 2). This unit emphasizes rehabilitation and restoration of functional status despite requirements for prolonged ventilation. Special needs of patients that require PMV addressed in this unit include evaluation of the optimum form of ventilator support, special attention to swallowing dysfunction, impaired communication skills, psychological dysfunction, nutritional repletion, respiratory muscle and whole body reconditioning, as well as close attention to new or changing medical conditions. 

Votto J, Brancifort JM, Scalise PJ, et aL COPD and other diseases in chronically ventilated patients in a prolonged respiratory care unit a retrospective 20-year survival study. Chest 1998 113(l) 86-90. 

Other challenges may override the medical issues. Financial resources are limited, and in the United States, reimbursement has driven the current care process. These issues will continue to be the major force shaping the nature of care for LTMV patients. The availability of institutions for placement of chronically ventilated patients as well as the infrastructure to manage LTMV patients in the home all depend on funding. Ethical issues also influence the management of chronically ill patients. These issues are considered below. 

The prevalence of PMV depends upon the definition used. Most patients (65-85%) are easily weaned from ventilatory support after less than one week. In a multicenter observational study of >5000 medical and surgical ICU patients, 25% required greater than seven days of MV (23). In the acute physiology and chronic health evaluation III (APACHE III) database of medical and surgical ICUs, one in five patients remained ventilated for at least seven days (24). When the definition of PMV is extended to >21 days, the incidence predictably falls. In a cohort of nearly 600 medical patients admitted to a tertiary care medical intensive care unit, approximately 10% remained invasively ventilated at day 21... 

Each year, over 400,000 patients in the United States receive mechanical ventilation as a result of acute or acute-on-chronic respiratory failure (1,2). About a quarter of acutely ventilated patients repeatedly fail attempts at weaning and may require prolonged mechanical ventilation (PMV) (Fig. 1) (3,4). The proportion of patients experiencing PMV ranges between 0% and 20% (5-13). Out of patients who survive PMV, 9-66% become dependent on long-term mechanical ventilation (LTMV) (4,9,14-21). Two factors account for these wide variations in the outcome. The first factor is differences in patient population. The second one is the nosology of what constitutes PMV and what constitutes LTMV is unsatisfactory. 

A three-month prospective cohort study of 26 Italian RICUs reported on 756 patients (14). Of all patients receiving invasive mechanical ventilation, 61% were tracheotomized and therefore considered ventilator dependent. According to the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the predicted mortality was 22%, while the actual mortality rate was 16%. The results indicate that units with a level of care below ICU can successfiilly manage patients with acute-on-chronic respiratory failure. 

Recent advances in intensive care have resulted in an increased salvage of critically ill patients a number of patients have become dependent upon mechanical ventilation as a chronic form of life support (1). The increased use of prolonged mechanical ventilation (PMV) has led to greater intensive care unit (ICU) bed use, resource consumption, and costs (2,3). It is important to characterize such patients to define treatment goals and expectations, to establish ventilatory care units for their specialized care, and to provide prognostic information for overall survival, morbidities, and health-related quality of life. The goals of this chapter are to provide definitions of PMV, to characterize the patient population requiring this modality of treatment, and to briefly describe a multidiscipUnaiy approach to treatment. 

In the United Kingdom, resources for LTMV patients (ventilated > 21 days) outside of the acute care setting are extremely limited, with few specialist chronic respiratory care centers, despite the fact that LTMV patients are increasing. The following comments describe a management strategy developed by a nurse consultant (NC), to meet the needs of LTMV patients. 

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