Chronic Ventilatory Assistance

Gracey et al. reported the outcomes in 206 consecutive patients admitted to the Mayo Clinic Ventilator-Dependent Unit during a five-year study period (27). Two hundred and six patients who met the current definition of PMV were admitted 92% (190) were discharged of which 77% returned to their homes, and 153 of the patients were weaned totally from mechanical ventilation, whereas 37 remained completely or partially ventilator dependent. Of the patients receiving mechanical ventilation at the time of discharge, 73% received it only noctumally. The four-year survival rate of the patients was 53%. However, a significant number (60%) of patients received prolonged ventilation as a result of postoperative conditions, which may have skewed the results to a more optimistic report. 

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. 

Overall, both these studies suggest that when patients receiving PMV were properly selected, they had an acceptable clinical outcome with a return to preadmission functional status and successful home discharge. 

Patients requiring PMV account for a disproportionate amount of health care costs and resources, with those who are ventilator dependent in the ICU for 21 days accounting for 37% of all ICU costs (29). Therefore, there has been a significant drive to improve outcomes and to increase non-ICU facilities, where such patients can receive appropriate care. The decision to transfer a patient who requires PMV may be difficult. Clinical stability and a determination that the patient s staffing needs will be met are necessary before transfer to a step-down unit. A noninvasive respiratory care unit is less expensive than an ICU, allows for more effective transition home or to a nonacute care location, fosters patient independence, and improves quality of life (Fig. 1). 

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. 

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Avendano M, Wijstra P. Chronic ventilatory assistance in the hospital. In Donner CF, Ambrosino N, Goldstein R, eds. Pulmonary Rehabilitation Efficacy and Scientific Basis. London Arnold, 2005 332-342. 

Fauroux B, Pigeot J, Polkey MI, et al. Chronic stridor caused by laryngomalacia in children. Work of breathing and effects of noninvasive ventilatory assistance. Am J Respir Crit Care Med 2001 164 1874-1878. 

Abbreviations. LTAC, long-term acute care CAVC, chronic assisted ventilatory care SNF, skilled nursing facility. 

Wijkstra PJ, Avendano MA, Goldstein RS. Inpatient chronic assisted ventilatory care. A 15-year experience. Chest 2003 124(3) 850-856. 

Unfortunately, it is not always possible—often because of the lack of family support and the unavailability of home care. One of the most viable alternatives is the chronic assisted ventilatory care unit (CAVC). In this chapter, we will discuss CAVC, based on our experience in such a unit, located in a center that specializes in rehabilitation and complex continuing care center. 

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