Experience in a CAVC Unit

West Park Healthcare Centre, Toronto, Ontario, Canada 

Prolonged mechanical ventilation (PMV) has been defined as the need for ventilatory support for 21 consecutive days for 6 hr/day (1). Patients who require PMV could be classified as chronically critically ill, as they depend on life support for survival. PMV is part of the continuum of critical care medicine. 

Most patients requiring PMV do not need the sophisticated monitoring available in the intensive care unit (ICtJ). However, they are often obliged to remain in the ICU due to their need for PMV. This results in a disproportionately high number of ICU beds occupied by patients requiring PMV, beds that are therefore unavailable for acutely ill patients, requiring intensive care. It also results in patients who are clinically stable and alert, but ventilator dependent, being housed in an environment with at best a minimal rehabilitative focus. 

A recent Canadian report, conducted on behalf of the Ontario Ministry of Health and Long-Term Care (MOHLTC), noted that in Ontario, over a nine-year period, there had been a steady increase in the use of mechanical ventilation (MV) and therefore a concomitant increase in inpatient bed days attributed to PMV (2). The increase in the use of MV has been attributed to the aging of the population as well as the increase in complex chronic diseases and their comorbidities, rather than to the increased availability of technology. This report also highlighted the increasingly important impact of PMV on health care resource utilization, both in the ICU and the broader medical system. 

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A CAVC unit should be led by one or more specialist physicians with experience in ventilation. The physician provides medical leadership and is responsible for the medical assessment and overall management of the patients. Together with the respiratory therapist (RT), the physician is involved in decisions relating to ventilator parameters, interfaces, and airway management. The physician also leads the rapid response team (8) and the cardiac arrest team when on site. 

CAVC units include multidisciplinary teams and are led by a physician, preferably a respiratory or rehabilitation specialist with experience in LTMV. Nurses provide medications, airway care hygiene, and skin care. Respiratory therapists supervise all aspects of ventilation, in collaboration with the physician. Other team members, such as occupational and physical therapists, supervise exercise, mobility, and communication issues. Detailed descriptions of the multidisciplinaiy team are found elsewhere in this text. 

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. 

Since its inception in 1986 in response to the growing need for a more appropriate environment for LTMV patients, our unit has expanded from 5 to 22 beds. For the CAVC unit to be successful, it is important to carefully select patients who meet written admission criteria, to have an interdisciplinary clinical team with technical knowledge and experience, and to have the capability for the ongoing monitoring of ventilation and gas exchange. 

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