Intensive care units ventilator-dependent patients

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... 

Cordasco EM, Jr., Sivak ED, Percz-Trepichio A. Demographics of long-term ventilator-dependent patients outside the intensive care unit. Cleve Clin J Med 1991 58(6) 505-509. 

Sapijaszko MJ, Brant R, Sandham D, et al. Nonrespiratory predictor of mechanical ventilation dependency in intensive care unit patients. Crit Care Med 1996 24(4) 601-607. 

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. 

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. 

Simonds AK. From intensive care unit to home discharge in the 24 h ventilator dependent patient. In C. Roussos, ed. Mechanical Ventilation from Intensive Care to Home Care. Sheffield European Respiratory Society Journal Ltd, 1998 364—379. 

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. 

Factors that influence the most appropriate communication methods depend on the acuity of the respiratory failure—during an acute intensive care unit episode or for longterm mechanical ventilation the communication status—does the patient have the ability to speak, write, or use communication aids functional abilities—does the patient produce reliable and consistent movement Other factors include the cost, funding resources, patient preference, and skills of the communication partner. 

Meanwhile, years of productive research have demonstrated that patients with chronic respiratory insufficiency can also benefit from mechanical ventilation. As the Preface of this volume mentions their survival as well as their health status may be dependent on long-term ventilatory support. The ever increasing incidence and prevalence of chronic respiratory disease suggests that the use of ventilatory support will markedly increase. However, the techniques and strategies to use it, and when and where (non-intensive care unit, or home), are very different from treating the respiratory failure resulting from acute conditions and in patients with structurally near normal lungs. 

In intensive care units (ICUs), pneumonia is the most frequent nosocomial infection (1-3) and occurs most often as ventilator-associated pneumonia (VAP) in patients on mechanical ventilation. The overall incidence of VAP in different studies varies between 10% and 85%, depending on the patient population and the criteria used to establish the diagnosis. Ventilator-associated pneumonia has been associated with an attributable mortality rate ranging from 13% to 47% (4-7), although this is not a consistent finding (8-10). 

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