Ventilator Dependents Managed

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. 

Schmidt-Ohlemann M. Ventilation in nursing homes. Management of ventilator-dependent patients in inpatient facilities for handicapped—a report of experiences. Med Klin (Munich) 1996 91(suppl 2) 56-58. 

CF patients with severe disease are likely to become progressively ventilator dependent, and NIV should always be combined with careful risk management, rapid access to admission for acute exacerbations, and use of palliative care to control symptoms. Many CF patients report that NIV is most effective at relieving symptoms of SDB and assisting physiotherapy, and less effective in reducing dyspnea. 

Tearl DK, Cox TJ, Hertzog JH. Hospital discharge of respiratory-technology-dependent children role of a dedicated respiratory care discharge coordinator. Respir Care 2006 51 744—749. Simonds AK. Non-invasive Respiratory Support. London Oxford University Press, 2001. Simonds AK. Risk management of the home ventilator dependent patient. Thorax 2006 61(5) 369-371. 

The purpose of this chapter is to describe some of the legal and ethical issues pertinent to the practice of critical care medicine, in particular, to the management of those patients who are stable but remain ventilator dependent with little prospect of ventilator independence. 

Few, if any, patients with NMD should be left to develop unexpected ventilatory failure as appropriate assessment, self-management education, and follow-up will identify disease progression and risk of respiratory complications. When ventilatory failure occurs, tracheostomy tubes can be avoided, for the most part, irrespective of the degree of ventilator dependence, with the exception of those with insufficient bulbar-innervated musculature for speech, deglutition, and airway protection. Those with indwelling tracheostomy tubes should be offered decannulation as part of their rehabilitation, irrespective of the extent of their respiratory muscle failure. The only exceptions to this therapy are patients with advanced bulbar ALS or those with rare facioscapulohumeral muscular dystrophy, who lose all bulbar-innervated muscle function and aspirate saliva to the extent of Sao2 remaining below 95% (13). 

Survival beyond respiratory failure may last months or years [when mechanical ventilation (MV) is used] (1-3). When planning optimal management of care, physicians and health care providers may unintentionally overlook crucial problems regarding the needs of family caregivers who are held hostage in their homes. Those who are severely disabled and ventilator dependent rarely visit their physicians. Furthermore, health care professionals may have limited experience in observing LTMV patients in the home setting. 

There is little doubt that fertility- and productivity-affecting features of soils, such as liquid and electrolyte household management, i.e. the capacity to take up, hold, and pass liquids, ventilation, sorptional capacity, and the transport of dissolved substances, are highly dependent upon the structure and permeability of soil component colloid aggregates [1, 2]. Accordingly, the structure and permeability of mineral component clays are important factors [3]. 

On the first day after discharge, it is advisable for a home visit to be carried out by an experienced practitioner, ideally the case manager, who is able to troubleshoot and address issues that have occurred in the short span of time since discharge. It is also usefiil at this point to ensure that the family and patient are well aware of any follow-up referrals that are going to be needed, i.e., referral back to the respiratory physician or to the critical care team dependant on how practice is agreed locally. Technical support may be needed to address any ventilation issues, alarm, or interface problems. The ventilator will need annual servicing. The family must know whom to contact if they have problems with their ventilator, whether they have second machine available, and how to set it up in such a way that it is simple to connect (14). 

Most children are managed with NPPV (1,50). However, some require invasive ventilation through a tracheostomy. The main indications for a tracheostomy in children are airway abnormalities such as tracheobronchomalacia or tracheal stenosis, chronic disease of prematurity, and NMD (1,51,52). The indications for a tracheostomy are comparable to those of the adult population. They include the persistence of hypercapnia despite NPPV and additional measures such as daytime mouthpiece ventilation, aspiration, and bulbar dysfunction (53). In children, NPPV is more difficult to perform in those who might be 24-hour dependent, than in adults. Infants with primaiy alveolar hypoventilation (Ondine s curse) are preferentially ventilated by means of a tracheostomy (18). Tracheostomy ventilation favors airway inflammation (54) and may affect speech and language development (55). In children with progressive NMD, the decision of a tracheostomy has to be discussed on an individual basis, taking into account the familial environment and the parent s and child s perspective (52,56). In any case, sending children home with invasive ventilation is more difficult than when noninvasive ventilation is used (52). 

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