Ventilator rehabilitation unit

Figure 2 Multidisciplinary plan of patient care in the ventilator rehabilitation unit at Temple University Hospital. Patients daily care is divided into four components medical, nursing, respiratoiy, and rehabilitative. All four groups deliver the care as indicated daily. Team members meet for discharge planning once a week and communicate with outpatient resources and the outpatient clinic staff. Source From Criner GJ. Respir Care Clin N Am 2002 8 580.

Abbreviations VRU, ventilator rehabilitation unit PEEP, positive end-expiratory pressure Sao2, oxygen saturation SBT, spontaneous breathing trial Fio2, fraction of inspired oxygen CHE, congestive heart failure. 

Gracey DR, Hardy DC, Naessens JM, et al. The Mayo ventilator-dependent rehabilitation unit a 5-year experience. Mayo Clin Proc 1997 72(1) 13-19. 

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. 

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. 

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. 

The unit has demonstrated that ongoing ventilatory support can be safely provided outside of the acute care setting. Its main achievements include providing a safe environment with a rehabilitative focus that will promote functional ability and autonomy among ventilator-assisted individuals (VAI). 

The 1960s witnessed the continued support of some polio patients at home, as well as the introduction of mouthpiece ventilation for long term, even continuous, support at some specialized rehabilitation hospitals (4). The 1960s also ushered in intensive care units (ICUs) that served as specialized centers to treat patients with acute respiratory failure. Sophisticated mechanical ventilators were developed to treat these patients. Some of whom failed to wean and often spent weeks or months in these units because no other facilities were available to adequately care for them. 

Figure 1 The management of respiratory failure in the United States. Many patients are admitted initially to an acute care hospital. If they wean ptomptiy, they may spend time in an LTAC hospital for rehabilitation, and eventually return home. If they fail to wean, they undergo tracheostomy and are transferred to an LTAC when stable. Weaning attempts continue, and a mincnity of patients return home the rest remain at the LTAC or are transferred to a SNF. Patients who deteriorate while at LTACs or at home return to the acute care hospital fOT stabilization. Some patients with chronic respiratory failure do not require acute care but are ventilated noninvasively and remain home. Abbreviations COPD, chronic obstructive pulmonary disease NIV, noninvasive ventilation LTAC, long-term acute care SNF, skilled nursing facility.

NICOLINO AMBROSINO is Director of Respiratory Unit, Cardio-Thoracic Department, University Hospital of Pisa, Italy, Director of Pulmonary Rehabilitation and Weaning Center, Volterra, Italy and is or was Professor at the Universities of Pisa, Pavia, Florence, and Trieste, Italy. Professor Ambrosino s research and clinical activity has been devoted to Respiratory Critical Care, Pulmonary Rehabilitation and Home Respiratory Care. He contributed to the development of the use of non-invasive mechanical ventilation techniques in acute and chronic respiratory failure, with several clinical trials and original experimental studies. Results of his studies have been published in more than 155 peer-reviewed international journals. The former Head of Pulmonary Rehabilitation Working Croup of the European Respiratory Society (ERS), Dr. Ambrosino is a member of various editorial boards of several international journals, has written over 60 books and chapters, 200 articles, and has spoken at over 100 international conferences. 

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