Intensive care decision making in the seriously ill and elderly

OBJECTIVE: To determine the influence of self-reported preadmission quality of life, hypothetical quality of life and mortality prognosis, and length and intensity of intensive care on decision making in the seriously ill and elderly. DESIGN: Prospective cohort study. SETTING: Medical university. SUBJECTS: Adult inpatients with chronic illness and an estimated 50% 6-month mortality along with patients > or =80 yrs old with an acute illness. INTERVENTIONS: Patients were presented with two scenarios: a) mechanical ventilation for 14 days; and 2) mechanical ventilation for 1 month with tracheostomy and feeding tube placement. A modified time trade-off was used to vary survival and quality of life over plausible ranges. Patients could consent to intensive care or choose care directed at comfort measures. MEASUREMENTS AND MAIN RESULTS: Fifty patients were interviewed. As projected intensive care unit mortality rate or postintensive care unit quality of life decreased, patients were less likely to consent to intensive care. Postintensive care quality of life was as important to patients as intensive care survival estimates. However, prehospitalization quality of life did not significantly influence decision making regarding life-extending treatment. When progressing from the acute intensive care scenario to chronic mechanical ventilation with associated interventions, patients demanded a significant increase in survival and quality of life. Neither race nor previous intensive care unit admission was associated with consent to intensive care. CONCLUSIONS: There is wide variation in preference for aggressive care that does not appear to be influenced by prehospitalization quality of life. However, predicted quality of life appears to be as important as estimates of intensive care unit survival in decision making. When confronted with extended mechanical ventilation and associated care, a significant proportion of patients would accept this care only for an improved prognosis. Length and intensity of intensive care should be incorporated into discussions regarding intensive care.     

Clinical review: Long-term noninvasive ventilation

Noninvasive positive ventilation has undergone a remarkable evolution over the past decades and is assuming an important role in the management of both acute and chronic respiratory failure. Long-term ventilatory support should be considered a standard of care to treat selected patients following an intensive care unit (ICU) stay. In this setting, appropriate use of noninvasive ventilation can be expected to improve patient outcomes, reduce ICU admission, enhance patient comfort, and increase the efficiency of health care resource utilization. Current literature indicates that noninvasive ventilation improves and stabilizes the clinical course of many patients with chronic ventilatory failure. Noninvasive ventilation also permits long-term mechanical ventilation to be an acceptable option for patients who otherwise would not have been treated if tracheostomy were the only alternative. Nevertheless, these results appear to be better in patients with neuromuscular/-parietal disorders than in chronic obstructive pulmonary disease. This clinical review will address the use of noninvasive ventilation (not including continuous positive airway pressure) mainly in diseases responsible for chronic hypoventilation (that is, restrictive disorders, including neuromuscular disease and lung disease) and incidentally in others such as obstructive sleep apnea or problems of central drive.     

Home mechanical ventilation

Recently, interest in the use of mechanical ventilation outside the hospital setting has been increasing. Patients with various types of chronic respiratory failure may benefit from this approach. Evaluation for long-term mechanical ventilation necessitates assessment of the underlying disease process, the goals of the medical team, and the needs of the patient and family. Externally applied negative-pressure devices can provide adequate ventilation for many patients, particularly those with neuromuscular diseases. Positive-pressure ventilation by means of a tracheostomy provides greater control of the airway, allows adjustment of tidal volume and minute ventilation, and may be delivered by portable equipment. Ongoing care and support services in the home must be provided. A variety of mechanical devices and new techniques of ventilator support have made home mechanical ventilation a realistic option for long-term care.     

Long-term management of acute respiratory failure in metabolic myopathy

Objective To describe how patients cope with the proposal of treatment with intermittent artificial ventilation after acute respiratory failure due to progressive respiratory muscle weakness.Design Case series, follow-up study.Setting Neurological intensive care unit (ICU).Patients 7 consecutive patients with metabolic myopathy treated for acute respiratory failure between 1983 and 1992.Interventions Intermittent positive pressure ventilation (IPPV) via tracheostomy.Measurements and results Symptoms of chronic hypoventilation preceded acute respiratory failure for months. With one exception, patients were mainly disabled from respiratory muscle weakness and sleep-related breathing disorders. IPPV was recommended to prevent recurrent respiratory failure. Two of three patients who accepted home IPPV returned to full-time jobs. One patient, who decided against IPPV, died from CO₂ narcosis several months after discharge. All patients adhered to the respiratory regimen once instituted.Conclusions Acute respiratory failure in chronic myopathy is heralded by daytime drowsiness. IPPV, or at least regular monitoring of waking and sleeping partial pressure of carbon dioxide, is highly recommended even if weaning is successful. IPPV improved quality of life. The treatment strategy at discharge from the ICU should be optimal, as patients are reluctant to modify regimens.     

Pressure support ventilation attenuates ventilator-induced protein modifications in the diaphragm

Common medical conditions that require mechanical ventilation include chronic obstructive lung disease, acute lung injury, sepsis, heart failure, drug overdose, neuromuscular disorders, and surgery. Although mechanical ventilation can be a life saving measure, prolonged mechanical ventilation can also present clinical problems. Indeed, numerous well-controlled animal studies have demonstrated that prolonged mechanical ventilation results in diaphragmatic weakness due to both atrophy and contractile dysfunction. Importantly, a recent clinical investigation has confirmed that prolonged mechanical ventilation results in atrophy of the human diaphragm. This mechanical ventilation-induced diaphragmatic weakness is important because the most frequent cause of weaning difficulty is respiratory muscle failure due to inspiratory muscle weakness and/or a decline in inspiratory muscle endurance. Therefore, developing methods to protect against mechanical ventilation-induced diaphragmatic weakness is important.     

Critical illness neuromyopathy and the role of physical therapy and rehabilitation in critically ill patients

Neuromuscular complications of critical illness are common, and can be severe and persistent, with substantial impairment in physical function and long-term quality of life. While the etiology of ICU-acquired weakness (ICUAW) is multifactorial, both direct (ie, critical illness neuromyopathy) and indirect (ie, immobility/disuse atrophy) complications of critical illness contribute to it. ICUAW is often difficult to diagnose clinically during the acute phase of critical illness, due to the frequent use of deep sedation, encephalopathy, and delirium, which impair physical examination for patient strength. Despite its limitations, physical examination is the starting point for identification of ICUAW in the cooperative patient. Given the relative cost, invasiveness, and need for expertise, electrophysiological testing and/or muscle biopsy may be reserved for weak patients with slower than expected improvement on serial clinical examination. Currently there are limited interventions to prevent or treat ICUAW, with tight glycemic control having the greatest supporting evidence. There is a paucity of clinical trials evaluating the specific role of early rehabilitation in the chronic critically ill. However, a number of studies support the benefit of intensive rehabilitation in patients receiving chronic mechanical ventilation. Furthermore, emerging data demonstrate the safety, feasibility, and potential benefit of early mobility in critically ill patients, with the need for multicenter randomized trials to evaluate potential short- and long-term benefits of early mobility, including the potential to prevent the need for prolonged mechanical ventilation and/or the development of chronic critical illness, and other novel treatments on patients' muscle strength, physical function, quality of life, and resource utilization. Finally, the barriers, feasibility, and efficacy of early mobility in both medical and other ICUs (eg, surgical, neurological, pediatric), as well as in the chronic critically ill, have not been formally evaluated and require exploration in future clinical trials.     

Tracheostomy in critically ill patients

Tracheostomy is a common critical care procedure in patients with acute respiratory failure who require prolonged mechanical ventilatory support. Tracheostomy usually is considered if weaning from mechanical ventilation has been unsuccessful for 14 to 21 days. A recent clinical trial suggested that early tracheostomy may benefit patients who are not improving and who are expected to require prolonged respiratory support. In this study, early tracheostomy improved survival and shortened duration of mechanical ventilation. Minimally invasive bedside percutaneous tracheostomy was introduced recently as an alternative to the traditional surgical technique. In expert hands, the 2 techniques are equivalent in complications and safety; however, the bedside percutaneous approach may be more cost-effective. Tracheostomy should be considered early (within the first week of mechanical ventilation) in patients with a high likelihood of prolonged mechanical ventilation. Depending on local medical expertise and costs, either the percutaneous or the surgical technique may be used.     

Definitions and epidemiology of the chronically critically ill

Patients who are chronically critically ill constitute 5-10% of patients with acute respiratory failure but demand a disproportionate share of ICU resources. Epidemiologic studies and clinical trials require definitions for enrollment, and a uniform definition would be ideal to allow comparisons between studies. While a consensus definition exists (≥ 21 consecutive days of mechanical ventilation for ≥ 6 h/d), many study designs have required alternative definitions that include requirement for a tracheostomy, a different period of mechanical ventilation, or admission to a weaning facility. Regardless of definition, studies have indicated that the incidence of chronic critical illness has doubled in recent decades and may double again in the next decade. The overall 1-year survival for chronically critically ill patients is between 40% and 50%, depending on the cohort studied. New clinical prediction rules have been developed to better identify patients who are at high risk and low risk of death. These models could be enhanced by data on functional outcomes for survivors. The healthcare system has been adapting to the increase in chronic critical illness by increasing critical beds in short-term and long-term acute care hospitals, but continued monitoring of resources will be necessary, since the prevalence of chronic critical illness is expected to increase further.     

Mechanical ventilation in the home

Despite advances in the application of mechanical ventilation as a short-term, life-saving technique, intensive care units are increasingly faced with patients who cannot be weaned from ventilatory assistance and who require mechanical ventilation as a long-term, life-supporting necessity. Because of limited resources in health care facilities for the management of chronic ventilator-assisted individuals, home care has become an important option. With careful selection of appropriate candidates, home care for ventilator-assisted individuals can result in not only decreased respiratory symptoms, reduction in hospitalization, and improved physiologic measures, but also an improved quality of life with substantial survival and a reduction in the costs of medical care.     

Patient-ventilator interaction during acute lung injury, and the role of spontaneous breathing: part 1: respiratory muscle function during critical illness

Since the early 1970s there has been an ongoing debate regarding the wisdom of promoting unassisted spontaneous breathing throughout the course of critical illness in patients with severe respiratory failure. The basis of this debate has focused on the clinical relevance of opposite problems. Historically, the term "disuse atrophy" has described a situation wherein sustained inactivity of the respiratory muscles (ie, passive ventilation) results in deconditioning and weakness. More recently it has been referred to as "ventilator-induced diaphragmatic dysfunction." In contrast, "use atrophy" describes a situation where chronic high-tension inspiratory work causes structural damage to the diaphragm and weakness. Both laboratory and clinical studies demonstrated that relatively brief periods of complete respiratory muscle inactivity, as well as intense muscle loading, result in acute inflammation, loss of muscle mass, and weakness. Yet in critical illness other factors also affect respiratory muscle function, including prolonged use of neuromuscular blocking agents, administration of corticosteroids, and sepsis. This makes the attribution of acquired respiratory muscle weakness and ventilator-dependence to either ventilator-induced diaphragmatic dysfunction or loaded breathing extremely difficult. Regardless, the clinical implications of this research strongly suggest that passive mechanical ventilation should be avoided whenever possible. However, promotion of unassisted spontaneous breathing in the acute phase of critical illness also may carry a substantial risk of respiratory muscle injury and weakness. Use of mechanical ventilation modes in a manner that induces spontaneous breathing effort, while simultaneously reducing the work load on the respiratory muscles, is probably sufficient to minimize both problems.     

Critical illness neuromuscular syndromes

Critical illness neuromyopathy (CINM) is the most common peripheral neuromuscular disorder encountered in the ICU. Bilateral diffuse weakness predominant in the proximal part of the limbs after improvement of the acute phase of the critical illness is highly suggestive of CINM. Although muscle and peripheral nerve are often involved in combination, muscle involvement alone is increasingly identified on electrophysiologic investigation, including direct muscle stimulation. Respiratory weakness results in delayed weaning and prolonged mechanical ventilation. Besides muscle immobilization and prolonged sepsis-induced multiorgan failure, which are risk factors for CINM, hyperglycemia and use of corticosteroids might have a deleterious effect on the neuromuscular system in critically ill patients.     

慢性肺源性心脏病急性发作伴多脏器衰竭的护理体会

回顾性总结36例慢性肺源性心脏病急性发作伴多脏器衰竭的护理,认为通过正确有效排痰、合理给氧以及必要时行机械通气以保持呼吸道通畅,采取措施控制感染并预防感染加重或再感染,严密观察病情变化等可以有效提高治疗和护理效果,从而改善病人的生活质量.     

Neuromuscular disease causing acute respiratory failure

In the developed world, Guillain-Barré syndrome and myasthenia gravis account for the majority of cases of acute respiratory failure associated with neuromuscular disease. The 4 components that contribute to respiratory failure are upper-airway dysfunction, inspiratory-muscle weakness, expiratory-muscle weakness, and the pulmonary complications associated with these conditions. Careful observation and objective monitoring are essential to determine the appropriate timing of intubation and mechanical ventilation. Pulmonary function tests that can help predict the need for mechanical ventilation include vital capacity, peak inspiratory pressure, and peak expiratory pressure. The morbidity and mortality of patients who require mechanical ventilation are not insubstantial. This paper will review the mechanisms underlying acute respiratory failure, the clinical assessment of patients, the predictors of the need for mechanical ventilation, and the intensive-care-unit morbidity and mortality of patients with Guillain-Barré syndrome or myasthenia gravis.     

Inspiratory muscle training for intensive care patients: A multidisciplinary practical guide for clinicians

ObjectivesTo describe a multidisciplinary approach to inspiratory muscle training (IMT) for patients in the intensive care unit (ICU).BackgroundInspiratory muscle weakness is a known consequence of prolonged mechanical ventilation, and there is emerging evidence that specific IMT can ameliorate this weakness. However, IMT is not yet standard practice in many ICUs, possibly because of the wide variety of methods reported and a lack of published practical guidelines. While the optimal parameters for IMT are yet to be established, we share our detailed methodology which has been shown to be safe in selected ventilator-dependent patients and is the only approach which has been shown to increase quality of life in ICU patients.MethodsPatients who have experienced invasive mechanical ventilation for at least 7 days can commence IMT in either the ventilator-dependent phase or when weaned from mechanical ventilation. Intensity should be prescribed based on maximum inspiratory pressure, which is measurable through the tracheostomy or endotracheal tube via the ventilator or a respiratory pressure meter. Using a removable threshold device, we recommend high-intensity training (5 sets of 6 breaths at a minimum of 50% of maximum inspiratory pressure) performed once per day, supervised by the physiotherapist, with intensity increased daily such that patients can only just complete the 6th breath in each set.ResultsUsing this high-intensity approach, IMT is likely to improve not only inspiratory muscle strength but also quality of life in patients recently weaned from mechanical ventilation of 7 days' duration or longer. Effective IMT requires a multidisciplinary approach to maximise feasibility, with doctors, nurses, and therapists working closely to optimise conditions for successful IMT.ConclusionsThis multidisciplinary approach to implement IMT in ICU patients should assist clinicians in translating best-available evidence into practice, with the potential to enhance patient recovery.     

The ventilator-dependent child: issues in diagnosis and management

Infants, children, and adolescents with chronic respiratory failure are surviving in increasing numbers and, thereby, producing a significant population of ventilator-dependent pediatric patients. Chronic respiratory failure can occur as a complication of a wide variety of disease states; in pathophysiologic terms, it generally results from either decreased central nervous system output or inadequate force generated by the respiratory pump. Its laboratory hallmark is hypercapnia with or without hypoxemia. Stabilization of the patient with mechanical ventilatory support may permit long-term survival. Management of the ventilator-dependent pediatric patient is a complex task that must begin with an accurate prognostication of each patient's survival and quality of life. Once a decision is made concerning the practicality and appropriateness of long-term ventilatory support, informed choices must be made with respect to need for an artificial airway, mode of ventilation, and location of care. Many younger patients, especially those with intrinsic lung disease (like bronchopulmonary dysplasia), may require a hospital setting for long-term care, whereas others with neuromuscular or central disorders may benefit from being discharged to home. The patient's family must be thoroughly educated in the child's care, and they must be involved in decision-making. A multidisciplinary team of physicians, therapists, nurses, and other professionals is required to deliver optimal care. Outcome is good for most patients who are carefully selected.     

Safety of percutaneous dilational tracheostomy in hematopoietic stem cell transplantation recipients requiring long-term mechanical ventilation

Purpose

Recent reports have shown that the outcome of mechanically ventilated patients after hematopoietic stem cell transplantation (HSCT) has improved. This study was conducted to clarify if percutaneous dilational tracheostomy is safe in this group of patients and to report the outcome of HSCT recipients requiring long-term mechanical ventilation.

Methods

A retrospective review of our 8-year experience with patients with acute respiratory insufficiency after HSCT, requiring long-term mechanical ventilation and percutaneous dilational tracheostomy and an analysis of patient outcomes were made.

Results

Percutaneous dilational tracheostomy was safely performed in all 51 patients. Although 1 patient (2%) developed a pneumothorax that required drainage, stoma infections or severe bleeding complications were not observed. Of the 51 patients in the study, 14 (27%) survived the intensive care unit stay, and 10 of them were ventilated for more than 20 days. The intensive care unit survival rate for the period from 1998 to 2001 was 11% compared with 38% for the period from 2002 to 2005 (P = .053).

Conclusions

Percutaneous dilational tracheostomy can be safely performed on patients with acute respiratory failure after HSCT. This procedure did not result in postoperative wound infections or significant bleeding complications. Furthermore, the results of our study indicate that today even patients with prolonged mechanical ventilation (>20 days) have a chance of long-term survival.     

Managing ventilatory insufficiency and failure in a patient with kyphoscoliosis: a case study

This article reports a case study of ‘Sue’, a 37 year old female who was transferred to a metropolitan hospital's intensive care unit in acute respiratory failure secondary to severe kyphoscoliosis (KS). KS is defined as a deformity of the spine involving both lateral displacement (scoliosis) and anteroposterior angulation (kyphosis). Over time, this anatomical distortion results in ventilatory insufficiency due to muscle weakness. Sue displayed a restrictive lung pattern, evidenced by a decreased vital capacity and tidal volume with severe nocturnal dyspnoea, resulting in raised carbon dioxide levels in arterial blood and decreased oxygenation.

This paper reviews Sue's progress throughout her hospitalisation and examines the key issues involved in her care. Particular attention is given to specific problems encountered on the acute care ward related to oxygen delivery, tracheostomy care, non-invasive ventilation and rehabilitation. The paper highlights the increased acuity of respiratory ward patients who require the use of substantial technological support to optimise their management. Nurses working in these wards need specialised knowledge, excellent patient communication ability and well-developed technical skills. The trend is to treat patients with respiratory failure, either chronic or acute, on wards rather than in critical care units which has promoted the development of a specialised role in respiratory nursing.