Approach to patients with long-term weaning failure

Efforts to treat reversible disease processes that contribute to ventilator dependency in the intensive care unit (ICU) fail in up to 20% of patients, resulting in prolonged mechanical ventilation (PMV). Resolution of the insults that necessitated ICU admission and mechanical ventilation may be incomplete, and the economic pressure to transfer patients is ever increasing. The choice of post-ICU disposition depends on the patient's clinical condition, the resources of the transfer destination, and whether weaning attempts will continue. This article reviews data from a decade of weaning beyond the ICU, including outcomes of more than 2700 patients with PMV afforded continued attempts at liberation in long-term acute care facilities and other post-ICU weaning venues. Assessment and treatment, weaning strategies, and complications of patients with PMV are described.     

Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference

Patients requiring prolonged mechanical ventilation (PMV) are rapidly increasing in number, as improved ICU care has resulted in many patients surviving acute respiratory failure only to then require prolonged mechanical ventilatory assistance during convalescence. This patient population has clearly different needs and resource consumption patterns than patients in acute ICUs, and specialized venues, management strategies, and reimbursement schemes for them are rapidly emerging. To address these issues in a comprehensive way, a conference on the epidemiology, care, and overall management of patients requiring PMV was held. The goal was to not only review existing practices but to also develop recommendations on a variety of assessment, management, and reimbursement issues associated with patients requiring PMV. Formal presentations were made on a variety of topics, and writing groups were formed to address three specific areas: epidemiology and outcomes, management and care settings, and reimbursement. Each group was charged with summarizing current data and practice along with formulation of recommendations. A working draft of the products of these three groups was then created and circulated among all participants. The document was reworked with input from all concerned until a final product with consensus recommendations on 12 specific issues was achieved.     

Risk factors for and outcomes of prolonged mechanical ventilation in patients received DeBakey type I aortic dissection repairment

BackgroundThis study aimed to identify risk factors for prolonged mechanical ventilation (PMV) and its association with disease prognosis following acute DeBakey type I aortic dissection surgery.MethodsA total of 582 patients who received emergency surgery for acute DeBakey type I aortic dissection from 2014 to 2018 were enrolled in this study. Mechanical ventilation period after surgery longer than 48 hours was defined as postoperative PMV. Multiple logistic regression analysis was used to identify risk factors for PMV. This study also compared short- and long-term outcomes in patients who developed PMV with patients who did not develop this complication. To identify and compare long-term cumulative survival rate, Kaplan-Meier survival curve was plotted.ResultsAmong all enrolled patients, 259 (44.5%) received PMV treatment. Our data suggested that the length of intensive care unit and hospital stay were longer for patients who received PMV treatment. Thirty-day mortality was also higher in patients with PMV than in patients without PMV. Elevated leukocyte count and increased serum cystatin C level upon admission, lower preoperative platelet count and longer cardiopulmonary bypass (CPB) duration were identified as risk factors for PMV. Interestingly, our data suggested that there was no significant difference of survival rate between patients with or without PMV history.ConclusionsPMV after DeBakey type I aortic dissection repair surgery was a common complication and associated with increased short-term mortality rate but did not affect long-term mortality rate. Elevated preoperative leukocyte count, increased preoperative serum cystatin C level, lower preoperative platelet count and longer CPB duration were risk factors for PMV.     

冠状动脉旁路移植术后患者延长机械通气时间的危险因素及近期临床结果分析

目的分析冠状动脉旁路移植术(CABG)后患者延长机械通气(PMV)时间的危险因素及其对近期临床结果的影响。方法回顾性分析阜外心血管病医院2006年1月1日至2008年12月31日行单纯CABG术的4022例患者,单因素及Logistic回归多因素分析影响患者PMV时间的术前、术中、术后的危险因素及PMV与住院期间并发症及其他事件的关系。结果患者术后平均辅助通气(MV)时间19.12 h,中位数为13 h。年龄(OR=1.04,P<0.001)、BMI(OR=0.96,P<0.001)、高血压(OR=1.30,P<0.001)、心绞痛(OR=1.18,P=0.01)、术前心功能NYHA分级(OR=1.20,P=0.002)、病变冠状动脉数量(OR=1.19,P=0.03)、血制品使用(OR=1.97,P<0.001)、术后多巴胺和(或)多巴酚丁胺(OR=1.31,P<0.001)、术后肾上腺素(OR=2.06,P<0.001)、术后去甲肾上腺素(OR=1.67,P<0.001)的使用为CABG术后PMV的独立危险因素。PMV与患者院内并发症(OR=2.10,95%CI:1.75～2.51)、术后主要事件(OR=6.70,95%CI:3.80～11.80)及次要事件(OR=1.28,95%CI:1.02～1.61)的发生有显著相关性。结论高龄、低BMI、高血压、心绞痛发作、心功能低下、病变冠状动脉数量多、血制品及血管活性药物大量使用是CABG术后PMV危险因素。掌握其危险因素,有助于治疗方案的选择、降低患者的并发症发生率及死亡率。     

Risk factors for prolonged mechanical ventilation following surgery for acute type a aortic dissection

BACKGROUND: The aim of this study was to identify predictors of prolonged mechanical ventilation (PMV) following surgery for acute type A aortic dissection (AAAD) and to assess the influence of this complication on clinical outcomes. METHODS AND RESULTS: A total of 243 patients underwent emergency surgery for AAAD in the period of 1997-2006. Ten patients died within 48 h after surgery. The remaining 233 patients were divided into 2 groups according to the duration of mechanical ventilation; less than 48 h (group A: n=149) or 48 h or longer (group B; n=84). Multivariate analysis was used to identify predictors of PMV. Short and late outcomes were compared between groups. Multivariate analysis showed that shock (systolic BP <90 mmHg; p=0.007), postoperative renal dysfunction (creatinine >2.0 mg/dl; p=0.016), coronary artery bypass grafting (CABG) (p=0.017), and limb ischemia (p=0.044) were independent predictors of PMV. There was no significant difference in in-hospital mortality (group A, 2.7% vs group B, 3.6%) or 5-year survival (group A, 85.9% vs group B, 76.8%). CONCLUSIONS: Shock, limb ischemia, CABG, and postoperative renal dysfunction increase the risk for PMV. Knowing the predictors of PMV should help optimize postoperative management of these patients.     

A latent class analysis of prolonged mechanical ventilation patients at a long-term acute care hospital: Subtype differences in clinical outcomes

RationalePatients on prolonged mechanical ventilation (PMV) at Long-Term Acute Care Hospital's (LTACHs) are clinically heterogeneous making it difficult to manage care and predict clinical outcomes.ObjectivesIdentify and describe subgroups of patients on PMV at LTACHs and examine for group differences.MethodsLatent class analysis was completed on data obtained during medical record review at Midwestern LTACH.Main resultsA three-class solution was identified. Class 1 contained young, obese patients with low clinical and co-morbid burden; Class 2 contained the oldest patients with low clinical burden but multiple co-morbid conditions; Class 3 contained patients with multiple clinical and co-morbid burdens. There were no differences in LTACH length of stay [F(2,246) = 2.243, p = 0.108] or number of ventilator days [F(2,246) = 0.641, p = 0.528]. Class 3 patients were less likely to wean from mechanical ventilation [χ²(2, N = 249) = 25.48, p < 0.001] and more likely to die [χ²(2, N = 249) = 23.68, p < 0.001].ConclusionPatient subgroups can be described that predict clinical outcomes. Class 3 patients are at higher risk for poor clinical outcomes when compared to patients in Class 1 or Class 2.     

Stable patients receiving prolonged mechanical ventilation have a high alveolar burden of bacteria

INTRODUCTION: In patients receiving prolonged mechanical ventilation (PMV), quantitative bronchoscopic culture has not been validated for the diagnosis of ventilator-associated pneumonia (VAP). OBJECTIVE: To measure the alveolar burden of bacteria in patients receiving PMV. SETTING: Respiratory care units of a university hospital and a long-term care facility. PATIENTS: Fourteen patients requiring PMV without clinical evidence of pneumonia. MEASUREMENTS: Quantitative culture of BAL from the right middle lobe and lingula. RESULTS: In 29 of 32 lobes, there was growth of at least one organism at > 10(4) cfu/mL. Most lobes had polymicrobial growth. CONCLUSIONS: Stable patients receiving PMV without clinical pneumonia have a high alveolar burden of bacteria. The bacterial burden in most patients exceeds the commonly accepted threshold for diagnosing VAP. The utility of quantitative bronchoscopic culture in the diagnosis of VAP in this patient population requires further study.     

Analysis of risk factors of prolonged mechanical ventilation in patients with severe burn injury

Background

Mechanical ventilation is an essential means of life support for patients with severe burns. However, prolonged mechanical ventilation (PMV) increases the incidence of complications and length of hospital stay. Therefore, studying the risk factors of mechanical ventilation duration is of great significance for reducing the duration of mechanical ventilation, reducing related complications, and improving the success rate of severe burn treatment.

Method

This study was a retrospective study of patients with burns ≥30% of the area admitted to the BICU of Guangzhou Red Cross Hospital affiliated with Jinan University from January 2016 to January 2023 who were mechanically ventilated. Patients were classified into the prolonged mechanical ventilation group if they were mechanically ventilated for ≥21 days. Then, independent risk factors for prolonged mechanical ventilation were determined by logistic regression analysis of the collected data.

Result

Of all the 112 enrolled patients, 79 had prolonged mechanical ventilation, with an incidence of 70.5%. Logistic regression analysis revealed that including abbreviated burn severity index (ABSI%) (P < 0.001), moderate and severe inhalation injury (P = 0.005, P = 0.044), albumin (P = 0.032), lactic acid (P < 0.001) were independent risk factors for prolonged mechanical ventilation. In addition, ventilator-related complications were 44% in the PMV group and 21% in the non-PMV group.

Conclusion

ABSI%, inhalation injury, albumin, and lactic acid on admission are the risk factors for PMV in severe burn patients. In addition, ventilator-related complications were higher in group PMV than in group non-PMV in our study.     

Elevated Tissue Kallikrein Activity in Airway Secretions from Patients with Tracheobronchitis Associated with Prolonged Mechanical Ventilation

The clinical course of patients undergoing prolonged mechanical ventilation is often complicated by the development of purulent tracheobronchitis. The purpose of this study was to assess whether ventilator-associated hypersecretion is associated with elevated levels of tissue kallikrein (TK) activity. TK can induce marked bronchial inflammation in animal models and TK activity is increased in the airway secretions of symptomatic asthmatics. It has not been studied in conditions with predominantly neutrophilic bronchial secretions, although animal data indicate that neutrophil elastase may stimulate TK activity. We measured TK activity in airway secretions of patients undergoing mechanical ventilation for more than 4 weeks (PMV group) and in two comparator groups: patients with cystic fibrosis, who were colonized with Pseudomonas aeruginosa (CF group) and patients undergoing mechanical ventilation for less than one week who did not have clinical evidence of purulent airway secretions (acute mechanical ventilation, AMV group). We also compared the level of neutrophil elastase (NE) activity, an index of neutrophil activation, in the three patient groups. TK and NE activity in the sol phase were measured by the degradation of chromogenic substrates (DL Val-Leu-Arg pNA and N-Methoxy Succinyl Ala-Ala-Pro-Val pNA, respectively). Intergroup differences in cell counts were not significant. However, TK activity was significantly less in the AMV group than in the PMV and cystic fibrosis patients (Kruskal-Wallis ANOVA, p < 0.05). Elastase activity was significantly greater in the CF group (p < 0.05) than in the other two groups. Compared to patients undergoing short-term mechanical ventilation (AMV group), TK activity was elevated in patients with purulent tracheobronchitis associated with prolonged mechanical ventilation (PMV group). The elevation in TK activity in these patients is comparable to levels in sputum from patients with cystic fibrosis (CF group), although the latter had a significantly higher level of NE activity. The observation of increased TK activity in patients with neutrophilic airway inflammation suggests that TK may play a role in modulating inflammation in ventilator-associated tracheobronchitis and may be worthy of further study to determine its source and significance.     

Determinants of prolonged mechanical ventilation in patients with chronic obstructive pulmonary diseases and acute hypercapnic respiratory failure

BACKGROUND: The aim of the present study was to identify early risk factors for prolonged mechanical ventilation (PMV) in chronic obstructive pulmonary disease (COPD) patients admitted to respiratory intensive care units (RICU) for acute hypercapnic respiratory failure. METHODS: PMV was defined as invasive ventilation lasting longer than 7 days. Between January 1, 2000 and December 31, 2005, epidemiological and clinical data on RICU admission day were retrospectively analyzed for eligible patients. Univariate and multiple stepwise logistic regression analyses were used for statistical analysis. RESULTS: A total of 152 patients were eligible for evaluation during the 6-year study period and their mean age was 63+/-12 years. Fifty-one patients died before day 7 after the onset of MV (early death group). Of the remaining 101 patients who survived until day 7, 56 had been weaned successfully (non-PMV group) and 45 continued to receive MV (PMV group). Logistic regression analysis showed that age above 65 (OR=1.98, 95% CI=0.96-4.17, P=0.011), a pH of 7.30 or less measured 12 h after ventilation (OR=2.09, 95% CI=1.17-5.64, P=0.002), an APACHE II score above 20 (OR=3.25, 95% CI=1.58-7.10, P<0.001), development of non-respiratory organ failure (OR=4.67, 95% CI=1.54-9.71, P<0.001), and the presence of shock (OR=4.71, 95% CI=2.14-10.09, P<0.001) were independently associated with PMV. The presence of two factors predicted PMV with a sensitivity of 86% and a specificity of 94%. CONCLUSION: Age, APACHE II score, refractory acidosis, presence of non-respiratory organ failure, and shock on RICU admission day were early determinants of PMV in patients with COPD and acute hypercapnic respiratory failure.     

Causes of prolonged mechanical ventilation after coronary artery bypass surgery

STUDY OBJECTIVE: To evaluate causes of failure to be extubated (FTE) after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective observational study. SETTING: Cardiovascular surgical ICU. PATIENTS: Four hundred patients undergoing CABG surgery. Following surgery, patients were extubated by a standardized respiratory protocol and were assessed at 8, 24, and 48 h. Patients who could not be extubated at 8 h were designated as FTE, and at 24 and 48 h they were labeled as requiring prolonged mechanical ventilation (PMV) > 24 h and PMV > 48 h, respectively. MEASUREMENTS AND RESULTS: One hundred sixty-seven patients (41.75%), 27 patients (6.75%), and 21 (5.25%) patients, respectively, could not be extubated at 8, 24, and 48 h. Depressed level of consciousness was the most common reason for FTE in 58 of 167 patients (34.7%). The main cause of depressed level of consciousness was prolonged sedation due to anesthetic agents (51 patients; 30.5%). Hypoxemia was the most common cause for PMV for > 24 h (15 patients) and PMV > 48 h (13 patients). The causes of hypoxemia were cardiogenic and noncardiogenic pulmonary edema, pneumonia, and "hypoxemia of unknown etiology." Tachypnea due to acid-base disturbances was a reason for FTE and PMV for > 24 h in 27 and 3 patients, respectively. Cardiovascular instability was a rare reason for FTE. Postoperative bleeding was a cause for PMV in 18 patients. Four patients had more than a single reason for FTE at each assessment. Different causes have a variable effect on the duration of mechanical ventilation. CONCLUSION: The causes of PMV are heterogeneous, vary with time, and have a variable impact on the duration of mechanical ventilation required after the patient undergoes CABG surgery.     

Incidence and causes of prolonged mechanical ventilation in children with Down syndrome undergoing cardiac surgery

Introduction

Trisomy 21 is the most common syndrome in children with a 30–50% association with congenital heart disease (CHD). Cardiac surgeries are required in the majority of Down syndrome (DS) with CHD cases. Because of the distinctive abnormalities in their respiratory system, children with DS may require longer positive pressure ventilation after cardiac surgery. The aim of this study is to investigate the incidence and possible risk factors for prolonged mechanical ventilation (PMV) need in DS patients undergoing cardiac surgery.

儿童法洛四联症根治术后机械通气时间延长风险的预测模型建立与内部验证

目的 建立并内部验证预测法洛四联症(tetralogy of Fallot,TOF)根治术后机械通气时间延长(prolonged mechanical ventilation, PMV)风险的列线图模型。 方法 连续入选2019年6月至12月在我院行TOF根治术的6月龄到6岁患儿，并回顾性分析其临床数据。PMV定义为术后机械通气持续时间超过48h。基于入选的患儿做为训练集开发预测PMV风险的列线图模型。采用最小绝对收缩与选择算子(The least absolute shrinkage and selection operator, LASSO)回归模型用于列线图模型的变量选择；应用多因素logistic回归分析来建立预测模型，该模型纳入由LASSO回归模型所选择的所有变量。采用C指数，校准图和决策曲线分析(Decision curve analysis, DCA)评估预测模型的准确性，一致性和临床实用性。采用Bootstrap重复抽样的方法对模型进行内部验证。 结果 入选的109名患儿，分为机械通气延长组（PMV组）（n=32，占29.4%）与非机械通气延长组（非PMV组）（n=77，占70.6%）。PMV组患儿术后机械通气时间显著长于非PMV组（P<0.01）。多因素logistic回归分析显示术前McGoon比<1.5（OR=3.564，95%CI:1.078-11.782，P<0.05），术中较长的体外循环时间（OR=1.020，95%CI:1.007-1.032，P<0.01）和术后较低的左室射血分数（OR=0.885，95%CI:0.792-0.988，P<0.05）为术后PMV的独立预测因素。并且，该模型具有良好的一致性和区分能力，C指数为0.774。模型经过内部验证后，校正曲线表现良好，C指数较高，等于0.756。DCA表明，当阈概率在大于2%且小于76%的范围内，ICU医师做出改变通气策略的干预决定，列线图模型具有很好的临床效果。 结论 我们开发并内部验证一种高精度的列线图模型，以协助ICU医生进行与术后PMV相关的临床决策。然而，在推荐用于临床实践之前，该模型需要进行外部验证。     

Validity of scoring systems to predict risk of prolonged mechanical ventilation after coronary artery bypass graft surgery

STUDY OBJECTIVE: Two scoring systems, (the Spivack scoring system [SSS] and the cardiac risk score [CRS]), have been proposed to predict the risk of prolonged mechanical ventilation (PMV) after coronary artery bypass graft surgery (CABG). The primary objective of this study was to validate the efficacy of these scoring systems to predict the risk of PMV. DESIGN: Prospective observational study. SETTING: Cardiovascular surgical ICU. PATIENTS: Three hundred forty-eight patients underwent CABG. Following surgery, patients were extubated by a standardized respiratory weaning protocol. MEASUREMENTS AND RESULTS: Forty-nine percent of patients had SSS > 0 and had significantly longer duration of mechanical ventilation. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the SSS for failure to extubate at 48 h are 80, 49, 9%, and 98%, respectively. Two hundred thirty-two patients (67.5%), 101 patients (29%), and 12 patients (3.5%) had a CRS of 0 to 4, 5 to 8, and > 8, respectively. Patients with lower scores had shorter duration of mechanical ventilation. The sensitivity, specificity, PPV, and NPV of the CRS for failure to extubate at 10 h are 42, 73, 47% and 69%, respectively. CONCLUSION: The SSS may be used as a preoperative screening tool. A simple questionnaire that includes history of unstable angina, diabetes, congestive heart failure, and smoking prior to hospital admission can be used to calculate the SSS. Patients with SSS 相似文献   

A randomized,controlled, multicenter clinical study of the “improved sitting Wuqinxi” intervention for mechanically ventilated patients in the intensive care unit

Introduction:Mechanical ventilation is a powerful tool for the treatment of various critical emergencies. However, surviving critically ill patients often have poor psychological and physiological outcomes. Prevention of various complications and adverse outcomes of mechanical ventilation is a priority and a challenge in the intensive care unit (ICU). Early intervention is the key to reducing complications and improving outcomes of mechanical ventilation in the ICU. As an auxiliary rehabilitation treatment, the improved sitting Wuqinxi intervention has recognized unique advantages. It has achieved beneficial therapeutic effects during early intervention in clinical practice. It can reduce the incidence of delirium, shorten the duration of mechanical ventilation, and prevent complications and secondary damages related to mechanical ventilation in the ICU. Therefore, the purpose of this study will be to explore the effect of improved sitting Wuqinxi on the clinical outcomes of mechanically ventilated ICU patients.Methods:This prospective, multicenter, randomized, single-blinded, parallel controlled clinical study will involve 160 patients who met the inclusion criteria. The patients will be randomly divided into the experimental and control groups. Both groups will be given standardized comprehensive western medicine treatment (including mechanical ventilation) and routine care in the ICU. Management of the experimental group will also include “improved sitting Wuqinxi,” with the treatment objective to observe the effect of the improved sitting Wuqinxi intervention on the clinical outcomes in mechanically ventilated ICU patients. The outcome measures will include the incidence of complications, duration of mechanical ventilation, length of ICU stay, and cost of hospitalization. In addition, the effect of the improved sitting Wuqinxi intervention on the safety indexes of mechanically ventilated ICU patients will be assessed and the clinical effects of the improved sitting Wuqinxi intervention will be comprehensively evaluated.Discussion:The purpose of this study will be to evaluate the effect of the improved sitting Wuqinxi intervention on the incidence of complications, duration of mechanical ventilation, length of ICU stay, cost of hospitalization, and safety indicators. If successful, it will provide a reliable, simple, and feasible auxiliary rehabilitation treatment scheme for mechanically ventilated ICU patients.     

The Outcomes and Prognostic Factors of the Very Elderly Requiring Prolonged Mechanical Ventilation in a Single Respiratory Care Center

This study investigated the outcomes and the prognostic factors among the very elderly (patients ≥80 years old) requiring prolonged mechanical ventilation (PMV).Between 2006 and 2014, all of the very elderly patients of age 80 or more transferred to respiratory care center (RCC) of a tertiary medical center were retrospectively identified, and only patients who used mechanical ventilation (MV) for >3 weeks were included in this study.A total of 510 very elderly patients undergoing PMV were identified. The mean age of the patients was 84.3 ± 3.3 years, and it ranged from 80 to 96 years. Male comprised most of the patients (n = 269, 52.7%), and most of the patients were transferred to RCC from medical ICU (n = 357, 70.0%). The APACHE II scores on RCC admission was 17.6 ± 6.0. At least 1 comorbidity was found in 419 (82.2%) patients. No significant differences of gender, disease severity, diagnosis, dialysis, laboratory examinations, comorbidities, and outcome were found between octogenarians (aged 80–89) and nonagenarians (aged ≥ 90). The overall in-hospital mortality rate was 21.8%. In the multivariate analysis, patients who had APACHE II score ≥ 15(odds ratio [OR], 2.30, 95% confidence interval [CI], 1.36–3.90), or albumin ≤ 2 g/dL (OR, 3.92, 95% CI, 2.17–7.01) were more likely to have significant in-hospital mortality (P < 0.05).The in-hospital mortality rate of the very elderly PMV patients in our RCC is 21.8%, and poor outcomes in this specific population were found to be associated with a higher APACHE II score and lower albumin level.     

Weaning from prolonged mechanical ventilation

The development of weaning failure and need for PMV is multifactorial in origin, involving disorders of pulmonary mechanics and complications associated with critical illness. The underlying disease process is clearly important when discussing mechanisms of ventilator dependence; interventions therefore must be tailored to individual patients. Unfortunately, the main conclusion that can be drawn from the sum of the studies investigating patients on PMV to date is that an evidence-based approach to weaning is not possible and more research needs to be done. New studies need to incorporate severity-of-illness scores and an assessment of principal and comorbid conditions to allow for comparison of the findings from different centers. The best approach to a patient requiring PMV after exclusion of easily treatable conditions is not known. The literature regarding both acute and chronic cases suggests that a systematic approach to weaning involving the participation of multiple caregivers, including nurses, physicians, and respiratory, physical, and speech therapists facilitates liberation from MV. Although a gradual decrement in ventilator support would seem prudent, Scheinhorn et al have begun to identify a subpopulation of patients who can tolerate an acceleration of the weaning process. Given the known complications associated with MV, it is crucial that further research be performed to identify patients as soon as they are capable of breathing spontaneously. The literature demonstrates through multiple studies that satisfactory patient outcomes are attainable and can be achieved at LTAC facilities in a more cost-effective manner than in an ICU setting. The trend toward the concentration of patients into specialized regional weaning centers should facilitate the research process and continue to improve outcomes in this population.     

The evolution of care for the chronically critically ill patient

The post acute health care system has evolved its infrastructure to accommodate the growing complex medical patient population, a direct result of the expanded capability in supporting critically ill patients in the ICU setting. When patients fail to wean from mechanical ventilation in the ICU, there is often less emphasis on continuing these efforts, and patients appear better served in specialized units dedicated to weaning patients from mechanical ventilation. Long-term acute care hospitals also provide an ideal environment to support patient care for other complex medical illnesses, including populations with oncologic, cardiovascular, and infectious disease. The LTAC hospital seems best adapted to this role. Its infrastructure includes significant physician support and the blending of immediate and long-term care services and provides an ideal opportunity to serve this resource-intensive group. An emphasis on the transition from acute illness to recovery serves to define the role and mission of this important entity and highlights the specialized nature of the LTAC hospital.     

Medical and economic implications of prolonged mechanical ventilation and expedited post-acute care

This article describes the increasingly common phenomenon of prolonged mechanical ventilation in the context of the transition between the acute care hospital and post-acute care. Prolonged mechanical ventilation or chronic critical illness is associated with hospital mortality in the range of 20 to 40%, with median hospital length of stay ranging from 14 to 60 days. Fewer than 10% of patients are discharged home, and most hospital survivors require institutionalized post-acute care in the form of long-term acute care, skilled nursing facilities, or inpatient rehabilitation. Acute hospital readmission is common. Because of prolonged functional disabilities and multiple underlying comorbid conditions, overall 1 year mortality for prolonged mechanical ventilation patients ranges from 50 to 60%. Survivors experience significant functional limitations. The prolonged institutional care and poor long-term outcomes of these patients bring into question the cost-effectiveness of prolonged mechanical ventilation after acute illness, especially for patients with poor long-term prognoses. New measures to facilitate assessments of long-term prognosis and improve communication with surrogate decision makers may reduce the amount of ineffective care for some patients requiring prolonged mechanical ventilation.