Papel dos cuidados intermédios num serviço de insuficientes respiratórios

Abstract

During 1960s Intermediate Care Units started to spread all over North America, promoted to solve the increasing demands on Intensive Care Units admissions, and the high costs of intensive care. The new model of organization designed establishes a hierarchy between different levels of hospital care – general ward, intermediate care units and intensive care units – based on the amount of human and technical resources available and aimed to provide a continuum in the level of care, without decreasing the quality of treatment or adversely affecting the outcome, representing a cost-effective approach to the care of a substantial number of patients. Respiratory Intermediate Care Units are designed to treat medically stable ventilator patients for weaning and chronic care; hemodynamically stable patients with evidence of compromised gas exchange and underlying disease with the potential for worsening respiratory insufficiency who require frequent observation and/or nasal continuous positive airway pressure; and patients who require frequent vital signs or aggressive pulmonary physiotherapy. The Respiratory Insufficiency Division from the Pulmonary Department of Hospital de Pulido Valente incorporates a 26-bed respiratory ward providing intermediate level care in 8 beds, an Intensive Respiratory Care Unit (IRCU) and a Respiratory Insufficiency Day Care Center (RIDCC). In order to evaluate the work developed in the 8-bed intermediate care, a systematic retrospective review of all records was performed from January 1, 1995 to December 31, 2000. Results: during this period of time 545 patients were admitted (167 women and 378 men) with an average age of 64 years (14-92). The provenience of the patients was 34% from IRCU, 19% from the respiratory ward and 4% from RIDCC; 19% directly from the emergency room and the remaining 24% from other areas. The reasons for admission were: 25% following invasive mechanical ventilation (IMV), 6% for chronic invasive mechanical ventilation (CIMV), 7% with tracheostomy tubes after prolonged invasive mechanical ventilation, 27% for noninvasive mechanical ventilation (NIV), 27% for cardiorespiratory monitoring and 8% for different reasons. The patients suffered in 96% from chronic disease, mostly from: COPD (51%), TB sequelae (18%) and kyphoscoliosis (7%). In 94% of the patients, respiratory insufficiency was present, mainly hypercapnic failure. The average length of stay in intermediate care was 18,5 days (1-599). Eighty patients were transferred to the intensive care unit because of clinical deterioration and 60 patients died prior to hospital discharge. Five patients were weaned from CIMV (33%) and 2 were discharged home with invasive ventilatory support. Tracheostomy was definitively closed in 11 patients (31%) and 2 were discharged home with a tracheal button. In 83% of patients with respiratory failure NIV succeeded to solve the acute event. Comments: The availability of 8-bed intermediate care has enabled to liberate 5599 days of intensive care, 3110 from patients on chronic ventilatory support and 2489 from patients with tracheostomy following weaning from CIMV; despite the advanced stage of chronic respiratory disease with mortality ranging from 53 and 40%, respectively, the number of patients in whom weaning was obtained is comparable to the literature. The possibility of close monitoring and observation is greatly responsible for the success obtained with NIV, sparing patients from IMV. REV PORT PNEUMOL 2001; VII (6):