Chronic Ventilator Dependence Research Articles

Failure to Attempt Weaning After Classification as Chronically Ventilator-Dependent: A Tragic System Failure

PURPOSE: We have observed recurrent admissions of individual ventilator patients from eight local SNFs to our hospital. They all had long hospital stays and weaning was seldom attempted during these admissions. The only diagnosis provided for most of them was Chronic Ventilator Dependence (CVD-code V-4611). To investigate these issues, joint ventilator rounds were conducted by Pulmonary Medicine and Respiratory Therapy from April through November 2009 evaluating the weaning potential of all patients with admission diagnoses of CVD.

No Death by PEG: PEG Related Complications in a Community Hospital

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) is a widely used enteral access for nutrition and medication administration. PEG placement and its use results in a diverse variety of complications. This study is a retrospective review aimed at estimating the etiology of post PEG complications and its outcome in a community hospital. Methods: A retrospective chart review of patients admitted due to PEG related complications in year 2006 and 2007 (n=61). Patients were divided according to complications, co-morbidities, treatment outcome and length of stay. Results: PEG site infection was the most common complication (n=23, 37.8%, p<0.05) followed by dislodgement (n=15, 24.5%), leakage (n=13, 21.3%), malfunction (n=7, 11.4%), and miscellaneous complications (n=3, 5%) Figure 1. Among patients with PEG site infection, three developed systemic infection (13%). All patients responded to systemic antibiotics. Patients with neurological disorders had the highest rate of complication (n=24, 39.3%). Patients with chronic ventilator dependency had a high rate of complications (n=22, 36%). Cancer patients had a lower rate of complication (n=13, 21.3%). The cancer patient group had a combination of self-care and nursing care of their PEG tubes. Mean duration of hospitalization was 8.7 days and was mainly related to co-morbid conditions. There were five deaths among these patients, and were unrelated to the PEG related complications. Conclusion: Patients with PEG experience a diverse range of complications and suffer from high morbidity, mortality and longer hospitalization. PEG site infection was the most common complication followed by leakage and dislodgement. All infections resolved with the removal of PEG, and systemic antibiotics. Neurological disorders and ventilator dependency had the highest risk of developing a PEG related complication. Patients without cognitive impairment had less PEG related complications likely due to their ability to perform self care of their PEG. There was no direct mortality connected to the PEG complication.Figure

Tracheostomy after pediatric cardiac surgery: Frequency, indications, and outcomes

This study was designed to review baseline characteristics and outcomes of children requiring tracheostomy after cardiac surgery. A retrospective review of children under age 2 requiring tracheostomy after cardiac surgery between January 1999 and December 2005 was performed. Indications for tracheostomy, survival, and completion of staged palliation were documented. After cardiac surgery, 59 (1.3%) of 4503 patients with a median age at surgery of 15 days and weight of 3.5 kg required tracheostomy. Median duration from surgery to tracheostomy was 36 days (range 10-145 days). Genetic syndromes or major noncardiac comorbidities were present in 40% of patients. Biventricular repair was performed in 34 patients and univentricular repair in 25. Tetralogy of Fallot variants (29%) and coarctation±ventricular septal defect (21%) constituted the majority of biventricular lesions associated with tracheostomy, whereas unbalanced atrioventricular septal defect and hypoplastic left heart syndrome with highly restrictive atrial septal defect accounted for 52% of the single ventricle group. Indications for tracheostomy included the following: multifactorial (37%), tracheobronchomalacia, (24%), cardiac (12%), bilateral vocal cord paralysis (10%), bilateral diaphragm paralysis (2%), and other airway issues (15%). Hospital survival was 75% with intermediate-term (median, 25.5 months; range, 1-122 months) survival of 53%. Of 25 single ventricle patients, 6 (24%) had successful completion of the Fontan procedure. Of 12 patients with single ventricle who were ventilator-dependent after initial repair, 10 died, 1 remains at hemi-Fontan, and 1 has undergone completion of the Fontan procedure. Requirement for tracheostomy in pediatric patients after cardiac surgery was associated with significant mortality. Patients with single ventricle have the highest late death rate and those with chronic ventilator dependency were unlikely to undergo successful Fontan completion.

Victims of Our Own Success or Quo Vadis Pediatric Anesthesia?

Victims of Our Own Success or Quo Vadis Pediatric Anesthesia?

Tracheostomy After Major Vascular Surgery

Major vascular surgery such as aortic aneurysm repair may be associated with prolonged in-patient hospitalization. Certain patients undergo a tracheostomy to aid in weaning from mechanical ventilation or for secretion management. The authors hypothesized that tracheostomy after aortic reconstruction for aneurysmal disease was associated with poor outcomes. A retrospective, observational study. Vascular surgical intensive care unit (ICU) of a tertiary referral hospital. Eighty-one patients who underwent a tracheostomy after open thoracoabdominal or abdominal aortic aneurysm (AAA) repair between 1993 and 2002. None. Of 1,940 patients who underwent aneurysm repair, 81 (4.2%) had a tracheostomy during their index hospitalization. Of those patients, 40.7% did not survive to hospital discharge. Postoperative sepsis was associated with an increased mortality (relative risk 2.45, 95% confidence interval [CI] 1.22-4.90). Many developed postoperative renal failure and were more likely to die in the hospital (relative risk 1.53, 95% CI 1.00-2.33). The preoperative diagnosis of chronic obstructive pulmonary disease (COPD) was not associated with increased mortality (relative risk 0.471, 95% CI 0.23-0.96). Thirty-two (39.5%) patients were transferred from the ICU to a chronic ventilator dependency unit (CVDU). Tracheostomy in patients after aortic reconstruction for aneurysmal disease is associated with a high incidence of in-hospital mortality. Patients who survive to ICU discharge are likely to be transferred to a CVDU for further respiratory management. The preoperative diagnosis of COPD is associated with improved survival, whereas postoperative sepsis is associated with an increased mortality. These observations should be considered when counseling patients and their families regarding tracheostomy after aortic surgery.

Tracheotomy and Decannulation Rates in a Level 3 Neonatal Intensive Care Unit: A 12‐Year Study

The objective of this study was to determine the rates of tracheotomy tube placement and subsequent decannulation in all admissions to a single-site, tertiary newborn intensive care unit (NICU). Records from total admissions to a tertiary single-site NICU between January 1, 1991, and December 31, 2002, were retrospectively analyzed. Long-term medical follow-up for this cohort included data through September 1, 2003. All patients were analyzed for occurrence of tracheotomy tube placement and decannulation, airway procedures, and comorbidities. There were 10,428 total NICU admissions during the 12-year study period. Seventy-eight (0.7%) of these patients underwent tracheotomy tube placement. Sixty-six of these 78 (85%) infants survived. None of the 12 deaths were related to tracheotomy tube placement. The most common indications for tracheotomy tube placement were subglottic stenosis (32%), chronic lung disease (28%), craniofacial abnormality (14%), chronic ventilator dependency (11%), and a neurologic disorder (8%). Decannulation was achieved in 41 of 66 (62%) survivors. Patients who failed decannulation had a major neurologic disorder, underlying pulmonary disorder, or both. A baseline tracheotomy tube placement rate of 0.7% was observed in this single-site tertiary NICU setting. Decannulation was accomplished early in life in two thirds of the surviving infants. Those infants failing decannulation had either severe underlying pulmonary or neurologic disorders.

The Learning curve for investigational surgery: lessons learned from laparoscopic diaphragm pacing for chronic ventilator dependence

Electrical stimulation of the phrenic nerve motor point of the diaphragm through laparoscopic implantation of a pacing system is an option for high spinal cord-injured patients with chronic respiratory insufficiency. This study assesses the operative learning curve for the initial series of patients. A series of six patients underwent laparoscopic placement of a diaphragm pacing system. The operative procedure was divided into the following four steps for analysis and rapid adjustment after each operation: exposure of the diaphragm, mapping of the phrenic nerve motor point, implantation of the pacing electrodes, and final routing of the wires to the external system. The first case required two operations, and the second case was unsuccessful because of a nonfunctioning phrenic nerve that led to a change in the preoperative screening criteria. The operative time decreased from 469 min for the first operation to 165 min for the sixth operation. The significant time decrease can be attributed to changes in the mapping and routing aspects of the operation. Key changes during this series that helped to reduce the operative time include abandonment of a software-dependent mapping technique, development of a grid algorithm for mapping, software improvement to increase the speed of stimulation and mapping, refinement of the mapping probe to maintain adequate suction on the diaphragm, shortening of the electrode lengths, and experience with the implantation of connections to the external electrodes. Presently, all five of the successfully implanted patients can be maintained on prolonged ventilatory support with the device. Analysis of every step of this investigational procedure enabled us to make rapid changes in surgical protocol, leading to decreases in operative times and expectant improvements in patient safety and efficacy. In this series, analysis was the key to developing a low-risk cost-effective outpatient diaphragm pacing system.

Use of Inspiratory Strength Training to Wean Six Patients Who Were Ventilator-Dependent

Patients who are unable to wean from mechanical ventilation (MV) after resolution of critical illness or surgery risk increased morbidity and death and consume a disproportionate amount of intensive care unit resources. Decreased inspiratory muscle strength is often cited as a major factor contributing to prolonged MV. The purpose of this case report is to describe the rationale and application of inspiratory strength training (IST) as an adjunct to lengthen unassisted breathing trials and to ultimately wean patients with chronic mechanical ventilator dependency. Six patients who had been ventilator-dependent for 18 to 221 days (mean of 72 days) after surgery and were diagnosed with "failure to wean" performed low-repetition, high-resistance breathing exercises that were coupled with increasing time off the ventilator. All 6 patients were weaned from the ventilator in 9 to 28 days (mean of 17 days). The patients' training pressure increased from a mean of 9.3 cm/H2O to 27.5 cm/H2O, for an increase of 195%. The volitional maximum inspiratory pressure (MIP) increased from a mean of 22.5 cm/H2O to 54 cm/H2O, for a 140% gain in pressure. Although it is not clear why the patients appeared to benefit from IST, possible explanations include: (1) addressing inspiratory muscle pump dysfunction, (2) standardization of breathing patterns, 3) routinization of the patients' unassisted breathing trials, and (4) nonspecific training effects. Future research should address these possibilities when attempting to understand the effects of IST in the weaning of patients with chronic ventilator dependency.

Bacteremia In The Chronic Spinal Cord Injury Population: Risk Factors For Mortality

Background: Individuals with spinal cord injury (SCI) have a lifelong increased risk of systemic infection, which may be associated with episodes of life-threatening bacteremia. Information concerning specific organisms causing bacteremia, the sites of primary infection, and clinical predictors for mortality are necessary to provide optimal treatment.Methods: A retrospective review of positive blood cultures collected over a 3 2-month period in chronic SCI patients treated at the Veterans Affairs Medical Center SCI Unit.Results: One hundred and twenty-three episodes of bacteremia occurred in 63 patients during 83 hospitalizations; 30 patients had multiple episodes of bacteremia. There were 1 ,644 admissions during this period, yielding an incidence of bacteremia of 7 .5% (5.8% after excluding positive cultures that were believed to be caused by contaminants). The patients (31 with paraplegia and 32 with quadriplegia) had a mean age of 59 ± 2 years, and a mean duration of injury of 23 ± 2 years. Bladder management technique consisted of indwelling bladder catheter (n = 53), ileal conduit (n = 6), intermittent catheterization (n = 2), and spontaneous voiding (n = 2). Episodes of bacteremia were nosocomial in 89 out of 123 episodes. Multiple debilitating factors were present, including pressure ulcers in 3 6 out of 63 patients, chronic ventilator dependency in 5 out of 63 patients, recent surgical procedures in 17 out of 63 patients, unde rlying malignancy in 5 out of 63 patients, and evidence of malnutrition in 2 9 out of 63 patients (serum albumin concentration < 2.5 g/dl). Early mortality rate (death within 30 days of bacteremia) occurred in 8 out of 63 patients (13 %) and late mortality (> 1 month following a bacteremic episode) occurred in 1 0 additional participants, such that total mortality was 1 8 out of 63 (2 9%). The sources of bacteremia were urinary tract infection (n = 3 9), presumed contaminant (n = 28), decubitus ulcers (n = 21 ), intravascular catheter (n = 1 9), pneumonia (n = 5), and other (n = 11 ). Gram-negative rods accounted for 2 6 out of 3 9 episodes of bacteremia from a urinary source. Methicillin-resistant Staphylococcus au reus, methicillin-sensitiveS au reus, and coagulase-negative staphylococci were the predominant organi sms when intravascular catheters or pressure ulce rs were the source of bacteremia.Conclusion: In this population, bacteremia predominantly was caused by hospital-associated organisms, and occurred mainly in malnourished patients who required hospitalization for major unde rlying debilitating conditions, particularly pressure ulcers. Chronic indwelling bladder cathet e rs and chronic vascular catheter usage also were highly prevalent in patients with bacteremic episodes. Hypoalbuminemia was the strongest independent predictor for mortality.

OPTIONS FOR LONG-TERM VENTILATORY SUPPORT

Long-term mechanical ventilator support for patients with chronic respiratory failure is becoming more common. This article reviews the common causes for chronic ventilator dependence, and offers an approach to weaning these patients from the ventilator. In addition, the details for preparing these patients for prolonged mechanical ventilation outside of the acute-care hospital setting are discussed. Appropriate education of the patient's caregivers is key to the success of long-term ventilatory support outside of the acute-care hospital.

Lung Volume Reduction Surgery at a Community Hospital: Program Development and Outcomes

Description of the development and results of a program in lung volume reduction surgery (LVRS) at a community hospital. Prospective data collection. A 320-bed community hospital. Fifty-five patients consecutively discharged from the hospital following LVRS. The mean preoperative FEV1 averaged 28% (+/-8%) of predicted values, while the preoperative PaCO2 averaged 49 mm Hg (+/-11.5 mm Hg). Forty-eight patients completed a preoperative conditioning regimen and underwent the procedure on an elective basis. Seven patients underwent the procedure during a hospital admission for a COPD exacerbation. Eight patients required mechanical ventilation preoperatively, including three who had required long-term mechanical ventilatory support. Three patients (5%) died in the hospital following surgery. One patient developed chronic ventilator dependence. All three of the patients who required long-term mechanical ventilation preoperatively were weaned from the ventilator and returned home. Follow-up pulmonary function testing is available for 42 patients 3 months after surgery, and for 20 patients 6 months after the operation. At 3 months, the mean FEV1 improved 0.19 L (p=0.0002), the mean improvement for FVC was 0.37 L (p=0.0001), and the mean drop in residual volume was 0.97 L (p=0.0001). Similar changes are seen at 6 months. Highly significant improvements were also seen in quality of life measurements and exercise performance. The benefits of surgical treatment of emphysema seemed similar in both elective and urgent groups. LVRS can be done safely and effectively at a community hospital, with significant improvement in pulmonary function and quality of life.

Interrupter Mechanics of Patients Admitted to a Chronic Ventilator Dependency Unit

We analyzed the results of interrupter mechanics tests of 73 consecutive patients who were admitted to a chronic ventilator dependency unit. The purposes of this study were (1) to establish guidelines for grading the severity of airway obstruction based on interrupter mechanics measurements; (2) to estimate the prevalence of airway obstruction in this population; (3) to compare interrupter test results with the clinical assessment of airway function; and (4) to characterize the distribution of bronchodilator-induced changes in isorecoil flow. Measurements from 65 of 73 patients (89%) were considered technically adequate. Of 65 patients, 29 (45%) showed signs of flow limitation during passive expiration. All patients with severe obstruction documented with spirometry during clinical stability were flow-limited and achieved maximal flows < or = 0.45 L/s at recoil pressures of 10 cm H2O. In contrast to measures of expiratory dynamics, the inspiratory resistance of the respiratory system was a poor index of severity of obstruction. In seven of 12 patients, interrupter testing failed to substantiate a clinical diagnosis of severe obstruction while revealing unsuspected obstruction in six of 25 (24%) patients. The administration of 270 micrograms of albuterol increased flows at comparable recoil pressures by > or = 0.1 L/s in 29% of 41 patients. Changes in flow were unimodally distributed and were not correlated with severity of obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Contribution of airway collapse to supramaximal expiratory flows.

Contribution of airway collapse to supramaximal expiratory flows.