Prolonged Mechanical Ventilation Patients Research Articles

Low Levels of Physical Activity During Critical Illness and Weaning: The Evidence-Reality Gap.

Background:Physical rehabilitation can benefit critically ill patients during intensive care unit (ICU) admission, but routine clinical practice remains inconsistent nor examined in prolonged mechanical ventilation patients transferred to a specialist ventilator weaning unit (VWU). Behavioral mapping is a sampling approach that allows detailed reporting of physical activity profiles. The objective of this study was to characterize the physical activity profile of critically ill patients in a UK ICU and VWU.Methods:Single-center, prospective observational study in a university teaching hospital. Patient observations, conducted Monday through Sunday from 08:30 am to 08:00 pm and for 1 minute every 10 minutes, included data points of patient location, people in attendance, and highest level of activity. Descriptive statistics were utilized to analyze and report data.Results:Forty-two ICU and 11 VWU patients were recruited, with 2646 and 693 observations, respectively, recorded. In the ICU, patients spent a median (interquartile range) of 100% (96%-100%) of the day (10.5 [10.0-10.5] hours) located in bed, with minimal/no activity for 99% (96%-100%) of the day (10.4 [9.7-10.5] hours). Nursing staff were most frequently observed in attendance with patients irrespective of ventilation or sedation status, although patients still spent approximately two-thirds of the day alone. Bed-to-chair transfer was the highest activity level observed. In the VWU, patients spent 94% (73%-100%) of the day (9.9 [7.7-10.5] hours) in bed and 56% (43%-60%) of time alone. Physical activity levels were higher and included ambulation. All physical activities occurred during physical rehabilitation sessions.Conclusions:These profiles of low physical activity behavior across both patients in the ICU and VWU highlight the need for targeted strategies to improve levels beyond therapeutic rehabilitation and support for a culture shift toward providing patients with, and engaging them in, a multidisciplinary, multiprofessional environment that optimizes overall physical activity.

Burden on caregivers of ventilator-dependent patients: A cross-sectional study.

Caring for prolonged mechanical ventilation (PMV) patients imposes heavy psychological, physical, social, and financial burdens on caregivers. Currently, studies regarding the burden on caregivers of PMV patients are scant; therefore, the present study investigated the burden on caregivers of PMV patients.This cross-sectional study was approved by the Institutional Review Board of Zuoying Armed Forces General Hospital. A survey was conducted among the caregivers of PMV patients who were admitted to a chronic respiratory care ward (RCW) or were receiving home care from June to December 2010. The survey included basic demographic information of PMV patients and their caregivers and the Burden Assessment Scale scores for 4 domains comprising a total of 21 questions (physical burden, n = 5; psychological burden, n = 6; social burden, n = 6; financial burden, n = 4). Statistical analyses were conducted using the t test, 1-way analysis of variance with the Scheffé post hoc test, and the chi-square test, and P < .05 was considered statistically significant.A total of 160 caregivers (age, 50–53 years) were recruited (n = 80 each in the home care and RCW groups), and most of these caregivers were married women. Due to insufficient sleep, physical exhaustion, back pain, and caregiving, home caregivers had significantly higher physical burden levels than RCW caregivers (P < .01).Home caregivers experienced higher physical burden levels than RCW caregivers. Therefore, clinical and professional support must be provided to home caregivers of PMV patients.

Survival and medical utilization of children and adolescents with prolonged ventilator-dependent and associated factors.

Over the course of a year, more than 20,000 patients in Taiwan require prolonged mechanical ventilation (PMV). Data from the National Health Insurance Research Database for patients between 2005 and 2011 were used to conduct a retrospective analysis on ventilator dependence. The study subjects were PMV patients aged <17 years in Taiwan. A multiple regression model employing general estimating equations was applied to investigate the factors affecting the use of medical resources by children and adolescent PMV patients. A Cox proportional hazard model was incorporated to explore the factors affecting the survival of these patients. Data were collected for a total of 1,019 children and adolescent PMV patients in Taiwan. The results revealed that the average number of outpatient visits per subject was 32.1 times per year, whereas emergency treatments averaged 1.56 times per year per subject and hospitalizations averaged 160.8 days per year per subject. Regarding average annual medical costs, hospitalizations accounted for the largest portion at NT$821,703 per year per subject, followed by outpatient care at NT$123,136 per year per subject and emergency care at NT$3,806 per year per subject. The demographic results indicated that the patients were predominately male (61.24%), with those under 1 year of age accounting for the highest percentage (36.38%). According to the Kaplan—Meier curve, the 1-year and 5-year mortality rates of the patients were approximately 32% and 47%, respectively. The following factors affecting the survival rate were considered: age, the Charlson Comorbidity Index (CCI), diagnosis type necessitating ventilator use, and whether an invasive ventilator was used. This study investigated the use of medical resources and the survival rates of children and adolescent PMV patients. The findings of this study can serve as a reference for the National Health Insurance Administration in promoting its future integrated pilot projects on ventilator dependency.

Regional ventilation redistribution measured by electrical impedance tomography during spontaneous breathing trial with automatic tube compensation**This study was endorsed by the Far Eastern Memorial Hospital Research Ethics Review Committee, approval number: FEMH-IRB-103133-E.

Objective. Automatic tube compensation (ATC) was developed to overcome the flow resistance of endotracheal tube and decrease the imposed work of breathing. Although ATC is used as an evidence-based strategy to predict successful weaning from assisted ventilation, the changes in regional ventilation distribution induced by this technique are not known. We hypothesized that continuous positive airway pressure plus ATC (CPAP + 100%ATC) could reactivate the respiratory muscles in patients with prolonged mechanical ventilation (PMV) more effectively than volume assist-control mandatory ventilation (ACMV). Approach. A total of 16 PMV patients were included. Patients were ventilated under volume ACMV mode and subsequently under CPAP + 100%ATC for 50 min. Two periods of 5 min electrical impedance tomography (EIT) data at the end of each mode were analyzed. Main results. Tidal variations of electrical impedance determined by EIT during CPAP + 100%ATC were significantly smaller than during ACMV (p < 0.001), while no significant differences in end-expiratory lung impedance were found. Regional ventilation was distributed significantly more towards dorsal regions during CPAP + 100%ATC as indicated by the EIT-based index center of ventilation (46.2 ± 5.8 during ACMV versus 51.7 ± 6.5 during CPAP + 100%ATC, values in %, p < 0.001). However, the overall degree of ventilation inhomogeneity was not improved as indicated by the global inhomogeneity index (0.42 ± 0.09 during ACMV versus 0.42 ± 0.06 during CPAP + 100%ATC). The onset of ventilation was significantly less delayed during CPAP + 100%ATC in both ventral and dorsal regions as indicated by the ventilation delay index (ACMV versus CPAP + 100%ATC, 53.0 versus 42.6 in ventral; 50.2 versus 39.3 in dorsal regions; values in %, p < 0.001). Significance. Dorsal redistribution of ventilation and reduction of ventilation delay as identified by EIT indicate that CPAP + 100%ATC was effective in reactivating the respiratory muscles in the PMV patients of the present study.

Prognostic Factors for Long-Term Mortality in Critically Ill Patients Treated With Prolonged Mechanical Ventilation: A Systematic Review.

Long-term survival for patients treated with prolonged mechanical ventilation is generally poor; however, patient-level factors associated with long-term mortality are unclear. Our objective was to systematically review the biomedical literature and synthesize data for prognostic factors that predict long-term mortality in prolonged mechanical ventilation patients. We searched PubMed, CINAHL, and Cochrane Library from 1988 to 2015 for studies on prolonged mechanical ventilation utilizing a comprehensive strategy without language restriction. We included studies of adults 1) receiving mechanical ventilation for more than or equal to 14 days, 2) admitted to a ventilator weaning unit, or 3) received a tracheostomy for acute respiratory failure. We analyzed articles that used a multivariate analysis to identify patient-level factors associated with long-term mortality (≥ 6 mo from when the patient met criteria for receiving prolonged mechanical ventilation). We used a standardized data collection tool and assessed study quality with a customized Newcastle-Ottawa Scale. We abstracted the strength of association between each prognostic factor and long-term mortality. Individual prognostic factors were then designated as strong, moderate, weak, or inconclusive based on an a priori previously published schema. A total of 7,411 articles underwent relevance screening; 419 underwent full article review. We identified 14 articles that contained a multivariate analysis. We abstracted 19 patient-level factors that showed association with long-term mortality. Six factors demonstrated strong strength of evidence for association with the primary outcome: age, vasopressor requirement, thrombocytopenia, preexisting kidney disease, failed ventilator liberation, and acute kidney injury ± hemodialysis requirement. All factors, except preexisting kidney disease and failed ventilator liberation, were measured at the time the patients met criteria for prolonged mechanical ventilation. Despite the magnitude of the public health challenge posed by the prolonged mechanical ventilation population, only 14 articles in the biomedical literature have tested patient-level factors associated with long-term mortality. Further research is needed to inform optimal patient selection for prolonged mechanical ventilation.

Effects of Reinstitution of Prolonged Mechanical Ventilation on the Outcomes of 370 Patients in a Long-Term Acute Care Hospital.

To investigate the effects of the reinstitution of continuous mechanical ventilator support of >21 days in 370 prolonged mechanical ventilation (PMV) patients, all free from ventilator support for ≥5 days. Four groups were formed based on the time and number of PMV reinstitutions and compared (group A: reinstitutions within 28 days, n = 51; group B: a single reinstitution after 28 days, n = 53; group C: multiple reinstitutions after 28 days, n = 52; and group D: no known reinstitutions, n = 214). Of the 370 patients, 156 (42%) required PMV reinstitutions. Most reinstitutions occurred within 7 months: 51 (33%) of the 156 patients within 28 days and 49 (31%) within the next 6 months. Group comparisons revealed a progression of outcomes from group A, the worst, to group D, the best, with groups B and C having intermediate but significantly different values. Decannulation was associated with an 88% decreased risk of PMV reinstitution and a 43% lower risk of death (all P < .001). Prolonged mechanical ventilation reinstitution rates were high, with most occurring within 7 months of freedom from MV. In general, the longer the period of ventilator freedom, the less the likelihood of a PMV reinstitution. The identification of 4 distinct PMV groups of patients by time and number of reinstitutions added useful prognostic information. Since PMV reinstitutions within 28 days lead to permanent MV support, >28 days of ventilator freedom provided an optimal cut point for assessing the likelihood of again requiring PMV.

Development and Validation of a Mortality Prediction Model for Patients Receiving 14 Days of Mechanical Ventilation

For an increasing number of patients, critical illness or injury is neither self-limited nor imminently fatal1. As survival from life-threatening illness improves, pre-existing disease and newly-acquired organ dysfunction may conspire against recovery, leaving patients dependent on life supporting therapies for extended time periods. This syndrome, termed “chronic critical illness”, is commonly typified by persistent respiratory failure that requires prolonged mechanical ventilation (PMV). Long-term mortality is high, approaching rates of 40% to 60% at one-year in inclusive cohorts2–10. Patients have a very high symptom burden during the weeks of prolonged ventilation11,12 and chances of living at home with functional independence at the end of the year are as low as 10%9,13. Most PMV patients are unable to participate in their own clinical decision making and must therefore rely on surrogates to guide their goals of care. These surrogate decision makers report that physicians rarely discuss prognosis, and studies have shown that physician and family estimates of one year outcome are highly discordant14,15. Traditional approaches to ICU mortality prediction, such as APACHE, are ill-suited to predicting longer term outcomes, particularly in this population16. Our research group developed and validated the ProVent mortality prediction model which estimates one-year mortality for patients receiving at least 21 days of mechanical ventilation to address prognostic uncertainty for these unique patients2,3,17. However, many important decisions regarding the care of PMV patients occur before 21 days have elapsed, including electing to perform tracheotomy18 or transfer care to a long-term acute care hospital (LTACH), both of which in are in some form decisions to continue life sustaining therapies19,20. If compelling prognostic data were available sooner for the patient whose goals of care are known, these decisions might be made more easily and earlier in the course of illness21–23. Building on our previous work, we hypothesized that a simple mortality prediction model constructed from factors clinically available by day 14 in the course of mechanical ventilation could discriminate between PMV patients at high and low risk of death at one year. Using a heterogeneous multicenter cohort of PMV patients in addition to a contemporaneous cohort of patients with acute lung injury (ALI) who were enrolled in a randomized, controlled trial, we sought to develop and validate a new model using data collected on day 14 of mechanical ventilation rather than on day 21 as in our previous model.

A derived and validated score to predict prolonged mechanical ventilation in patients undergoing cardiac surgery

ObjectivesProlonged mechanical ventilation after cardiac surgery imposes a significant burden on the patient in terms of morbidity as well as a financial burden on the hospital. We undertook a retrospective analysis of 2 prospectively collected databases developed in tertiary cardiac care centers to derive and validate a risk index predicting prolonged mechanical ventilation after cardiac surgery. MethodsWe studied a retrospective cohort of 32,045 patients undergoing cardiac surgery in 2 hospitals in Toronto, Canada. The development cohort consisted of 21,661 patients at Toronto General Hospital. Data Sunnybrook Health Sciences Centre, Toronto, Canada, with 10,384 patients, served as an institutional validation cohort. We operationally characterized prolonged mechanical ventilation as the duration from surgery completion to extubation exceeding 48 hours. ResultsProlonged postoperative mechanical ventilation rates in the development and validation cohort were 6% and 7%, respectively. Multivariable regression in the development cohort showed that the following factors were strong predictors of prolonged mechanical ventilation after cardiac surgery: previous cardiac surgery, lower left ventricular ejection fraction, shock, surgery involving repair of congenital heart disease, and cardiopulmonary bypass time. The intraoperative multivariable model retained good discrimination in the validation cohort, achieving a c statistic of 0.787. ConclusionsProlonged mechanical ventilation after cardiac surgery can be accurately predicted by readily available pre- and intraoperative information.

Preadmission tracheostomy is associated with better outcomes in patients with prolonged mechanical ventilation in the postintensive care respiratory care setting.

Prolonged mechanical ventilation (PMV) is the most common situation where tracheostomy is indicated for intensive care unit (ICU) patients. However, it is unknown if this procedure confers survival benefits on PMV patients in a post-ICU setting. Patients who were admitted to the specialized weaning unit from 2005 to 2008 and received PMV were included in this study. On admission, data pertaining to patient characteristics, physiologic status, and type of artificial airway (tracheostomy vs. no tracheostomy) were obtained. Outcomes of tracheostomized and nontracheostomized patients were evaluated using multivariate Cox proportional hazards and propensity score-matching models. The primary outcome of interest was 1-year survival. A total of 401 patients (mean age 74.4years, 204 male) were identified. In multivariate analyses, higher Acute Physiology and Chronic Health Evaluation II score [hazard ratio (HR)=1.061, 95% confidence interval (CI)=1.016-1.107] and presence of comorbidities, including congestive heart failure (HR=1.562, 95% CI=1.119-2.181), malignancy (HR=1.942, 95% CI=1.306-2.885), and liver cirrhosis (HR=2.373, 95% CI=1.015-5.544), were independently associated with 1-year mortality. An association between having tracheostomy and a better 1-year outcome was observed (HR=0.625, 95% CI=0.453-0.863). The matched cohort study also demonstrated a favorable 1-year survival for tracheostomized patients, and these patients had significantly lower in-hospital mortality (24% vs. 36%, p=0.049) and risk of ventilator-associated pneumonia (10% vs. 20%, p=0.030) than nontracheostomized ones. Preadmission tracheostomy may be associated with better outcomes of PMV patients in a post-ICU respiratory care setting. The findings suggest that this procedure should be recommended before PMV patients are transferred to specialized weaning units.

A feasibility study of functional status and follow-up clinic preferences of patients at high risk of post intensive care syndrome.

After prolonged mechanical ventilation patients may experience the 'post intensive care syndrome' (PICS) and may be candidates for post-discharge follow-up clinics. We aimed to ascertain the incidence and severity of PICS symptoms in patients surviving prolonged mechanical ventilation and to describe their views regarding follow-up clinics. In a teaching hospital, we conducted a cohort study of all adult patients discharged alive after ventilation in ICU for ≥7 days during 2013. We administered the EuroQol-5D (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) via telephone interview and asked patients their views about the possible utility of a follow-up clinic. We studied 48 patients. At follow-up (average 19.5 months), seven (15%) patients had died and 14 (29%) did not participate (eight declined; two were non-English speakers; four were non-contactable). Among the 27 responders, 16 (59%) reported at least moderate problems in ≥1 EQ-5D dimension; 10 (37%) in ≥2 dimensions, and 8 (30%) in ≥3 dimensions. Moreover, 10 (37%) patients reported marked psychological symptoms; six (22%) scored borderline or abnormal on the HADS for both anxiety and depression; and four (15%) scored borderline or abnormal for one component. Finally, 21/26 (81%) patients stated that an ICU follow-up clinic would have been beneficial. At long-term follow-up, the majority of survivors of prolonged mechanical ventilation reported impaired quality of life and significant psychological symptoms. Most believed that a follow-up clinic would have been beneficial.

Relationship of the Duration of Ventilator Support to Successful Weaning and Other Clinical Outcomes in 437 Prolonged Mechanical Ventilation Patients.

To investigate the relationships between durations of ventilator support and weaning outcomes of prolonged mechanical ventilation (PMV) patients. Cohort study of 957 PMV patients sequentially admitted to a long-term acute care hospital (LTACH). The study population was 437 PMV patients who underwent weaning, having achieved ≥4 hours of sustained spontaneous breathing. They were divided into tertiles of mechanical ventilation (MV) durations and compared for differences (tertile A: 21-58 days, n = 146; tertile B: 59-103 days, n = 147; and tertile C: ≥104 days, n = 144). Tertiles showed comparable weaning success rates and survival. As MV durations increased, LTACH postweaning days became progressively greater, whereas decannulations and discharge physical function diminished, and home discharges decreased while nursing facility discharges increased (all P < .001). Patients with lower physical function before critical illness or greater burdens of comorbidities were least likely to be weaned (all P < .001). Younger ages, lower comorbidity burdens, neurological diagnoses, higher admission prealbumin levels, and successful weaning, each independently reduced the risk of death (all P < .01). Durations of MV did not affect weaning success or survival, although deleterious effects were found in discharges, decannulations, LTACH postweaning days, and discharge physical function. Durations of MV alone should not guide transfer decisions for subsequent continuing care.

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.

Lung volume distribution in prolonged mechanical ventilation patients from assist control mode to spontaneous trial mode of automatic tubing compensation in electrical impedance tomography

Electrical impedance tomography (EIT) is a non-invasive and portable lung imaging technique for dynamic evaluation of lung volume distribution. Previous studies had proved the EIT can provide information on regional distribution of ventilation and changes in end-expiratory lung volume (△EELV). The effect of EIT application in ventilation distribution of prolonged mechanical ventilation (PMV) patients underwent weaning program is unknown.

Clinical presentations as predictors of prolonged mechanical ventilation in Guillain-Barré syndrome in an institution with limited medical resources.

Severe Guillain-Barré syndrome (GBS) causes ventilatory insufficiency and the need for prolonged artificial ventilation. Under circumstances where medical care for patients with severe GBS is required in a resource-limited institution, identifying initial clinical presentations in GBS patients that can predict respiratory insufficiency and the need for prolonged mechanical ventilation (> 15 days) may be helpful for advanced care planning. The medical records of patients diagnosed with GBS in a tertiary care and medical teaching hospital from January 2001 to December 2010 were retrospectively reviewed. The demographic data and clinical presentations of the patients were summarised using descriptive statistics. Clinical predictors of respiratory insufficiency and the need for prolonged mechanical ventilation (> 15 days) were identified using univariate logistic regression analysis. A total of 55 patients with GBS were included in this study. Mechanical ventilation was needed in 28 (50.9%) patients. Significant clinical predictors for respiratory insufficiency were bulbar muscle weakness (odds ratio [OR] 5.08, 95% confidence interval [CI] 1.31-21.60, p = 0.007) and time to peak limb weakness ≤ 5 days (OR 0.75, 95% CI 0.62-0.91, p < 0.001). Bulbar muscle weakness (p = 0.006) and time to peak limb weakness ≤ 5 days (p < 0.001) were also found to be significantly associated with the need for prolonged mechanical ventilation (> 15 days). Bulbar weakness and time to peak limb weakness ≤ 5 days were able to predict respiratory insufficiency and the need for prolonged mechanical ventilation in patients with GBS.

Effectiveness of surgical rib fixation on prolonged mechanical ventilation in patients with traumatic rib fractures: A propensity score–matched analysis

PurposeWe investigated whether surgical rib fixation improved outcomes in patients with traumatic rib fractures. Materials and MethodsThis was a retrospective study using a Japanese administrative claim and discharge database. We included patients with traumatic rib fractures admitted to hospitals where surgical rib fixation was available from July 1 2010, to March 31, 2013. We detected patients who underwent surgical rib fixation within 10 days of hospital admission (surgical group) and those who did not (control group). The main outcome was prolonged mechanical ventilation, defined as that performed for 5 or more days, or death within 28 days. One-to-four propensity score matching was performed between the 2 groups with adjustment for possible confounders. ResultsAmong 4577 eligible patients, 90 (2.0%) underwent the surgical rib fixation. After the matching, we obtained 84 and 336 patients in the surgical and control groups, respectively. Logistic regression analyses showed that the surgical group was significantly less likely to receive prolonged mechanical ventilation or die within 28 days than the control group (22.6% vs 33.3%; odds ratio, 0.59; 95% confidence interval, 0.36-0.96; P = .034). ConclusionsSurgical rib fixation within 10 days of hospital admission may improve outcomes in patients with traumatic rib fractures.

Outcomes following prolonged mechanical ventilation: analysis of a countywide trauma registry.

The care of mechanically ventilated patients at high-volume centers in select nontrauma populations has variable effects on outcomes. We evaluated outcomes for trauma patients requiring prolonged mechanical ventilation (PMV). We further hypothesized that the higher mechanical ventilator volume trauma center would have better outcomes. A retrospective review of a county's trauma registry was performed for trauma patients who were at least 18 years old admitted from 2006 to 2010. Eleven hospitals serve this suburban county, with a population of approximately 1.5 million people. The state has designated them as nontrauma centers (n = 6), area trauma centers (ATCs, n = 4), or regional trauma center (RTC, n = 1), where the last one provides the highest echelon of care. Patients requiring mechanical ventilation for at least 96 hours following injury were evaluated. A total of 3,382 trauma patients were admitted to the RTC, and 5,870 were admitted to the other 10 hospitals in the county. Seven hundred seventy-one received mechanical ventilation at the RTC, and 687 at the other 10 hospitals combined. Of these patients, 407 at the RTC and 308 at the remaining facilities (291 at ATCs and 17 at nontrauma centers) required PMV. Median (interquartile range [IQR]) Injury Severity Score (ISS) at the RTC was higher (29 [21-41] vs. 22 [16-29] p < 0.001) than that at ATCs. Hospital length of stay (in days) was comparable between the RTC and ATCs (28 [18-45] vs. 26 [16-44.7]). With regard to complications, rates of renal failure, sepsis, and myocardial infarction were similar. The RTC had higher pneumonia rates (59% vs. 45.4%, p < 0.001) and venous thromboembolic disease rates (20.4% vs. 10.4%, p < 0.001) than did ATCs. In-hospital mortality was 17% at the RTC and 34.4% at ATCs (p < 0.001). A mortality benefit but higher VTE and pneumonia rate for PMV patients at the RTC was noted. Collaborative practice initiatives are warranted to reduce morbidity and mortality across the region. Epidemiologic study, level IV.

The reality of patients requiring prolonged mechanical ventilation: a multicenter study.

ObjectiveThe number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days).MethodsThis study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality.ResultsThere were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs.ConclusionThe classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation dependency ≥ 21 days) identified patients with a high risk for complications during intensive care unit stay, longer intensive care unit and hospital stays, high death rates, and higher costs.

Abstract 17306: The Most Expensive Patients in the Hospital

Introduction: In the Medicare population, 1% of the patients is responsible for 15% of spending. There are two patterns typical of highest-cost patients: those who cycle in and out of the hospital with preventable conditions, and those who have a single catastrophic event. While a great deal of focus has been placed on the former, much less is known about the latter. We do know that a large proportion of these most-expensive patients receive prolonged mechanical ventilation (PMV). Methods/Results: We used national Medicare data to explore diagnoses, procedures, and costs associated with these most-expensive patients. There were 91,054 hospitalizations for Medicare patients with a DRG containing PMV in 2010. The majority of PMV patients were admitted emergently (71.9%); an additional 16.7% were admitted urgently. Elective admissions represented 9.5%, and trauma accounted for 1.8%. Median length of stay was 16 days, and the median stay in the intensive care unit was 11 days. Procedures were performed in the majority of these patients, and clinical outcomes were exceedingly poor (table). The financial costs associated with this group of patients were high. The average total hospitalization charge was $227,917; the maximum charge was over $9 million. The mean Medicare payment for PMV patients in 2010 was $61,995, with a maximum of $1.3 million. This was largely through the set DRG price (mean $59,491), though outlier payments (mean $5,957, maximum $1.2 million) and patient-paid coinsurance (mean $835, maximum $88,644) played a significant role as well. Conclusions: A small group of Medicare beneficiaries undergoing PMV have extremely high costs and poor outcomes. This shared clinical pathway suggests that there is room for improvement, both in terms of identifying these patients early during hospitalization to prevent progression to PMV, as well as in terms of clinical innovation to improve care within the intensive care unit for those who are already ventilated.

High‐frequency chest wall oscillation in prolonged mechanical ventilation patients: a randomized controlled trial

Patients with prolonged mechanical ventilation (PMV) often retain airway secretions, which may be cleared with the assistance of high-frequency chest wall oscillation (HFCWO). This study aimed to determine the effectiveness, safety and tolerance/comfort of HFCWO after extubation in PMV patients. This parallel-designed, randomized controlled trial enrolled subjects with both intra-tracheal intubation and mechanical ventilator support continuously for at least 21 days between January 2011 and December 2012. Upon extubation, the participants were randomly assigned to either receive HFCWO for 5 days or not. The effectiveness [based on weaning success rates, daily clearance volume of sputum, serial changes in sputum coloration and chest X-ray (CXR) improvement rates], safety (by physiologic parameters) and tolerance/comfort [using the Modified Borg Scale (MBS) and Hamilton Anxiety Scale (HAS)] of HFCWO were investigated. There were 43 PMV subjects, including 23 in the HFCWO group and 20 in the non-HFCWO group. The weaning success rates were 82.6% (19/23) and 85% (17/20) in the HFCWO and non-HFCWO groups, respectively (P = 1.000). The HFCWO group had persistently greater numbers of daily sputum suctions and higher CXR improvement rates compared with the non-HFCWO group. There was significant sputum coloration lightening in the HFCWO group only. There was no significant difference in the MBS and HAS between the two groups and between pre- and post-HFCWO physiologic parameters. In PMV patients, HFCWO was safe, comfortable and effective in facilitating airway hygiene after removal of endotracheal tubes, but had no positive impact on weaning success.

Pediatric tracheostomy: a ten-year analysis in the Intensive Care Unit of Sancti Spiritus “José Martí” Pediatric Teaching Hospital

There has been a significant change in the role of pediatric tracheostomy over the last twenty years. Obstruction of the upper airway caused by infectious agents is no longer the leading cause of tracheostomy in children. Structural anomalies of the upper airway as well as the need for prolonged ventilator assistance have become the most frequent indication for pediatric tracheostomy. The purpose of this paper is to assess the incidence, indications, complications, and role in mortality of tracheostomy in our pediatric population. A retrospective descriptive study of pediatric patients who underwent tracheostomy was conducted between 1999 and 2008 in the Pediatric Intensive Care Unit of the José Martí de Sancti Spiritus Pediatric Teaching Hospital in Cuba. Tracheostomy was performed in 14 patients during the period of the study (0.5% of admitted patients). Nine of them (64.2%) were younger than one year. The most frequent indication for the procedure was the need for prolonged mechanical ventilation in patients with neurologic disorders in 10 patients (71.42%). Upper airway malformations and acute infections were infrequent indications for tracheostomy. The most frequent complications were infectious in 10 patients (71.4%) and obstruction in four patients (28.5%). The following germs were found: Pseudomona aeruginosa in six patients (60%), Staphylococcus aureus in three patients (30%), and Enterobacter cloacae in three patients (30%). Furthermore, four patients were successfully decannulated (28.5%), five patients died (35.7%) but only in one (7.14%), death could be attributed to tracheostomy. The need for prolonged mechanical ventilation in patients with neurologic disorders was the main indication for tracheostomy in our pediatric population; most of these children were younger than one year. The procedure had little impact in overall mortality in this group of patients.