Ventilator-assisted Individuals Research Articles

Acceptability of the Long-Term In-Home Ventilator Engagement virtual intervention for home mechanical ventilation patients during the COVID-19 pandemic: A qualitative evaluation.

Clinical management of ventilator-assisted individuals (VAIs) was challenged by social distancing rules during the COVID-19 pandemic. In May 2020, the Long-Term In-Home Ventilator Engagement (LIVE) Program was launched in Ontario, Canada to provide intensive digital care case management to VAIs. The purpose of this qualitative study was to explore the acceptability of the LIVE Program hosted via a digital platform during the COVID-19 pandemic from diverse perspectives. We conducted a qualitative descriptive study (May 2020-April 2021) comprising semi-structured interviews with participants from eight home ventilation specialty centers in Ontario, Canada. We purposively recruited patients, family caregivers, and providers enrolled in LIVE. Content analysis and the theoretical concepts of acceptability, feasibility, and appropriateness were used to interpret findings. A total of 40 individuals (2 VAIs, 18 family caregivers, 20 healthcare providers) participated. Participants described LIVE as acceptable as it addressed a longstanding imperative to improve care access, ease of use, and training provided; feasible for triaging problems and sharing information; and appropriate for timeliness of provider responses, workflows, and perceived value. Negative perceptions of acceptability among healthcare providers concerned digital workload and fit with existing clinical workflows. Perceived benefits accorded to LIVE included enhanced physical and psychological safety in the home, patient-provider relations, and VAI engagement in their own care. Study findings identify factors influencing the LIVE Program's acceptability by patients, family caregivers, and healthcare providers during pandemic conditions including enhanced access to care, ease of case management triage, and VAI safety. Findings may inform the implementation of digital health services to VAIs in non-pandemic circumstances.

Exploring factors affecting the timely transition of ventilator assisted individuals in Ontario from acute to long-term care: Perspectives of healthcare professionals.

Ventilator Assisted Individuals (VAIs) frequently remain in intensive care units (ICUs) for a prolonged period once clinically stable due to a lack of transition options. These VAIs occupy ICU beds and resources that patients with more acute needs could better utilize. Moreover, VAIs experience improved outcomes and quality of life in long-term and community-based environments. To better understand the perspectives of healthcare providers (HCPs) working in an Ontario ICU regarding barriers and facilitators to referral and transition of VAIs from the ICU to a long-term setting. We conducted semi-structured interviews with ten healthcare providers involved in VAI transitions. Perceived barriers included long wait times for long-term care settings, insufficient bed availability at discharge locations, medical complexity of patients, long waitlists, and a lack of transparency of waitlists. Facilitators included strong partnerships and trusting relationships between referring and discharge locations, a centralized referral system, and utilization of community partnerships across care sectors. Insufficient resourcing of long-term care is a key barrier to transitioning VAIs from ICU to long-term settings; strong partnerships across care sectors are a facilitator. System-level approaches, such as a single-streamlined referral system, are needed to address key barriers to timely transition.

Long-term mechanical ventilation and transitions in care: A narrative review.

Individuals dependent on long-term mechanical ventilation (LTMV) for their day-to-day living are a heterogenous population who go through several transitions over their lifetime. This paper describes three transitions: 1) institution/hospital to community/home, 2) pediatric to adult care, and 3) active treatment to end-of-life for ventilator-assisted individuals (VAIs). A narrative review based on literature and the author's collective practical and research experience. Four online databases were searched for relevant articles. A manual search for additional articles was completed and the results are summarized. Transitions from hospital to home, pediatric to adult care, and to end-of-life for VAIs are complex and challenging processes. Although there are several LTMV clinical practice guidelines highlighting key components for successful transition, there still exists gaps and inconsistencies in care. Most of the literature and experiences reported to date have been in developed countries or geographic areas with funded healthcare systems. For successful transitions, the VAIs and their support network must be front-and-center. There should be a coordinated, systematic, and holistic plan (including a multi-disciplinary team), life-time follow-up, with bespoke consideration of jurisdiction and individual circumstances.

Opening the digital front door for individuals using long-term in-home ventilation (LIVE) during a pandemic- implementation, feasibility and acceptability.

The COVID-19 pandemic led to an unprecedented need for virtual healthcare that was safe, acceptable and feasible to deliver. In May 2020, we launched the Long-term In-Home Ventilator Engagement (LIVE) program for ventilator assisted individuals using ventilators hosted on an e-platform in Ontario, Canada. To assess the acceptability, appropriateness, feasibility and usability of the LIVE program reported by patients, family caregivers, and healthcare providers (HCP). We conducted a cross-sectional study. We provided HCPs participating in the LIVE program anonymized questionnaires (Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), Feasibility of Intervention Measure (FIM), and mHealth App Usability (MAUQ). Patients and family caregivers completed the AIM and MAUQ. Questionnaires were administered via an e-platform. We recruited 105/251 (42%) patients and family caregivers and 42/48 (87.5%) HCPs. Patients and caregivers rated a mean (SD) overall AIM score of 4.3 (0.7) (maximum score 5; higher scores indicate greater acceptability) and a mean (SD) overall MAUQ score of 5.8 (1.5) (maximum score 7; higher scores indicate greater useability). HCPs rated a mean (SD) overall AIM score of 4.3 (0.7), IAM score of 4.3 (0.8), FIM score of 4.2 (0.7) and overall MAUQ score of 5.6 ± 1.5. There were no differences in AIM ((4.3 (0.7) vs 4.3 (0.8), p = 1) or MAUQ (5.8 (1.5) vs 5.6 (1.5), p = 0.5) scores between patients/ family caregivers and HCPs. This study suggests that the LIVE program was acceptable, appropriate, feasible, and usable from the perspective of patients, family caregivers and HCPs.

The experience of family caregivers of ventilator-assisted individuals who participated in a pilot web-based peer support program: A qualitative study.

Family caregivers play an important role supporting the day-to-day needs of ventilator-assisted individuals (VAIs) living at home. Peer-to-peer communication can help support these caregivers and help them sustain caregiving in the community. Online peer-support has been suggested as a way to help meet caregivers' support needs. A qualitative descriptive approach was used to elicit the perspectives of support received from caregivers who participated in a pilot web-based peer support program from October to December 2018. Data were collected through the transcripts of weekly online peer-to-peer group chats. Data were analyzed using an integration of thematic and framework analysis. In total, eight caregivers and five peer mentors participated in the pilot. All five mentors and four of the caregivers participated in the weekly chats. We identified three themes, a) The experience of caregivers is characterized by unique challenges related to the complexity of VAI care including technology; b) Mentors and caregiver participants reciprocally share support; c) Despite hardships, there are things that make caregiving easier and joyful. Our results add to the growing body of evidence pointing to the importance of online communities for supporting vulnerable caregivers. The reciprocal element of peer support, where trained mentors and untrained participants both benefit from support, can help sustain peer-support interventions. Despite the challenges of providing care to a VAI, there are facilitators that may help ease the caregiving experience and caregivers can benefit from ongoing support that is tailored to their needs along the caregiving trajectory.

The patient needing prolonged mechanical ventilation: a narrative review

Background: Progress in management has improved hospital mortality of patients admitted to the intensive care
 units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of
 ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients,
 caregivers and health services, as well as high human and financial resources consumption, despite poor long-term
 outcomes. An effort should be made to improve the management of these patients. This narrative review
 summarizes the main concepts in this field.
 Main body: There is great variability in terminology and definitions of prolonged mechanical ventilation.
 There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of
 protocols, early mobilisation and physiotherapy, specialised weaning units.
 There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival
 of these patients.
 Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and
 controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.
 There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative
 and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised
 controlled trials on this critical issue. End of life decisions should result from appropriate communication among
 professionals, patients and surrogates and national legislations should give clear indications.
 Conclusion: Present medical training of clinicians and locations like traditional intensive care units do not appear
 enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals
 but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects
 of management are needed.

The pattern of use and survival outcomes of a dedicated adult Home Ventilation and Respiratory Support Service in Singapore: a 7-year retrospective observational cohort study.

In Singapore, a dedicated adult multidisciplinary Home Ventilation and Respiratory Support Service (HVRSS) was set-up to assist individuals with chronic ventilatory failure. We aimed to study the use, survival outcomes and identify factors influencing survival in our cohort of ventilator-assisted individuals (VAIs). We retrospectively reviewed all referrals to HVRSS from 2009 to 2015. All VAIs were included and divided into 4 categories: (I) amyotrophic lateral sclerosis (ALS); (II) other neuromuscular and chest wall disease (NMCW); (III) spinal cord injury (SCI); and (IV) complex intensive care unit (ICU) groups for comparison of baseline characteristics, co-morbidities, therapy details and survival outcomes. Cox proportional analysis was used to identify important factors influencing survival for ALS and non-ALS VAIs. There were 112 VAIs; most were male (63%) and ethnic Chinese (83%). At baseline, median [interquartile range (IQR)] age was 61 [46-69] years, body mass index was 20.2 (17.1-23.8) kg/m2 and forced vital capacity was 38 [24-65] %predicted. The three most common diseases were ALS (43%), SCI (13%) and congenital muscular dystrophies (6%). Seventy-four (66%) VAIs received non-invasive ventilation (NIV). Median survival for ALS, Complex ICU, SCI and NMCW VAIs were 1.8, 2.6, 4.2 and 6.7 years respectively. In ALS, NIV conversion to invasive mechanical ventilation (IMV) was associated with longer survival [hazard ratio (HR) 0.24]. In non-ALS VAIs, older age (HR 1.40) and cardiovascular comorbidities (HR 2.61) were poor prognostic factors. The HVRSS managed a heterogenous group of VAIs in Singapore and survival is comparable to published cohorts. ALS had the worst survival whereas NMCW had the best survival with Complex ICU and SCI groups in between. Transition from NIV to IMV, age and cardiovascular disease were important prognostic factors.

Development of a Web-Based Peer Support Program for Family Caregivers of Ventilator-Assisted Individuals Living in the Community: Protocol for a Pilot Randomized Controlled Trial.

BackgroundAcross Europe, Canada, Australia, and the United States, the prevalence of home mechanical ventilation (HMV) prevalence is 6.6-12.9 per 100,000. At-home ventilator-assisted individuals (VAIs) are often vulnerable and highly comorbid, requiring complex care. In Canada, most VAI care is provided by family, leading to poor health-related quality of life and increased caregiver burden. No supportive interventions or peer support programs are tailored to VAI caregivers. Owing to the financial, geographic, and time limitations, Web-based support delivery may especially meet VAI family caregiver needs. We have developed a peer mentor training and Web-based peer support program for VAI caregivers including information-sharing, peer-to-peer communication, and peer mentorship.ObjectiveStudy Stage 1 aims to (1) evaluate the face and content validity of the peer mentor training program and (2) investigate participant satisfaction. Study Stage 2 aims to evaluate (1) the feasibility of participant recruitment and Web-based program delivery; (2) acceptability, usability, and satisfactoriness; (3) experiences of caregivers and peer mentors with the Web-based peer support program; and (4) effect of the Web-based peer support program on caregiver health outcomes.MethodsStudy Stage 1: We will train 7 caregivers to act as peer mentors for the Web-based peer support program trial; they will complete questionnaires rating the utility of individual training sessions and the training program overall. Study Stage 2: We will recruit 30 caregiver peers for a pilot randomized controlled trial of the 12-week Web-based peer support program using a waitlist control; the program includes private chat, a public discussion forum, and weekly moderated chats. Caregiver peers will be randomized to the intervention or waitlist control group using a 1:1 ratio using Randomize.net. Both groups will complete pre- and postintervention health outcome questionnaires (ie, caregiving impact, mastery, coping, personal gain, positive affect, and depression). Caregiver peers in the intervention arm will only complete a program evaluation and will be invited to participate in an interview to provide insight into their experience. Peer mentors will be invited to participate in a Web-based focus group to provide insight into their experience as mentors. We will judge the feasibility per the number of recruitment and program delivery goals met, use analysis of covariance to compare health outcomes between intervention and control groups, and analyze qualitative data thematically.ResultsPeer mentor training was completed with 5 caregivers in July 2018. To date, 2 caregivers have beta-tested the website, and the Web-based peer support program trial will commence in September 2018. Results are expected by early 2019.ConclusionsThis study will result in the production and initial evaluation of a rigorously developed, evidence- and stakeholder-informed Web-based peer training and peer support program for caregivers of VAIs residing at home.International Registered Report Identifier (IRRID)PRR1-10.2196/11827

Transition program for ventilator assisted individuals from acute care to home

RATIONALE: Physiologically stable ventilator dependent patients experiencing protracted intensive care unit (ICU) admission pose substantial burden on ICU bed capacity. We developed a program that transitions these patients to a more appropriate rehabilitative environment and ultimately to the community.OBJECTIVE: To identify the proportion of ventilator assisted individuals (VAIs) enrolled in the program, successfully transitioned to community dwelling. Other objectives were to determine acute hospitalization, other healthcare utilization, costs and mortality 12 months after program discharge.METHODS: Retrospective review of patient characteristics and program outcomes from inception to January 2014 with provincial health administrative databases linkage for healthcare utilization, costs and mortality after discharge to March 2015.RESULTS: We identified 52 VAIs from program inception to January 2014. Of these, 44 (85.6%) were successfully discharged home or to supportive housing after a median 7.6 weeks; 40% did not require hospital readmission. Those 31 VAIs requiring temporary hospital readmission used 1,670 hospital days (average 53.9 days/VAI), with 28 (53.8%) readmitted to ICU (total 1,151 ICU days; average 41.1 days/VAI). Respiratory causes accounted for 54/113 (47.8%) hospital readmissions and 42/81 (51.9%) ICU readmissions. Median (IQR) cost of healthcare utilization per VAI in the year following discharge was CaD$57,461 ($21,971, $126,866) (total cost of $4,473,884). Following program discharge, 25 (48.1%) died with a mean (SD) duration of survival of 1.9 (1.2) years.CONCLUSION: A transition program for clinically stable ventilator dependent patients can facilitate transfer from ICU to the community thereby avoiding protracted ICU admissions and affording substantial cost savings.

Transitions to Home Mechanical Ventilation: The Experiences of Canadian Ventilator-Assisted Adults and Their Family Caregivers.

Rationale: Several studies have explored the experiences of ventilator-assisted individuals living at home with family caregivers. However, few explore the experiences of these individuals as they ...

Tele-medicine in respiratory diseases

Information and Communication Technologies applied to health care and advances in sensor and data transmission technology allowed tele-medicine based programs of care also for patients with respiratory diseases. Different sensors, transmission devices and interventions are used in tele-medicine for some indications. Patients suffering from Chronic Obstructive Pulmonary Disease, asthma, neuromuscular diseases, ventilator assisted individuals and those undergoing pulmonary rehabilitation programs may benefit from this approach. The legal problems are still unsolved. Economic advantages for health care systems, though potentially high, are still poorly investigated. Despite the hopes, we need more evidence before this modality can be considered as a real progress in the management of patients with respiratory diseases. On one hand, these technologies can improve the care of patients with difficult access to services, particularly those in rural/remote areas, on the other hand, there is the risk that they will be used only to reduce standard services in health systems of developed countries.

Attitudes and preferences of home mechanical ventilation users from four European countries: an ERS/ELF survey.

Home mechanical ventilation is increasingly used by people with chronic respiratory failure. However, there are few reports on attitudes towards treatment.A web-based survey in eight languages was disseminated across 11 European countries to evaluate the perception of home mechanical ventilation provision in ventilator-assisted individuals and caregivers.Out of 787 responders from 11 European countries, 687 were patients and 100 were caregivers. 95% of patients and 94% of caregivers were from only 4 countries (Germany, the Netherlands, Italy, Spain). The majority of respondents were male and aged 46–65 years. Obstructive lung diseases were proportionally more represented among respondent patients (46%), and neuromuscular diseases (65%) were more represented among patients of respondent caregivers. About 20% of respondent patients and caregivers were not sure of the modality of ventilation. Different interfaces were used, with a minority of respondents in all countries using invasive home mechanical ventilation by tracheostomy.These results may be useful for healthcare providers and policy makers to improve the quality of patients' daily lives.

Home mechanical ventilation in Canada: a national survey.

No comprehensive Canadian national data describe the prevalence of and service provision for ventilator-assisted individuals living at home, data critical to health-care system planning for appropriate resourcing. Our objective was to generate national data profiling service providers, users, types of services, criteria for initiation and monitoring, ventilator servicing arrangements, education, and barriers to home transition. Eligible providers delivering services to ventilator-assisted individuals (adult and pediatric) living at home were identified by our national provider inventory and referrals from other providers. The survey was administered via a web link from August 2012 to April 2013. The survey response rate was 152/171 (89%). We identified 4,334 ventilator-assisted individuals: an estimated prevalence of 12.9/100,000 population, with 73% receiving noninvasive ventilation (NIV) and 18% receiving intermittent mandatory ventilation (9% not reported). Services were delivered by 39 institutional providers and 113 community providers. We identified variation in initiation criteria for NIV, with polysomnography demonstrating nocturnal hypoventilation (57%), daytime hypercapnia (38%), and nocturnal hypercapnia (32%) as the most common criteria. Various models of ventilator servicing were reported. Most providers (64%) stated that caregiver competency was a prerequisite for home discharge; however, repeated competency assessment and retraining were offered by only 45%. Important barriers to home transition were: insufficient funding for paid caregivers, equipment, and supplies; a shortage of paid caregivers; and negotiating public funding arrangements. Ventilatory support in the community appears well-established, with most individuals managed with NIV. Although caregiver competency is a prerequisite to discharge, ongoing assessment and retraining were infrequent. Funding and caregiver availability were important barriers to home transition.

Institutional care for long-term mechanical ventilation in Canada: A national survey.

No national Canadian data define resource requirements and care delivery for ventilator-assisted individuals (VAIs) requiring long-term institutional care. Such data will assist in planning health care services to this population. To describe institutional and patient characteristics, prevalence, equipment used, care elements and admission barriers for VAIs requiring long-term institutional care. Centres were identified from a national inventory and snowball referrals. The survey weblink was provided from December 2012 to April 2013. Weekly reminders were sent for six weeks. The response rate was 84% (54 of 64), with 44 adult and 10 pediatric centres providing data for 428 VAIs (301 invasive ventilation; 127 noninvasive ventilation [NIV]), equivalent to 1.3 VAIs per 100,000 population. An additional 106 VAIs were on wait lists in 18 centres. More VAIs with progressive neuromuscular disease received invasive ventilation than NIV (P<0.001); more VAIs with chronic obstructive pulmonary disease (P<0.001), obesity hypoventilation syndrome (P<0.001) and central hypoventilation syndrome (P=0.02) required NIV. All centres used positive pressure ventilators, 21% diaphragmatic pacing, 15% negative pressure and 13% phrenic nerve stimulation. Most centres used lung volume recruitment (55%), manually (71%) and mechanically assisted cough (55%). Lack of beds and provincial funding were common admission barriers.CONCLUSIONS: Variable models and care practices exist for institutionalized care of Canadian VAIs. Patient prevalence was 1.3 per 100,000 Canadians.

Patient transitions relevant to individuals requiring ongoing ventilatory assistance: a Delphi study.

Various terms, including 'prolonged mechanical ventilation' (PMV) and 'long-term mechanical ventilation' (LTMV), are used interchangeably to distinguish patient cohorts requiring ventilation, making comparisons and timing of clinical decision making problematic. To develop expert, consensus-based criteria associated with care transitions to distinguish cohorts of ventilated patients. A four-round (R), web-based Delphi study with consensus defined as >70% was performed. In R1, participants listed, using free text, criteria perceived to should and should not define seven transitions. Transitions comprised: T1 - acute ventilation to PMV; T2 - PMV to LTMV; T3 - PMV or LTMV to acute ventilation (reverse transition); T4 - institutional to community care; T5 - no ventilation to requiring LTMV; T6 - pediatric to adult LTMV; and T7 - active treatment to end-of-life care. Subsequent Rs sought consensus. Experts from intensive care (n=14), long-term care (n=14) and home ventilation (n=10), representing a variety of professional groups and geographical areas, completed all Rs. Consensus was reached on 14 of 20 statements defining T1 and 21 of 25 for T2. 'Physiological stability' had the highest consensus (97% and 100%, respectively). 'Duration of ventilation' did not achieve consensus. Consensus was achieved on 13 of 18 statements for T3 and 23 of 25 statements for T4. T4 statements reaching 100% consensus included: 'informed choice', 'patient stability', 'informal caregiver support', 'caregiver knowledge', 'environment modification', 'supportive network' and 'access to interprofessional care'. Consensus was achieved for 15 of 17 T5, 16 of 20 T6 and 21 of 24 T7 items. Criteria to consider during key care transitions for ventilator-assisted individuals were identified. Such information will assist in furthering the consistency of clinical care plans, research trials and health care resource allocation.

Family Caregiver Perspectives on Caring for Ventilator-Assisted Individuals at Home

The trend of patients who are invasively ventilated to prefer home care is one that benefits both the patient and the health care system. However, this assumes a role for patients' family members to become informal caregivers. To explore the impact of caring for a ventilator-assisted individual on informal caregivers. A descriptive design with semistructured caregiver interviews and the Caregiver Burden Inventory were used. Participants were informal caregivers of a family member with a progressive neuromuscular disease on invasive ventilation for at least six months. Transcript coding was performed and regularly reviewed, and recruitment continued until data saturation. Qualitative analysis was based on 'thematic analysis'. A total of 21 caregivers were interviewed. Five themes developed: a sense of duty; restriction of day-to-day life; physical and emotional burden; training and education; and the need for more paid support. Caregivers described a sense of duty to take care of loved ones, but suffered a significant restriction of their own time with a negative impact on their physical and mental health. The initial transfer home was highlighted as the most stressful part of the process. The Caregiver Burden Inventory scores supported a high level of burden: median 49 (interquartile range 39.5 to 53.0) of a maximum 96. Homecare for ventilator-assisted individuals with progressive neuromuscular disease causes significant burden to informal caregivers. Approaches to lessen this burden, such as increased paid care, improved professional support and respite care, may enable home ventilation to be a more sustainable modality of care.

The evolution of practice of noninvasive ventilation: epidemiologic outcomes and patient’s preference

One of the most important developments in the field of mechanical ventilation over the past 15 years has been the emergence of noninvasive ventilation (NIV) as an increasing part of the critical care armamentarium [1]. Noninvasive positive-pressure ventilation (NPPV) is the delivery of mechanical ventilation to patients with respiratory failure without the requirement of an artificial airway. Although NPPV is often used for long-term nocturnal or continuous support of patients with forms of chronic respiratory failure [2], its use is increasingly popular in varied clinical situations in the intensive care unit (ICU) setting as high-level evidence supporting its use continues to accumulate [3–5]. The attraction for NPPV relates primarily to its advantages over invasive mechanical ventilation (Table 1). It has been shown to comparatively decrease resource utilization and circumvent the myriad of complications associated with invasive mechanical ventilation such as upper airway trauma, ventilator-associated pneumonia, and compromise of speech and swallowing [6, 7]. NPPV should, however, be considered in some cases an alternative to invasive mechanical ventilation rather than its replacement [8–12]. Keys to the success of NPPV and to improve clinical outcomes of patients with acute respiratory failure are careful patient selection and a well-designed clinical protocol because failure of NPPV only delays potentially more definitive therapy with invasive ventilation [13]. Decades of experience during the polio epidemics [14, 15] and subsequently [16–18] established long-term nocturnal noninvasive ventilation stabilizes gas exchange and improves symptoms in patients with chronic respiratory failure. For home mechanical ventilation, noninvasive ventilation has a number of advantages over invasive mechanical ventilation, including greater ease of administration, reduced need for skilled caregivers, elimination of tracheostomy-related complications, enhanced patient comfort, and lower cost [19, 20]. However, as is the case in the acute setting, not all patients with chronic respiratory failure are good candidates for noninvasive ventilation. Long-term mechanical ventilation at home now incorporates both ventilator-dependent ([16 h per day ventilatory support) and ventilator-assisted (primarily nocturnal only) individuals, using a variety of devices and interfaces including invasive ventilation and NIV techniques [21]. The diversity of conditions and variability in level of care needed by these individuals means that introducing and maintaining long-term ventilation in the home requires skill and experience on the part of the prescribing center, particularly if the patient is using ventilatory support on a near continuous basis or has a tracheostomy in place for the delivery of ventilation [22–24]. Additionally, introducing medical technology into the home raises a number of issues for the patient and caregivers, as well as local health services, which need to be identified on an individual basis [25, 26].

Ventilator-associated pneumonia in long-term ventilator-assisted individuals

Information on the characteristics of pneumonia in long-term ventilator-assisted individuals is scarce. We evaluate the incidence, risk factors and outcome of ventilator-associated pneumonia (VAP) in a large series of chronically ventilated patients. All patients assisted in a chronic ventilator-dependent unit were prospectively followed up for the development of VAP. Patients with a new and persistent lung infiltrate and a purulent tracheal aspirate were suspected to have VAP. Pneumonia was considered microbiologically confirmed in the presence of (1) a positive blood culture and/or (2) ≥10⁵ CFU ml⁻¹ in quantitative bacterial culture of tracheal aspirates or ≥10³ CFU ml⁻¹ in quantitative mini-bronchoalveolar lavage cultures. In total, 100 consecutive long-term ventilated individuals with spinal cord injury (mean age 49 years) were prospectively followed up. The length of mechanical ventilation before admission in the unit was 54±37 days, and the follow-up after admission was 119±127 days. There were 32 episodes of VAP in 27 patients (1.74 episodes per 1000 days of mechanical ventilation). By logistic regression analysis, hypoalbuminaemia (P=0.03), administration of antacids (P=0.002) and length of mechanical ventilation (P=0.05) were independent risk factors for VAP. The most frequently isolated organisms were Pseudomonas aeruginosa (62%), methicillin-resistant Staphylococcus aureus (25%) and Acinetobacter baumannii (15%); 9 (28%) episodes were polymicrobial. Antimicrobial treatment, including monotherapy in 66%, was successful in most patients. Only three patients (11%) died in relation to VAP. Patients on long-term ventilation are at significant risk for the development of VAP, but the mortality is low.

Survey on long-term ventilator-assisted individuals in Japanese National Hospital Organization

Survey on long-term ventilator-assisted individuals in Japanese National Hospital Organization

Survey on long-term ventilator-assisted individuals in Japanese National Hospital Organization

Survey on long-term ventilator-assisted individuals in Japanese National Hospital Organization