Prolonged Mechanical Ventilation Shannon S. Carson, MD Associate Professor and Chief Pulmonary and Critical Care Medicine University of North Carolina
AJRCCM 2010
Projected Growth of Prolonged Acute MV Zilberberg et al. Crit Care Med 2008;36:1451
Outcomes of Prolonged Ventilation Cohort Definition Ventilation for 14 days Ventilation for 21 days Tracheostomy for Prolonged Mechanical Ventilation Weaning Center Study Combes Carson Cox Engoren Rose N 347 200 114 267 347 115 Hospital Length of Stay median (IQR) -- 51 (36-72) 39 (30-52) 29 (22-38) 28-37 64 (35-109) Died in Hospital 43% 41% 31% 20% 22% 15% Discharged Home -- 11% 4% 7% -- 13% Alive at 12 months 32% 48% 42% 52% 50% 37%
Activities of Daily Living (ADL) scores 6 5 4 3 p = 0.04 between groups p = 0.0001 for time trend 2 1 PMV non-pmv 0-2 0 2 4 6 8 10 12 Follow-Up, Months Cox et al. Crit Care 2007.
Brain Dysfunction in PMV Prospective cohort 203 patients from Respiratory Care Unit Nelson et al. Arch Intern Med 2006;166:1993 82% cognitively intact at baseline 30% comatose throughout RCU stay 50% non-coma patients delirious 6 month follow-up 71% of survivors too cognitively impaired for tel. testing Remaining 25% cognitively intact (30 patients)
Management Prevent Complications Maximize Function Communicate Prognosis/Goals of Care
Preventing Infections Prevent Ventilator Associated Pneumonias HOB elevation Remove NG tubes Avoid gastric distension Chlorhexadine mouth rinses? Avoid sedatives, narcotics when possible Prevent Central Line Related Bloodstream Infections D/C unnecessary lines!!! Checklist Full drapes Line Cart
Infection Control in PMV High threshold for broad spectrum antibiotics Treat sepsis aggressively Confirm infection before treating isolated fever VAP BAL/mini-BAL/Quantitative trach aspirate Tracheobronchitis be appropriately conservative Bladder infections SIRS and Pyuria Positive culture with no other apparent source Know local Antibiograms
Maximize Function
Nutrition Avoid Overfeeding Volume expansion, hyperglycemia, steatocholestasis, increased ventilatory load McClave et al. J Parent Enteral Nutr. 1998;22:375 213 PMV patients from 32 hospitals Indirect calorimetry measurements 58.2% of patients receiving >110% of required calories 12.2% were being underfed 20-25 kcal/kg/day Enteral and parenteral feeding? Hollander, Mechanick. Nutr Clin Pract. Dec 2006;21(6):587
Pressure Ulcers Prevention Turning, Specialty Beds, Cleaning Early Mobilization Management Debridement Wet-to-dry dressings Wound Vac? Judicious use of antibiotics Specialist Care
Mobility Barriers or Excuses? Limitations in cardiovascular and respiratory reserve Bleeding risks Cognitive function Orthopedic issues, wounds Attachments, Devices Obesity Solution: Mobility Team Morris et al. Crit Care Med 2006; 34:A20 Adaptation of traditional roles Physiotherapist model Hopkins Crit Care Clinics 2007;23:81
Delirium Risk Age Baseline dementia Underlying illness Inflammation Coagulation Metabolic Disturbances Hypoxemia, hypercarbia Psychoactive Medications Sleep Deprivation Inouye, JAMA 1996;275:852-57 Dubois, Intens Care Med 2001;27:1297-1304 Inouye, NEJM 1999;340:669-676 Jacobi, Crit Care Med 2002;30:119-141 Milbrandt, Crit Care Med. 2005;33:226-9
Psychological Support Prevent delirium Early mobility Communication Speaking valve Oral feeding Careful treatment of pain and anxiety Depression Extremely common Jubran Intensive Care Med. May 2010;36(5):828 Antidepressants work slowly Methylphenidate Woods et al. J Clin Psychol 1986; 47:12
Dedicated Units for PMV Patients Multidisciplinary Rehabilitation Approach Specialization within disciplines RT, Nutrition, PT Protocolized care Lower nursing intensity; less monitoring Lower costs?? Short-term acute care hospital models Long-term care hospital (LTCH) models
LTAC vs Acute Costs for PMV LTCH patients and non-ltch patients matched based upon propensity for LTCH referral 68 days in episode with LTCH care vs 45.8 days without LTCH care www.rti.org/reports/cms Differences in episode payments and costs relative to non-ltch patient with low likelihood of LTCH referral (lower left point on graphs)
Unroe et al. Ann Intern Med 2010; 153;167.
Unroe et al. Ann Intern Med 2010; 153;167
Day 21 of MV Age >65-2 points Age 50-65 - 1 point Platelets <150-1 point Vasopressors - 1 point Dialysis - 1 point 0.00 0.25 0.50 0.75 1.00 Survival by ProVent Score 0 200 400 600 800 1000 Days Since Enrollment Score = 0 Score = 1 Score = 2 Score = 3 Score = 4 or 5 Area under ROC 0.79 (95% CI, 0.75, 0.81) Hosmer Lemeshow GoF p=0.89 Crit Care Med 2012; 40:1171-1176
Summary Managing the complications of PMV should be considered within the context of improving functional outcomes as well as survival Infections are the most common cause of death in PMV and are often preventable Prolonged physical limitations should be prevented with early mobility, wound prevention, and nutrition Care venues should be selected based upon patient needs, but are often determined by resources Tools are available to improve understanding and communication of prognosis/goals of care
Survival of LTCH PMV Patients
Discordance High Expectations For: Surrogates (%) Physicians (%) One-year Survival 93 43 Functional Status 71 6 Quality of Life 83 4 Concordance: κ = 0.08 Cox Crit Care Med 2009;37:2891