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department of Medicine

Section of pulmonary and critical care medicine

Research - Mechanical Ventilation

 

NOTE: Following is an abstract of an article that appeared in the May 1998 Supplement to Chest (Volume 113, No. 5). 


Mechanical Ventilation Beyond the Intensive Care Unit

 

Report of a Consensus Conference of the American College of Chest Physicians
Barry J. Make, MD, FCCP (Chairman); Nicholas S. Hill, MD, FCCP (Editor/Author); Allen I. Goldberg, MD, FCCP (Editor/Author); John R. Bach, MD, FCCP; Gerard J. Criner, MD, FCCP; Patrick E. Dunne, RRT; Mary E. Gilmartin, RN, RRT; John E. Heffner, MD, FCCP; Robert Kacmarek, PhD, RRT; Thomas G. Keens, MD, FCCP; Susan McInturff, RRT; Walter J. O'Donohue, Jr., MD, FCCP; Edward A. Oppenheimer, MD, FCCP; and Dominique Robert, MD


In most patients, mechanical ventilation is a short-term treatment used for up to 7 days to support or replace spontaneous breathing until the cause of respiratory failure resolves or results in death. In patients who receive mechanical ventilation for 7 days, 5% remain unweanable after 4 weeks1 and have been classified as chronic ventilator-dependent patients. After the resolution of their acute illness, however, it is more appropriate to refer to these patients as long-term ventilator-assisted individuals (VAIs). This term recognizes the individuality of these patients and their potential for satisfying and, in some cases, productive lives despite the need for ventilatory assistance.

 

Although the number of chronic VAIs in acute care hospitals is small relative to the total number of patients receiving mechanical ventilation, VAIs consume a disproportionate share of health-care expenditures and occupy ICU beds for prolonged periods. VAIs, therefore, pose a unique set of questions for the health-care team. When and how can VAIs be transferred from the busy resource-intensive ICU? What is the most appropriate and cost-effective site for optimal long-term care that will allow VAIs greatest independence, function, and quality of life? How and when can noninvasive mechanical ventilation be implemented, and can it decrease the need for more invasive and costly forms of mechanical ventilation (such as tracheostomy with positive pressure ventilation [PPV])?

 

The American College of Chest Physicians (ACCP) first addressed these questions in the 1986 Consensus Conference on long-term mechanical ventilation and then developed and published comprehensive guidelines for the treatment of VAIs.2 Since that time, however, not only has new information about the number and location of patients receiving long-term ventilation, as well as about the costs of their care and their outcomes become available, but also two major developments have had a marked impact on the care of VAIs.

 

One of these developments is that the health-care environment has placed increasing emphasis on reducing the financial costs of medical care through earlier discharge of patients from acute care hospitals to newer, less costly types of medical facilities for continued treatment. Discharge from intensive care settings to the newer sites for long-term care, when care for the VAI is not possible in the patient's home, frequently not only reduces costs but also improves the patient's quality of life. Further, the number of non-ICU sites available for acute, intermediate, and long-term care of ventilator-dependent individuals (such as specialized respiratory care units, subacute care units, and skilled nursing facilities) has greatly expanded since 1986.

 

The other major development with a marked impact on the care of VAIs is that noninvasive ventilation (NIV) is increasingly emphasized in clinical situations that include both acute and chronic respiratory failure. The expanding use of NIV helps to prevent emergency endotracheal tube ventilation, particularly in patients with exacerbations of COPD, neuromuscular disorders, and thoracic skeletal disorders.

 

This consensus statement was prepared under the direction of the Health and Science Policy Committee (HSPC) (formerly known as the Consensus Committee) of the ACCP, whose members represent each of the ACCP sections. After careful deliberation by the members of the HSPC, the subject was chosen as a focus topic for consensus development based on recommendations from the membership of the ACCP. In 1993, a chair was chosen who formed a consensus panel of 14 acknowledged experts in the field of mechanical ventilation, with broad scientific and clinical representation from around the world. This consensus statement is based on their extensive experience and available evidence. Each member of the committee was charged with reviewing the literature and writing a portion of the document. Following the conference, the statement was edited for content by the panel editors and for format and clarity by a professional editor. It was again reviewed and approved by the consensus panel. The final document was reviewed and approved by the members of the ACCP HSPC in October 1997. It was discussed by the ACCP Board of Regents in October 1997 and, after revisions, approved in February 1998.

 

The purpose of this report is to provide principles and guidelines for the selection and treatment of VAIs in non-ICU sites within the evolving health-care environment in the United States. Recommendations are provided on the continued care of VAIs in available sites, on the use of NIV (including both PPV and external negative pressure ventilation [NPV]), and on the use of invasive ventilation (via endotracheal tube or tracheostomy, with PPV). The recommendations are based on information published in medical journals. It must be recognized, however, that the available literature does not sufficiently address all of the issues in this evolving field; thus, the recommendations reflect the opinions of experts who represent a variety of health-care disciplines and who participate routinely in the treatment of VAIs. It should also be recognized that many of the guidelines resulting from the 1986 Consensus Conference, such as the medical and patient stability issues to be considered prior to transfer to an alternate care site, and the key elements of a comprehensive plan of care, remain relevant and should continue to be followed.

 

Management of VAIs is the focus of chapter 2, which first considers the problem of increasing numbers of patients and increasing costs and then treatment objectives and goals, sites for care in which the objectives and goals may be achieved, criteria for discharge to those facilities, and steps for making decisions on the most appropriate site for an individual patient. Chapter 3 first describes the types and applications of noninvasive mechanical ventilation, now being used more and more successfully (and cost-effectively) in adults, and then of invasive ventilation. Chapter 4 explores planning for discharge, care, and rehabilitation of ventilator-assisted patients; chapter 5 looks at the equipment and resources needed for care after discharge. Management of pediatric patients is discussed in chapter 6, which describes special considerations concerning pathophysiology, criteria for discharge, sites for care, ventilation techniques, and ventilation equipment and use. Chapter 7 briefly explores ethical issues.