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Abstract
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 weeks and have been classified as chronic ventilator-dependent patients. After the resolution of their acute illness, however, it is more appropriate to refer 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 tracheotomy with positive pressure ventilation (PPV).
The health-care environment has placed increasing emphasis on reducing the financial costs of medical care through curlier 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, sub acute 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.
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