Resp Care
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Technological innovations in the ICU have led to artificially prolonged life, with an associated cost. Chronic critical illness (CCI) occurs in patients with prolonged mechanical ventilation and allostatic overload, and is associated with a discrete and consistent metabolic syndrome. ⋯ Ideally, IMS should be under the supervision of a metabolic support consultative team. Further research specifically focused on the CCI population is needed to validate this current approach.
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Past research in chronic critical illness has been effective in defining the population and identifying unique aspects of their outcomes and resource needs, but there has been little research focused on interventions to improve outcomes. This review discusses some research priorities that could have immediate impact on patient outcomes. General topics include prevention or limiting the incidence of chronic critical illness; specific topics related to patient management, such as interventions for weaning, rehabilitation, nutrition or infections; and methods to enhance communication and end-of-life care. In addition to specific patient management interventions, further comparative effectiveness research on care settings is indicated, considering the expected growth in the patient population and the substantial resource needs.
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Palliative care is an essential component of comprehensive care for all patients with chronic critical illness, including those receiving restorative or life-sustaining therapies. Core elements include alleviation of symptom distress, communication about care goals, alignment of treatment with the patient's values and preferences, transitional planning, and family support. Here we address strategies for assessment and management of symptoms, including pain, dyspnea, and depression, and for assisting patients to communicate while endotracheally intubated. ⋯ Challenges for supporting families and planning for transitions between care settings are identified, while the value of interdisciplinary input is emphasized. We review "consultative" and "integrative" models for integrating palliative care and restorative critical care. Finally, we highlight key ethical issues that arise in the care of chronically critically ill patients and their families.
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Review
The growing role of noninvasive ventilation in patients requiring prolonged mechanical ventilation.
For many patients with chronic respiratory failure requiring ventilator support, noninvasive ventilation (NIV) is preferable to invasive support by tracheostomy. Currently available evidence does not support the use of nocturnal NIV in unselected patients with stable COPD. Several European studies have reported benefit for high intensity NIV, in which setting of inspiratory pressure and respiratory rate are selected to achieve normocapnia. ⋯ Pressure support ventilation, pressure controlled ventilation, and volume controlled ventilation have been used successfully for chronic applications of NIV. New modes have recently become available, but their benefits await evidence to support their widespread use. The success of NIV in a given patient population depends on selection of an appropriate patient, selection of an appropriate interface, selection of an appropriate ventilator and ventilator settings, the skills of the clinician, the motivation of the patient, and the support of the family.
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The chronically critically ill (CCI) patient population is characterized by a prolonged need for high cost medical interventions, a high 1-year mortality rate, and a very high demand for post acute care services. The best characterized CCI patient population is patients on prolonged mechanical ventilation (PMV). This review will focus on the current knowledge of costs and care venues for the care of this patient population. ⋯ Given the dramatic comparative acute care cost burden of PMV patients, the societal implications for managing both the care burden and the costs of care are staggering. Strategies to improve the efficiency in healthcare for this patient population will be essential. Limitations to the existing care models in the United States will be identified with a focus on our current research deficiencies, which limit healthcare providers and administrators in providing patient focused care for this patient population.