As many as 5% of patients who need mechanical ventilation will require prolonged mechanical ventilation (PMV). The cost of their care and its associated morbidity is alarming; however, good outcomes can be achieved when their care is specialized and delivered in a programmatic manner. In this article, we review some of the common and potentially reversible reasons why patients fail successfully liberation from mechanical ventilation. We examine the outcomes of patients requiring PMV and present evidence that supports the development of specialized units where patients can be cohorted and may produce better outcomes than would be likely if these patients remained in the ICU.
1. Aldrich TK , Karpel JP , Uhrlass RM et al. Weaning from mechanical ventilation: Adjunctive use of inspiratory muscle resistive training . Crit Care Med1989; 17: 143-147 .
2.
2. Scalise PJ , Gerardi DA , Wollschlager CM et al. A regional weaning center for patients requiring mechanical ventilation: an 18-month experience . Connecticut Medicine1997; 61: 387-389 .
3.
3. Nevins ML , Epstein SK . Predictors of outcome in patients with COPD requiring invasive mechanical ventilation . Chest2001; 119: 1840-1849 .
4.
4. Sivak ED . Prolonged mechanical ventilation: an approach to weaning . Cleve Clin Q1980; 47: 89-96 .
5.
5. Vallverdu L , Calaf N , Subirana M et al. Clinical characteristics, respiratory function parameters, and outcomes of a two-hour T-piece trial in patients weaning from mechanical ventilation . Am J Respir Crit Care Med1998; 158: 1855-1862 .
6.
6. Pierson DJ . Long-term mechanical ventilation and weaning . Respir Care1995; 40: 289-295 .
7.
7. Make BJ , Dayno S , Gertman P . Prevalence of chronic ventilator-dependency [abstract] . Am Rev Respir Dis1986; 133: A167-A167 .
8.
8. Gracey DR , Naessens JM , Viggiano RW et al. Outcome of patients cared for in a ventilator-dependent unit in a general hospital . Chest1995; 107: 494-499 .
9.
9. Gracey DR , Viggiano RW , Naessens JM et al. Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital . Mayo Clin Proc1992; 67: 131-136 .
10.
10. Scheinhom DJ , Artinian BM , Catlin JL et al. Weaning from prolonged mechanical ventilation. The experience at a regional weaning center . Chest1994; 105: 534-539 .
11.
11. Yang KL , Tobin MJ . A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation . N Engl J Med1991; 324: 1445-1450 .
12.
12. Gracey DR , Hardy DC , Naessens JM et al. The Mayo Ventilator-Dependent Rehabilitation Unit: a 5-year experience . Mayo Clin Proc1997; 72: 13-19 .
13.
13. Scheinhom DJ , Hassenpflug M , Artinian BM et al. Predictors of weaning after 6 weeks of mechanical ventilation . Chest1995; 107: 500-505 .
14.
14. Laghi F , D'Alfonso N , Tobin MJ . Pattern of recovery from diaphragmatic fatigue over 24 hours . J Appl Physiol1995; 79: 539-546 .
15.
15. Laghi F , Jubran A , Parthasarathy S et al. Can patients who fail a trial of weaning develop diaphramatic fatigue? [abstract] . Am J Respir Crit Care Med2000; 161: A790-A790 .
16.
16. Jubran A , Tobin MJ . Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation . Am J Respir Crit Care Med1997; 155: 906-915 .
17.
17. Tobin MJ , Perez W , Guenther SM et al. The pattern of breathing during successful and unsuccessful trials of weaning from mechanical ventilation . Am Rev Respir Dis1986; 134: 1111-1118 .
18.
18. Lemaire F , Teboul JL , Cinotti L et al. Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation . Anesththesiology1988; 69: 171-179 .
19.
19. Clark K . Psychosocial aspects of prolonged ventilator dependency . Respir Care1986; 31: 329-333 .
20.
20. Make B , Gilmartin M , Brody JS et al. Rehabilitation of ventilator-dependent subjects with lung disease . Chest1984; 86: 358-365 .
21.
21. Isaac L , Criner G . Patient and family perceptions on weaning from mechanical ventilation in a specialized rehabilitation unit [abstract] . Am Rev Respir Dis1990; 141: A411-A411 .
22.
22. Maclntyre NR . Respiratory factors in weaning from mechanical ventilatory support . Respir Care1995; 40: 244-248 .
23.
23. Arora NS , Rochester DREffect of body weight and muscularity on human diaphragm muscle mass, thickness and area . J Appl Physiol1982; 52: 64-70 .
24.
24. Thurlbeck WM . Diaphragm and body weight in emphysema . Thorax1978; 33: 483-487 .
25.
25. Kelsen SG , Ference M , Kapoor S . Effects of prolonged undernutrition on structure and function of the diaphragm . J Appl Physiol1985; 58: 1354-1359 .
26.
26. Knowles JB , Fauban M , Wiggs BJ et al. Dietary supplementation and respiratory muscle performance in patients with COPD . Chest1988; 93: 977-983 .
27.
27. Shaw JFH , Wolfe HH . An integrated analysis of glucose, fat and protein metabolism in severely traumatized patients . Ann Surg1989; 209: 63-72 .
28.
28. Rochester DF , Esau SA . Malnutrtion and the respiratory system . Chest1984; 85: 411-415 .
29.
29. Datta D , Foley R , Prunk S , Scalise P . Creatinine height index and nutritional status as predictors of successful liberation from prolonged mechanical ventilation. American College of Chest Physician, Chest2003, Orlando, FL, October 25-30, 2003.
30.
30. Aubier M , Murciano D , Legoguic Y et al. Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure . N Engl J Med1985; 313: 420-424 .
31.
31. Nixon DW , Heymsfield SB , Cohen AE et al. Protein-calorie undernutrition in hospitalized cancer patients . Am J of Med1980; 8: 683-690 .
32.
32. Molloy DW , Dhingra S , Soven F et al. Hypmagnesemia and respiratory muscle power . Am Rev Respir Dis1984; 129: 497-498 .
33.
33. Brussel T , Matthay MA , Chemow B . Pulmonary manifestations of endocrine and metabolic disorders . Clin Chest Med1989; 10: 645-653 .
34.
34. Nordquist P , Khuner KG , Stenberg K . Myxedema coma and CO2 retention . Acta Med Scand1960; 166: 189-194 .
35.
35. Pandya K , Lal C , Scheinhorn D et al. Hypothyroidism and ventilator dependency . Arch Intern Med1989; 149: 2115-2116 .
36.
36. Khaleeli AA , Griffin DG , Edwards RHT . The clinical presentation of hypthyroid myopathy and its relationship to abnormalities in structure and function of skeletal muscles . Clin Endocrinol1987; 19: 365-376 .
37.
37. Martinez FJ , Bermudez-Gomez M , Celli BR . Hypothyroidism a reversible cause of diaphragmatic dysfunction . Chest1989; 96: 1059-1063 .
38.
38. Stahl N , Leiberman A . Acute upper airway obstruction due to myxedema and upper airway abnormalities . J Laryngol Otol1988; 102: 733-734 .
39.
39. Orr WC , Males JL , Imes NK . Myxedema and obstructive sleep apnea . Am J Med1981; 70: 1061-1066 .
40.
40. Skatrud J , Iber C , Ewart R et al. Disordered breathing during sleep in hypothyroidism . Am Rev Respir Dis1981; 124: 325-329 .
41.
41. Rajagopal KR , Abbrecht PH , Derderian SS et al. Obstructive sleep apnea in hypothyroidism . Ann Intern Med1984; 101: 491-494 .
42.
42. Datta D , Scalise P . Hypothyroidism and failure to wean in patients on prolonged mechanical ventilation at a regional weaning center. Chest, accepted for publication, July 2004.
43.
43. Chertow GM , Christiansen CL , Cleary PD et al. Prognostic stratification in critically ill patients with acute renal failure requiring dialysis . Arch Intern Med1995; 155: 1505-1511 .
44.
44. Biesenbach G , Zazgornick J , Kaiser WF . Improvement in prognosis of patients with acute renal failure over a period of 15 years: an analysis of 710 cases in a dialysis center . Am J Nephrol1992; 12: 319-325 .
45.
45. Gillespie DJ , Marsh HMM , Divertie MB et al. Clinical outcome of respiratory failure in patients requiring prolonged (> 24 hours) mechanical ventilation . Chest1986; 90: 364-369 .
46.
46. Datta D , Scalise P . Renal function and weaning from prolonged mechanical ventilation. [abstract/poster] to be presented at Chest, October 2004, Seattle.
47.
47. Gracey DR , Hardy OC , Koenig GE . The chronic ventilator-dependent unit: a lower cost alternative to intensive care . Mayo Clin Proc2000; 75: 445-449 .
48.
48. Cordasco EM Jr , Sivak ED , Perez-Trepichio A . Demographics of long-term ventilator-dependent patients outside the intensive care unit . Cleve Clin J Med1991; 58: 505-509 .
49.
49. Spicher JE , White DPOutcome and function following prolonged mechanical ventilation . Arch Intern Med1987; 147: 421-425 .
50.
50. Indihar FJ . A 10-year report of patients in a prolonged respiratory care unit . Minn Med1991; 74: 23-27 .
51.
51. Scheinhorn DJ , Chao DC , Stearn-Hassenpflug M et al. Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center . Chest1997; 111: 1654-1659 .
52.
52. Indihar FJ , Walker NE . Experience with a prolonged respiratory care unitrevisited . Chest1984; 86: 616-620 .
53.
53. Rosen RL , Bone RC . Economics of mechanical ventilation . Clin Chest Med1988; 9: 163-169 .
54.
54. Scheinhorn DJ , Chao DC , Stern-Hassenpflug M . Prolonged mechanical ventilation treatment of 2171 patients over 14 years at a regional weaning center . Am J Resp Crit Care Med2003; 167, A458-A458 .
