Cost and Outcome of Mechanical Ventilation for Life-Threatening Stroke

Abstract

Background and Purpose-Hospital mortality rates of 50% to 90% have been reported for stroke patients treated with mechanical ventilation. These data have raised serious questions about the cost-effectiveness of this intervention. We sought to determine how often stroke patients are mechanically ventilated, identify predictors of 30-day survival among ventilated patients, and evaluate the cost-effectiveness of this intervention. Methods-We identified mechanically ventilated patients in a population-based multiethnic cohort of 510 incidence stroke patients who were hospitalized between July 1993 and June 1996. Factors affecting 30-day survival were identified in a multiple logistic regression analysis. We calculated the cost per patient discharged alive, life-year saved, and quality-adjusted life-year saved using a zero-cost, zero-life assumption. Results-Ten percent of patients (nϭ52) were mechanically ventilated. Thirty-day mortality was 65% overall and did not differ significantly by stroke subtype. Glasgow Coma Scale score on the day of intubation (PϽ0.01) and subsequent neurological deterioration (Pϭ0.02) were identified as predictors of 30-day mortality. The cost (1996 US dollars) of hospitalization per patient discharged alive was $89 400; the cost per year of life saved was $37 600; and the cost per quality-adjusted life-year saved was $174 200. Functional status of most survivors was poor; at 6 months, half were severely disabled and completely dependent. In a worst-case scenario of quality of life preferences, mechanical ventilation resulted in a net deficit of meaningful survival. Conclusions-Two thirds of mechanically ventilated stroke patients die during their hospitalization, and most survivors are severely disabled. Survival is particularly unlikely if patients are deeply comatose or clinically deteriorate after intubation. In our multiethnic urban population, mechanical ventilation for stroke was relatively cost-effective for extending life but not for preserving quality of life.

Predictors of weaning and extubation failure in mechanically ventilated acute ischemic stroke patients

“…The intubation rate (10.6%) and extubation failure (21%) in our patient cohort were similar to published literature [4,25]. However, we did not find any association between positive fluid balance and development of pneumonia [15,26] and ability to follow commands [15,23,27] with weaning outcome.…”

“…We observed 25% mortality rate in our total patient cohort, slightly better than previous reports [25]. Improvement in acute care and neurocritical care management of stroke may in part explain the observed difference.…”

Pneumonia in acute stroke patients fed by nasogastric tube

“…Second, even if one refrains from endotracheal intubation initially, it will anyway become necessary later in a substantial number of patients: in our study, more than one third of patients with pneumonia required endotracheal intubation and mechanical ventilation, 40% of them because of pneumonia related respiratory failure. Finally, although the outcome of stroke patients needing mechanical ventilation is generally considered to be unfavourable, [35][36][37][38] broadening the indications for this intervention along the lines suggested could change this assessment.…”

Combination of five clinical data as prognostic factors of mortality after ischemic stroke

“…The study by Mayer et al (19) states that two-thirds of stroke patients who use mechanical ventilators die during hospitalization and the majority of patients who survive experience severe disabilities. Patients who experience coma or worsening of their clinical condition after intubation have an extremely low chance of survival.…”