The patient needing prolonged mechanical ventilation: a narrative review

Abstract

Background: Progress in management has improved hospital mortality of patients admitted to the intensive care
 units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of
 ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients,
 caregivers and health services, as well as high human and financial resources consumption, despite poor long-term
 outcomes. An effort should be made to improve the management of these patients. This narrative review
 summarizes the main concepts in this field.
 Main body: There is great variability in terminology and definitions of prolonged mechanical ventilation.
 There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of
 protocols, early mobilisation and physiotherapy, specialised weaning units.
 There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival
 of these patients.
 Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and
 controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.
 There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative
 and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised
 controlled trials on this critical issue. End of life decisions should result from appropriate communication among
 professionals, patients and surrogates and national legislations should give clear indications.
 Conclusion: Present medical training of clinicians and locations like traditional intensive care units do not appear
 enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals
 but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects
 of management are needed.

Physiotherapy and Weaning From Prolonged Mechanical Ventilation

“…2 Muscle weakness is a major contributing factor, together with malnutrition, chronic cardiac and respiratory disease, depression, anxiety, and previous delirium. 19 Studies have suggested that a comprehensive rehabilitation strategy is desirable to facilitate the weaning program. 28 Our 15-y analysis yielded 3 main findings.…”

“…12 Evidence of benefits from early mobilization and physiotherapy has expanded through randomized, controlled trials and systematic reviews. [13][14][15][16][17][18][19] Accordingly, we conducted an analysis of all subjects admitted to our weaning unit over a 15-y period who were on prolonged mechanical ventilation and underwent an intensive physiotherapy program. We assessed the effect of the physiotherapy program on the weaning success rate, as well as the correlates of weaning success and changes in outcomes over time.…”

Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper

“…− Twice per day evaluation of respiratory clinical parameters (temperature, SpO 2 , SpO 2 /FiO 2 , cough, dyspnea, manual muscle test, isokinetic muscle test, and measurement of joint range of motion. − In weaned patients and those with prolonged weaning from mechanical ventilation and oxygen use, reconditioning interventions are indicated in order to improve the physical status and to correct the motor and cognitive effects of prolonged immobilization in the intensive care area [40][41][42][43][44][45][46][47][48]. − As the effect of muscle activity in infections related to viral agents is not known, exercises aiming [15] at a gradual load increase based on subjective symptoms are recommended to maintain a normal function.…”

In response to Na et al.’s long-term mortality of patients discharged from the hospital after successful critical care: do we need more comprehensive data?

“…Furthermore, 673 patients were also excluded because of ICU readmission, the number of patients readmitted within 1 year and the mortality data are unclear. Therefore, the data represent the long-term outcome of ICU survivals and not patients who required ICU care.Secondly, in comparison with the 1-year mortality data from 2006 to 2011, the 5-year mortality data presented only a sample size as the study was performed on only 831 patients from 2006 to 2007.Thirdly, the authors did not report the impact of ICU length of stay, treatment modalities such as the length of mechanical ventilation weaning modalities, tracheostomy, presence of specialized weaning units [2], and renal replacement on survival. No data on the quality of life of survivors were mentioned, including transfer to long-term care facilities or receiving in-home mechanical ventilation during the follow-up period [3].…”

“…Thirdly, the authors did not report the impact of ICU length of stay, treatment modalities such as the length of mechanical ventilation weaning modalities, tracheostomy, presence of specialized weaning units [2], and renal replacement on survival. No data on the quality of life of survivors were mentioned, including transfer to long-term care facilities or receiving in-home mechanical ventilation during the follow-up period [3].…”