UM Guidelines

Applies to BlueCare Only

Evidence Summary

Prolonged mechanical ventilation (PMV) is associated with some of the highest costs in medical care. The care of ventilator patients accounts for approximately 37% of all ICU cases and utilizes vast resources through clinical care needs and from the standpoint of case management resources. (5)

PMV has been variously defined but a common, accepted (e.g., expert panel consensus, used in peer-reviewed research on the topic) definition is an episode wherein a patient requires mechanical ventilatory support for 6 or more hours a day for 21 days. (7) (8) (9) (10) (11) Whatever the specific method of weaning employed, the vast majority of newly intubated patients are successfully extubated well before 21 days. (16) 

A randomized study examining 500 patients transferred to post-acute care after more than 21 days of mechanical ventilation found that 32% of patients passed an initial spontaneous breathing trial upon arrival at the facility and were rapidly liberated, highlighting the need to be aggressive in ICU-based weaning trials and to be cautious in prematurely labeling a patient ventilator-dependent.(10)  An accompanying editorial concludes that this data, showing such a high rate of initial ability to wean, suggests that a significant proportion of patients sent to post-acute care due to failure to wean may instead have experienced failure to adequately attempt to wean in the acute care hospital.(31)  This same trial then randomized the remaining truly ventilator-dependent patients admitted to post-acute care with a weaning strategy of reducing pressure-supported ventilation or spontaneous breathing trials through a tracheostomy collar and found that the spontaneous breathing strategy did not result in a higher proportion of patients successfully weaned but did shorten the median time to successful weaning (11 days vs 16 days). (10)  Various studies have reported ventilator liberation rates ranging between 51% and 67% in post-acute settings. (11) (32) (33) (34) (36) (37) (38)

Patients undergoing PMV should continue to be evaluated for weaning potential in the post-acute environment. Given appropriate time and effort a substantial number of the subgroup can be successfully removed from mechanical ventilation and liberated. (33) (38)

Clinical Indications for Admission to Recovery Facility

• Skilled nursing facility (SNF) care is/was needed for appropriate care of patient because of ALL the following:
  • Patient is stable for transfer to Skilled Nursing Facility - Enhanced Respiratory Care for ventilator weaning as indicated by ALL of the following (6):
    • Intravenous vasopressor blood pressure support absent for at least 24 hours
    • No significant acute hypotension (e.g., SBP less than 90 mm Hg)
    • Evaluation and plan of care submitted
    • Cardiovascular status stable
    • Stable chest x-ray findings
    • Renal function stable and/or back to baseline
    • Pain adequately managed
    • No acute severe unstable neurologic abnormalities (e.g., altered mental status, evidence of ongoing CNS embolization or ischemia, worsening hydrocephalus, no use of physical or chemical restraints)
    • No acute significant hepatic dysfunction (e.g., new encephalopathy)
    • No active bleeding or unstable disorders of hemostasis (e.g., no recent need for transfusion, severe thrombocytopenia with bleeding)
    • Adequate nutrition program in place with stable source for long term nutritional requirements
    • Treatment plan for comorbidities in place
    • No need for respiratory or other isolation, or isolation manageable at the next level of care
    • Respiratory stability, as indicated by ALL of the following: (5)
    • Safe and secure airway
    • Stable ventilator settings, and no need for sophisticated ventilator modes
    • Positive end-expiratory pressure requirement 10 cm H2O or less
    • Adequate oxygenation (SaO2 90% or greater) on FIO2 50% or less
    • Oxygenation stable during suctioning and repositioning
  • Prolonged mechanical ventilation present (PMV) - (21 days of mechanical ventilation for at least 6 hours per day, with multiple weaning attempts unsuccessful) (7) (8) (9) (10) (11)
  • Clinical assessment indicates expectation that patient will benefit from and improve (e.g., be weaned) with an Enhanced Respiratory Care program available at chosen facility (e.g., palliative care not more appropriate or preferred). (12) (13) (14) (15)

Hospital Care Planning – Criteria for Active Weaning

• Common treatments and tests include (16) (17) (18) (19) (20) (21) (22):
• Bronchodilators, steroids, chest physiotherapy, pulmonary toilet (e.g., suctioning)
• Parenteral antibiotics
• ABG, chest x-ray, oximetry
• Daily spontaneous breathing trials (SBT) with interruption of sedation
• Daily weaning parameters
• Weaning barriers assessment
• Enteral (preferred) or parenteral nutrition
• Evaluation of swallowing function (23)
• Tracheostomy occlusion trials (23)
• Surveillance testing for infection (24) (27) (25) (26)

Length of Stay and Rehabilitation Frequency

Goal Length of Stay: 7-days

Best Practice Recommendations

• Recommendation 1:

In patients requiring mechanical ventilation for 24 hours, a search for all the causes that may be contributing to ventilator dependence should be undertaken. This is particularly true in the patient who has failed attempts at withdrawing the mechanical ventilator. Reversing all possible ventilatory and non-ventilatory issues should be an integral part of the ventilator discontinuation process. (1)

• Recommendation 2:

Patients receiving mechanical ventilation for respiratory failure should undergo a formal assessment of discontinuation potential if the following criteria are satisfied: Evidence for some reversal of the underlying cause for respiratory failure; Adequate oxygenation - PEEP 5 to 8 cm H2O; Fio2 0.4 to 0.6 Hemodynamic stability, as defined by the absence of active myocardial ischemia and the absence of clinically significant hypotension (e.g., a condition requiring no vasopressor therapy) and The capability to initiate an inspiratory effort. Weaning Parameters daily (4) (18) (30) Afebrile HR < 120 EtCO2 < 50 or WNL for patient RSBI < 105 VC > 10 ml/kg IBW NIF @ least -20 cmH2O The decision to use these criteria must be individualized. Some patients not satisfying all of the above criteria (e.g., patients with chronic hypoxemia values below the thresholds cited) may be ready for attempts at the discontinuation of mechanical ventilation. (1)

• Recommendation 3:

Formal discontinuation assessments for patients receiving mechanical ventilation for respiratory failure should be performed during spontaneous breathing rather than while the patient is still receiving substantial ventilatory support. An initial brief period of spontaneous breathing can be used to assess the capability of continuing onto a formal SBT. The criteria with which to assess patient tolerance during SBTs are the respiratory pattern, the adequacy of gas exchange, hemodynamic stability, and subjective comfort. The tolerance of SBTs lasting 30 to 120 min should prompt consideration for permanent ventilator discontinuation. (1)

• Recommendation 4:

Weaning strategies in the PMV patient should be slow-paced and should include gradually lengthening self-breathing trials. (1)

• Recommendation 5:

Patients receiving mechanical ventilation for respiratory failure who fail a SBT should have the cause for the failed SBT determined. Once reversible causes for failure are corrected, and if the patient still meets the criteria, subsequent SBTs should be performed every 24 hours. (1)

• Recommendation 6:

Weaning/discontinuation protocols that are designed for non-physician healthcare professionals (HCPs) should be developed and implemented. Protocols aimed at minimizing sedation also should be developed and implemented. (1)

• Recommendation 7:

In patients with slowly resolving respiratory insufficiency, complete liberation from mechanical ventilation (or a requirement for only nocturnal NIV) for 7 consecutive days should constitute successful liberation. (8)

• Recommendation 8:

The removal of the artificial airway from a patient who has successfully been discontinued from ventilatory support should be based on assessments of airway patency and the ability of the patient to protect the airway. (1)

• Recommendation 9:

Unless there is evidence for clearly irreversible disease (e.g., high spinal cord injury or advanced amyotrophic lateral sclerosis), a patient requiring prolonged mechanical ventilatory support for respiratory failure should not be considered permanently ventilator-dependent until 3 months of weaning attempts have failed. (1)

References

1. MacIntyre NR, Cook DJ, Ely EW, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians, the American Association for Respiratory Care, and the American College of Critical Care Medicine. Chest 2001; 120(suppl):375S–395S.
2. Divo MJ, Murray S, Cortopassi F, Celli BR. Prolonged mechanical ventilation in Massachusetts: the 2006 prevalence survey. Respiratory Care 2010;55(12):1693-8.
3. Carson SS. Definitions and epidemiology of the chronically critically ill. Respiratory Care 2012;57(6):848-56; discussion 856-8. DOI: 10.4187/respcare.01736.
4. Geiseler J, Karg O, Borger S, Becker K, Zimolong A. Invasive home mechanical ventilation, mainly focused on neuromuscular disorders. GMS Health Technology Assessment 2010;6: Doc08. DOI: 10.3205/hta000086.
5. Make BJ, et. al. Mechanical Ventilation Beyond the Intensive Care Unit, Report of a Consensus Conference of the American College of Chest Physicians, Chest 1998.
6. Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine 2013;41(2):580-637. DOI: 10.1097/CCM.0b013e31827e83af. (Reaffirmed 2014 Oct)
7. White AC. Long-term mechanical ventilation: management strategies. Respiratory Care 2012;57(6):889-97; discussion 898-9. DOI: 10.4187/respcare.01850.
8. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest 2005;128(6):3937-54. DOI: 10.1378/chest.128.6.3937.
9. Carson SS. Definitions and epidemiology of the chronically critically ill. Respiratory Care 2012;57(6):848-56; discussion 856-8. DOI: 10.4187/respcare.01736.
10. Jubran A, et al. Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. Journal of the American Medical Association 2013;309(7):671-7. DOI: 10.1001/jama.2013.159.
11. Scheinhorn DJ, et al. Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest 2007;131(1):85-93. DOI: 10.1378/chest.06-1081.
12. Carson SS, et al. A multicenter mortality prediction model for patients receiving prolonged mechanical ventilation. Critical Care Medicine 2012;40(4):1171-6.
13. Singanayagam A, Schembri S, Chalmers JD. Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease. Annals of the American Thoracic Society 2013;10(2):81-9.
14. Edgerton JR, et al. Long-term fate of patients discharged to extended care facilities after cardiovascular surgery. Annals of Thoracic Surgery 2013;96(3):871-7.
15. Unroe M, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Annals of Internal Medicine 2010;153(3):167-75.
16. Donahoe MP. Current venues of care and related costs for the chronically critically ill. Respiratory Care 2012;57(6):867-86; discussion 886-8.
17. Maguire JM, Carson SS. Strategies to combat chronic critical illness. Current Opinion in Critical Care 2013;19(5):480-7.
18. Black CJ, Kuper M, Bellingan GJ, Batson S, Matejowsky C, Howell DC. A multidisciplinary team approach to weaning from prolonged mechanical ventilation. British Journal of Hospital Medicine 2012;73(8):462-6.
19. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. American Journal of Respiratory and Critical Care Medicine 2010;182(4):446-54.
20. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease. [Internet] Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2014 Jan Accessed at: http://www.goldcopd.org.
21. Brochard L, Thille AW. What is the proper approach to liberating the weak from mechanical ventilation? Critical Care Medicine 2009;37(10 Suppl): S410-5.
22. Ghamloush M, O'Connor HH, White AC. Patient-ventilator interaction in the long-term acute-care hospital. Respiratory Care 2011;56(2):207-13.
23. O'Connor HH, Kirby KJ, Terrin N, Hill NS, White AC. Decannulation following tracheostomy for prolonged mechanical ventilation. Journal of Intensive Care Medicine 2009 May-Jun;24(3):187-94.
24. Chitnis AS, Edwards JR, Ricks PM, Sievert DM, Fridkin SK, Gould CV. Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010. Infection Control and Hospital Epidemiology 2012;33(10):993-1000.
25. Bhargava A, et al. Risk factors for colonization due to carbapenem-resistant Enterobacteriaceae among patients exposed to long-term acute care and acute care facilities. Infection Control and Hospital Epidemiology 2014;35(4):398-405.
26. Hoskinson S. Cellulitis and soft tissue infections. ACP Smart Medicine [Internet] American College of Physicians. Accessed at: http://smartmedicine.acponline.org/.
27. Chitnis AS, Edwards JR, Ricks PM, Sievert DM, Fridkin SK, Gould CV. Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010. Infection Control and Hospital Epidemiology 2012;33(10):993-1000.
28. Thrush A, Rozek M, Dekerle.g.and JL. The clinical utility of the functional status score for the intensive care unit (FSS-ICU) at a long-term acute care hospital: a prospective cohort study. Physical Therapy 2012;92(12):1536-45.
29. O'Connor HH, White AC. Tracheostomy decannulation. Respiratory Care 2010;55(8):1076-81.
30. Vallverdu I, Calaf N, Subirana M, et al. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med 1998; 158:1855–1862.
31. Kahn JM, Carson SS. Generating evidence on best practice in long-term acute care hospitals. Journal of the American Medical Association 2013;309(7):719-20.
32. Lindsay ME, et al. Weaning at a nursing home ventilator unit: impact of non-invasive ventilation and cost savings. Chest 2000;118(Suppl):162S-163S.
33. Lindsay ME, et al. Shifting Care of Chronic Ventilator-Dependent Patients from the Intensive Care Unit to the Nursing Home. Joint Commission Journal on Quality and Safety May 2004 Volume 30 Number 5, 257-265.
34. Bagley P.H., Cooney E.: A community-based regional ventilator weaning unit: Development and outcomes. Chest 111:1024–1029, Apr. 1997.
35. Cook D. et al. AHRQ (Agency for Healthcare Research and Quality). Criteria for weaning from mechanical ventilation. www.ahrq.gov/clinic/epcsums/mechsumm.htm.
36. Gracey D.R., Hardy D.C., Koenig G.E.: The chronic ventilator-dependent unit: A lower-cost alternative to intensive care. Mayo Clin Proc 75:445–449, May 2000.
37. Latriano B., et al.: Non-ICU care of hemodynamically stable mechanically ventilated patients. Chest 109:1591–1596, Jun. 1996.
38. Gantt G., The Future of Prolonged Mechanical Ventilation in the Post-Acute Setting. 2011 American College of Chest Physicians International Congress.

 

 

 

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