Prolonged Mechanical Ventilation in the chronic critically ill Patient
Robert Cox | RRT, Senior Respiratory Therapist, Select Medical
Mary Burkett | R.N., M.S., CNS, Sr. VP Clinical, Select Medical
strategies for rapid liberation from the ventilator are no longer appropriate, as the
Prolonged mechanical ventilation (PMV) has
patient has transitioned from acute to chronic critical illness. Every intervention
been defined as the requirement oF at least six
needs to be carefully considered so that the underlying mechanism of rampant
hours of mechanical ventilation per day for at
unchecked inflammation is reduced. In addition, RT driven weaning protocols that
least 21 consecutive days. (Chest, 2005)
are consistently exercised as the patient is ready enhance the steady slow process of weaning in this patient population.
The need for PMV is rarely, if ever, about management of the cardiopulmonary system. The need for PMV is a result of acute critical illness transitioning to
MiniMuM sedation is a significant part of ventilator liberation of CCIS chronic critical illness Syndrome (cciS). There is evidence that this transition
patients with chronic respiratory failure. All sedating medications should be
takes place between seven to 14 days post acute illness, if the patient does not
reviewed and discontinued if possible. Patients who are awake and alert and
fully recover from the acute episode. The complex pathophysiology of CCIS,
fully able to participate in therapy are ready to begin Spontaneous Breathing
which is an overwhelming and unchecked inflammatory response, is mediated by
trials (SBt). Clinicians must develop alternative methods for patient safety as
the neuro-endocrine system, the sympathetic nervous system and the immune
sedating medications are removed and patients become more alert. Patient safety
system. The response of these systems, in the early phases of critical illness, are
devices that can be considered during this process are enclosure beds, freedom
compensatory and adaptive. When the response is prolonged, it is no longer
splints, low beds and wrist restraints. Discontinuing high dose narcotics and
adaptive and diffuse organ and tissue damage result. The defining characteristics
benzodiapines are obvious but the clinician should also limit medications with
of CCIS include: severe nutritional deficits with the catabolization of muscles
sedative side effects. In addition, many medications have anticholinergic effects
for energy, severe weakness from nerve and muscle dysfunction, endocrine
which contribute significantly to delirium. These should be evaluated as delirium
dysfunction including loss of glycemic control and hypothyroidism, delirium
contributes to the need to sedate a patient.
and other mental health issues, bone loss, infections and immune dysfunction, wounds and a high burden of suffering. Managing the PMV patient requires careful consideration and management of each of these issues. Success is less about the manipulation of the ventilator and more about careful de-escalation of acute critical care strategies and an incremental movement toward restoration of “normalcy.”
PMV patients do well and recover in long-term acute care (ltac) hospitals due to the specialized approach and care given to this group of patients who have failed weaning in the acute care setting. LTAC hospitals specialize in the care of these patients as they are placed in an environment with clinicians who are experienced with structured therapeutic processes and allow the patient time to regain strength and treat medical issues that are hampering the weaning process. The strategies for successful weaning of CCIS patients in an LTAC hospital setting are simple and straightforward. The execution of these strategies requires skill and expertise, diligence and hard work. The foundation for weaning the PMV patient includes: MiniMizing sedation, Maintaining nutrition and MaxiMizing Mobility. The “3M approach” of minimizing, maintaining and maximizing is a simple approach to treating a complex medical condition. The acute care
our hospitals are part of select medical’s network of more than 100 long-term acute care hospitals. Prolonged Mechanical Ventilation in the chronic critically ill Patient
First Generation H1 antagonists such as Benadryl (diphenhydramine), Vistaril
SucceSSFul weaning ProtocolS require :
(Atarax) and Tavist (chlorphenirame) and antiemetics such as Phenergan
• Endorsement and support by the pulmonologists.
(promethazine) and Compazine (prochlorperazine) are medications that should be
• Straightforward and simple criteria for a wean trial. There should
stopped due to sedative side and/or anticholinergic effects. Alternative medications
be more than five pulmonary-related criteria and an evaluation of
that can be used without sedation as a side effect are Claritin for H1 antagonism
and Zofran as an antiemetic. Further evaluation in medication reduction in the PMV
• Execution of the protocol in a competent and predictable
patient is considering discontinuation of drugs that produce CNS depression such as
clonidine and triyclclic antidepressants. Treatment of anxiety disorders not a result of insufficient ventilator support should be given oral dosing in the same manner
the Following rePreSentS an exaMPle
used to treat the anxiety in the outpatient setting. Large doses and parenteral
oF a Very SucceSSFul Protocol :
administration should be avoided as it may lead to confusion, delirium or respiratory instability.
Management of the mechanical ventilator should consist of the patient having a resting respiratory rate between 15 to 25 breaths per minute. The actual mode
Maintain adequate nutrition support by a registered dietician or metabolic
for resting ventilator support can be Assist Control, SIMV with PSV or Pressure
support staff. Malnutrition will significantly limit ventilator weaning and physical
Support only. A comfortable setting to ensure adequate patient rest on a resting
therapy outcomes. Weekly monitoring of protein, albumin and prealbumin levels
mode of ventilation should be a priority. This can be assessed as the patient having
should be part of the plan to make sure nutrition goals are met. Ensuring adequate
a resting rate of less than 25 breaths per minute, Fi02 less than 60% and awake, alert
nutrition in CCIS/PMV provides energy, enhances wound healing, prevents excess
breakdown of lean body mass and boosts the immune system. Patients who meet the criteria to begin SBt are placed on PSV mode with 5 PS
MaxiMizing Mobility in cciS patients is individualized to each patient and 5 PeeP and observed for 10 minutes for signs of respiratory insufficiency. If due to the significance of muscle weakness and atrophy. Minimum requirements
respiratory distress is noted, the patient is returned to a resting mode of mechanical
should be Passive Range of Motion and out of bed to chair twice a day with a goal
ventilation and is reassessed in 24 hours for another SBT attempt. If the patient
of two hours total. Therapeutic modalities should be increased to Active Range of
passes SBT, the initial goal will be a trach collar trials (TCT) one hour BID with close
Motion, resistance exercise and ambulation. In addition to strengthening of muscles,
supervision by the clinical team. once the patient is able to tolerate one hour trach
weight bearing is anti-inflammatory and contributes to the resolution of delirium,
trials, the time off the ventilator is increased to two hours BID, three hours BID, four
turns off the catabolic stimuli of inflammation and helps restore glycemic control.
hours BID, 8 a.m. to 4 p.m. daily, 6 a.m. to 6 p.m. daily and then 6 a.m. to 10 p.m. daily.
During therapies, RT may support patients with full mechanical ventilation to
As the patient progresses to 16 hours per day consistently (6 a.m. to 10 p.m.) and
maximize physical therapy if respirator fatigue limits therapeutic gains.
appears comfortable, is mobilizing easily and has minimal secretions, the ventilator may be discontinued.
WEANING PRoToCoLS ARE NEEDED IN CoNjuNCTIoN WITH THE “3MS.” THERE
care plans and therapeutic goals for the treatment of cciS/PMV patients are distinctly different from acute critically ill patients. CCIS/PMV patients benefit
from basic care involving minimum sedation, maximizing mobility and maintaining
adequate nutrition allowing patients time to recover from their initial critical illness.
The use of a structured, RT-driven weaning protocol supplements the care of these patients and supports success. Successful weaning of the PMV patient is a marathon as opposed to the sprint of ventilator liberation in the acute care ICu.
our hospitals are part of select medical’s network of more than 100 long-term acute care hospitals.
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