Key Point

A consensus statement has been developed to address the needs of the growing number of patients requiring prolonged mechanical ventilation.

DURHAM, NC—After reviewing the available data and current practice related to prolonged mechanical ventilation (PMV), the authors of a new consensus statement have developed 12 recommendations addressing three main areas of PMV—epidemiology/outcomes, management and care settings, and reimbursement.¹ The recommendations are summarized here.

• PMV should be defined as the need for at least six hours of mechanical ventilation daily for 21 days.

• Large prospective studies are needed to better define the population of patients requiring PMV. Current models are not accurate enough or sufficiently validated to guide decision making in individuals.

• In patients with slowly resolving respiratory insufficiency, complete liberation from mechanical ventilation or a need for only nocturnal noninvasive ventilation for seven consecutive days should be considered successful weaning.

• Although many factors for ventilator dependence have been identified, their frequency among PMV patients is unknown. It is important to identify potentially reversible factors, especially those that are iatrogenic.

• Post-ICU venue selection in hard-to-wean cases should take into account the patient’s perspective and the services needed. Comorbidities may preclude transfer to facilities without intensive or acute care capability.

• PMV-focused care should be introduced when tracheostomy is first considered.

• PMV weaning strategies in post-ICU settings should incorporate protocols that include daily spontaneous breathing trials of progressively greater duration after the reduction of ventilatory support.

• Weaning efforts should continue until the weaning team and the patient and family agree that these efforts should cease. When a patient is deemed unweanable, discussions with the patient and family about prognosis and long-term options are essential.

• By providing counseling and education, a palliative care service can add value to the patient and family experience surrounding PMV care. Palliative care should be employed early in the hospitalization, if possible.

• Medicare’s Prospective Payment System (PPS) should be modified to eliminate financial incentives to delay or prevent the discharge of ventilator-dependent patients to lower-cost venues.

• Leaders from PMV-focused care venues should regularly explore options for improving PPS with Medicare and other payers.

• Clinical studies of the effect of patient selection, care processes, and care settings on long-term outcomes are clearly needed. "Given the rapidly expanding PMV population, research funding sources should give a high priority to such studies," concluded the authors.

—Timothy Begany

Reference
MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005;128:3937-3954.

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