Prolonged Mechanical Ventilation
Prolonged mechanical ventilation (PMV) is defined as requiring mechanical ventilation for greater than 14 to 21 days for acute illness or injury. Use of the ProVent14 score to assess expected survival can guide provider communication with patients and car
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Thomas Bice and Shannon S. Carson
Case Presentation
Principles of Management
A 55 year-old woman with a history of type II diabetes mellitus and hypertension was admitted for acute hypoxemic respiratory failure from acute respiratory distress syndrome (ARDS) secondary to pneumonia and septic shock. She was managed with lung protective ventilation, antibiotics, vasopressors, and supportive care. Her clinical course was complicated by delirium and shock, both of which subsequently resolved, and acute renal failure requiring hemodialysis. On day 14 of mechanical ventilation she followed commands on intermittent analgesic for comfort, but she continued to fail all spontaneous breathing trials. She was scheduled to undergo tracheostomy the next day to facilitate prolonged mechanical ventilation.
Diagnosis
Question What approach should guide this patient’s ventilator management? Answer Daily tracheostomy collar trials as long as tolerated
T. Bice (*) • S.S. Carson Pulmonary and Critical Care Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA e-mail: [email protected]
Prolonged mechanical ventilation (PMV) is defined as requiring mechanical ventilation for greater than 14–21 days for acute illness or injury. This population comprises 5–10 % of mechanically ventilated patients; their long-term mortality, hospital lengths of stay, and resource utilization are significantly higher than for other mechanically ventilated patients [1–3]. By definition, PMV patients have failed to be weaned from mechanical ventilation in a timely manner using standard approaches. They are often weak with skeletal muscle atrophy, prone to delirium and recurrent infections, and can develop metabolic complications and skin breakdown. Therefore, special consideration to the management of PMV patients is required.
Assess Expected Survival Because PMV patients have survived the immediate phase of critical illness but often have poor long-term survival, the Provent14 score was developed to predict 1-year mortality in patients requiring PMV [4]. Using 5 simple clinical variables measured on day 14 of ventilation, the Provent14 score can accurately predict the 1-year mortality for this population (Table 28.1). The case patient would receive a score of 3 – 1 point for non-trauma, 1 point for hemodialysis, and 1
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_28
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T. Bice and S.S. Carson
252 Table 28.1 ProVent14 score and associated mortality Patient characteristics Non-trauma Requiring vasopressors Requiring hemodialysis Platelet count ≤100 Age 50–64 Age ≥65
Points 1 1
Total score 0 1
1-year mortality % (95 % CI) 4 (0, 9) 28 (19, 37)
1
2
43 (35, 51)
1
3
61 (52, 70)
1 2
4–6
92 (84, 100)
Data from Hough et al. [4]
point for her age – and would have an expected 1-year mortality of 61 % (95 % CI 52–70). These data can help inform discussions with the patient or their surrogates about the patient’s values and pre
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