Resp Care
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This paper reviews management strategies for patients undergoing prolonged mechanical ventilation (PMV). Topics covered include how to identify and correct barriers to weaning, the systematic approach to weaning trials, when to cease weaning trials and proceed with life-long support, managing the tracheostomy tube during PMV, and, finally, how to select a suitable mechanical ventilator for PMV.
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Neuromuscular complications of critical illness are common, and can be severe and persistent, with substantial impairment in physical function and long-term quality of life. While the etiology of ICU-acquired weakness (ICUAW) is multifactorial, both direct (ie, critical illness neuromyopathy) and indirect (ie, immobility/disuse atrophy) complications of critical illness contribute to it. ICUAW is often difficult to diagnose clinically during the acute phase of critical illness, due to the frequent use of deep sedation, encephalopathy, and delirium, which impair physical examination for patient strength. ⋯ However, a number of studies support the benefit of intensive rehabilitation in patients receiving chronic mechanical ventilation. Furthermore, emerging data demonstrate the safety, feasibility, and potential benefit of early mobility in critically ill patients, with the need for multicenter randomized trials to evaluate potential short- and long-term benefits of early mobility, including the potential to prevent the need for prolonged mechanical ventilation and/or the development of chronic critical illness, and other novel treatments on patients' muscle strength, physical function, quality of life, and resource utilization. Finally, the barriers, feasibility, and efficacy of early mobility in both medical and other ICUs (eg, surgical, neurological, pediatric), as well as in the chronic critically ill, have not been formally evaluated and require exploration in future clinical trials.
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An estimated 2-3% of all hospitalized patients become critically ill. These patients are in a state of relative immune exhaustion, which cripples their response to infections. Patients are sicker, have many comorbidities, and undergo complex procedures. ⋯ In addition, specific attention is required to environmental services and surface and equipment cleaning. A well organized infection control program and an antimicrobial stewardship program have become indispensable to achieve these goals. All of these key principles and recommendations are also relevant to the chronically ill patient in acute care hospital ICUs and step-down units.
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The chronically critically ill (CCI) patient population is characterized by a prolonged need for high cost medical interventions, a high 1-year mortality rate, and a very high demand for post acute care services. The best characterized CCI patient population is patients on prolonged mechanical ventilation (PMV). This review will focus on the current knowledge of costs and care venues for the care of this patient population. ⋯ Given the dramatic comparative acute care cost burden of PMV patients, the societal implications for managing both the care burden and the costs of care are staggering. Strategies to improve the efficiency in healthcare for this patient population will be essential. Limitations to the existing care models in the United States will be identified with a focus on our current research deficiencies, which limit healthcare providers and administrators in providing patient focused care for this patient population.
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The chronically critically ill (CCI) comprise a rapidly growing population of patients who have survived acute critical illness, only to be left with ongoing organ dysfunctions requiring high levels of specialized care for months or years. In many ways, CCI is an "iatrogenic" process, reflecting the ability of modern life support technologies to keep patients alive for prolonged periods of time despite ongoing life threatening illness. ⋯ Importantly, CCI patients transition among these venues frequently, reflecting the nature of CCI to be punctuated with episodes of acute critical illness. Management of the CCI population requires a special combination of intensive care and rehabilitative skills.