Resp Care
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Patients requiring prolonged mechanical ventilation are rapidly increasing in number. Improved ICU care has resulted in many patients surviving acute respiratory failure to require prolonged mechanical ventilation during convalescence. Also, mechanical ventilation is increasingly used as a therapeutic option for patients with symptomatic chronic hypoventilation, with an increased effort to predict nocturnal hypoventilation to initiate ventilation earlier. ⋯ These factors point to a likely increase in the number of patients receiving home mechanical ventilation in the United States. Unfortunately, there are no comprehensive databases or national registry of home ventilator patients-therefore the number of home ventilator patients is unknown. There are real challenges to providing mechanical ventilation in the home, which include caregiver training, adequacy of respiratory care, and reimbursement.
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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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Palliative care is an essential component of comprehensive care for all patients with chronic critical illness, including those receiving restorative or life-sustaining therapies. Core elements include alleviation of symptom distress, communication about care goals, alignment of treatment with the patient's values and preferences, transitional planning, and family support. Here we address strategies for assessment and management of symptoms, including pain, dyspnea, and depression, and for assisting patients to communicate while endotracheally intubated. ⋯ Challenges for supporting families and planning for transitions between care settings are identified, while the value of interdisciplinary input is emphasized. We review "consultative" and "integrative" models for integrating palliative care and restorative critical care. Finally, we highlight key ethical issues that arise in the care of chronically critically ill patients and their families.
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Technological innovations in the ICU have led to artificially prolonged life, with an associated cost. Chronic critical illness (CCI) occurs in patients with prolonged mechanical ventilation and allostatic overload, and is associated with a discrete and consistent metabolic syndrome. ⋯ Ideally, IMS should be under the supervision of a metabolic support consultative team. Further research specifically focused on the CCI population is needed to validate this current approach.
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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.