Clinical outcomes of difficult-to-wean patients with ventilator dependency at intensive care unit discharge
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Background: Ventilator-dependent patients in the intensive care unit (ICU) who are difficult to wean from invasive mechanical ventilation (IMV) have been increasing in number. However, data on the clinical outcomes of difficult-to-wean patients are lacking. We aimed to evaluate clinical outcomes in patients discharged from the ICU with tracheostomy and ventilator dependency. Methods: We retrospectively investigated clinical course and survival in patients requiring home mechanical ventilation (HMV) with a tracheostomy and difficulty weaning from IMV during medical ICU admission from September 2013 through August 2016 at Severance Hospital, Yonsei University, Seoul, Korea. Results: Of 84 difficult-to-wean patients who were started on HMV in the medical ICU, 72 survived, were discharged from the ICU, and were included in this analysis. HMV was initiated after a median of 23 days of IMV, and the successful weaning rate was 46% (n=33). In-hospital mortality rate was significantly lower in the successfully weaned group than the unsuccessfully weaned group (0% vs. 23.1%, respectively; P=0.010). Weaning rates were similar according to primary diagnosis, but high body mass index (BMI), low Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at ICU admission, and absence of neuromuscular disease were associated with weaning success. After a median follow-up of 4.6 months (range, 1–27 months) for survivors, 3-month (n=64) and 6-month (n=59) survival rates were 82.5% and 72.2%, respectively. Survival rates were higher in the successfully weaned group than the unsuccessfully weaned group at 3 months (96.4% vs. 69.0%; P=0.017) and 6 months (84.0% vs. 62.1%; P=0.136) following ICU discharge. Conclusions: In summary, 46% of patients who started HMV were successfully weaned from the ventilator in general wards. High BMI, low APACHE II score, and absence of neuromuscular disease were factors associated with weaning success.
Abstract
Background: Ventilator-dependent patients in the intensive care unit (ICU) who are difficult to wean from invasive mechanical ventilation (IMV) have been increasing in number. However, data on the clinical outcomes of difficult-to-wean patients are lacking. We aimed to evaluate clinical outcomes in patients discharged from the ICU with tracheostomy and ventilator dependency. Methods: We retrospectively investigated clinical course and survival in patients requiring home mechanical ventilation (HMV) with a tracheostomy and difficulty weaning from IMV during medical ICU admission from September 2013 through August 2016 at Severance Hospital, Yonsei University, Seoul, Korea. Results: Of 84 difficult-to-wean patients who were started on HMV in the medical ICU, 72 survived, were discharged from the ICU, and were included in this analysis. HMV was initiated after a median of 23 days of IMV, and the successful weaning rate was 46% (n=33). In-hospital mortality rate was significantly lower in the successfully weaned group than the unsuccessfully weaned group (0% vs. 23.1%, respectively; P=0.010). Weaning rates were similar according to primary diagnosis, but high body mass index (BMI), low Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at ICU admission, and absence of neuromuscular disease were associated with weaning success. After a median follow-up of 4.6 months (range, 1–27 months) for survivors, 3-month (n=64) and 6-month (n=59) survival rates were 82.5% and 72.2%, respectively. Survival rates were higher in the successfully weaned group than the unsuccessfully weaned group at 3 months (96.4% vs. 69.0%; P=0.017) and 6 months (84.0% vs. 62.1%; P=0.136) following ICU discharge. Conclusions: In summary, 46% of patients who started HMV were successfully weaned from the ventilator in general wards. High BMI, low APACHE II score, and absence of neuromuscular disease were factors associated with weaning success.
참고문헌 (25)
- Ambrosino N, "The difficult-to-wean patient", Expert Rev Respir Med, 4, pp.685~692 (2010)
- Esteban A, "How is mechanical ventilation employed in the intensive care unit? An international utilization review", Am J Respir Crit Care Med, 161, pp.1450~1458 (2000)
- Boles JM, "Weaning from mechanical ventilation", Eur Respir J, 29, pp.1033~1056 (2007)
- MacIntyre NR, "Evidence-based guidelines for weaning and discontinuing ventilatory support : a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine", Chest, 120(6 Suppl), pp.375S~395S (2001)
- Kahn JM, "Development and validation of an algorithm for identifying prolonged mechanical ventilation in administrative data", Health Serv Outcomes Res Methodol, 9, pp.117~132 (2009)
- Carpenè N, "A proposal of a new model for long-term weaning : respiratory intensive care unit and weaning center", Respir Med, 104, pp.1505~1511 (2010)
- Bigatello LM, "Outcome of patients undergoing prolonged mechanical ventilation after critical illness", Crit Care Med, 35, pp.2491~2497 (2007)
- Shin HJ, "Clinical factors associated with weaning failure in patients requiring prolonged mechanical ventilation", J Thorac Dis, 9, pp.143~150 (2017)
- Lee SH, "Outcomes and prognostic factors in patients with prolonged acute mechanical ventilation : a single-center study in Korea", J Crit Care, 30, pp.1016~1020 (2015)
- Lee K, "Sequential organ failure assessment score and comorbidity : valuable prognostic indicators in chronically critically ill patients", Anaesth Intensive Care, 36, pp.528~534 (2008)
- 김미현, "Prognostic Factors of Patients Requiring Prolonged Mechanical Ventilation in a Medical Intensive Care Unit of Korea", Tuberculosis and Respiratory Diseases, 73(4), pp.224~230 (2012), 대한결핵및호흡기학회[DOI]
- Mok JH, "Clinical application of the ProVent score in Korean patients requiring prolonged mechanical ventilation : a 10-year experience in a university-affiliated tertiary hospital", J Crit Care, 33, pp.158~162 (2016)
- Nelson JE, "Chronic critical illness", Am J Respir Crit Care Med, 182, pp.446~454 (2010)
- Scheinhorn DJ, "Post-ICU mechanical ventilation : treatment of 1, 123 patients at a regional weaning center", Chest, 111, pp.1654~1659 (1997)
- Slomka J, "Influence of clinicians’ values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation", Am J Crit Care, 9, pp.412~418 (2000)
- dos Santos CC, "Protective ventilation of patients with acute respiratory distress syndrome", Crit Care, 8, pp.145~147 (2004)
- Gillette MA, "Ventilator-induced lung injury and the evolution of lung-protective strategies in acute respiratory distress syndrome", Respir Care, 46, pp.130~148 (2001)
- Epstein SK, "Decision to extubate", Intensive Care Med, 28, pp.535~546 (2002)
- Charlson ME, "A new method of classifying prognostic comorbidity in longitudinal studies : development and validation", J Chronic Dis, 40, pp.373~383 (1987)
- Damuth E, "Long-term survival of critically ill patients treated with prolonged mechanical ventilation : a systematic review and metaanalysis", Lancet Respir Med, 3, pp.544~553 (2015)
- Lai YC, "Hemoglobin levels and weaning outcome of mechanical ventilation in difficult-to-wean patients : a retrospective cohort study", PLoS One, 8, pp.e73743~ (2013)
- Clochesy JM, "Weaning chronically critically ill adults from mechanical ventilatory support : a descriptive study", Am J Crit Care, 4, pp.93~99 (1995)
- Lim SY, "Body mass index and mortality in Korean intensive care units : a prospective multicenter cohort study", PLoS One, 9, pp.e90039~ (2014)
- 김형래, "Body mass index is inversely associated with mortality in patients with acute kidney injury undergoing continuous renal replacement therapy", Kidney Research and Clinical Practice, 36(1), pp.39~47 (2017), 대한신장학회
- Pickkers P, "Body mass index is associated with hospital mortality in critically ill patients : an observational cohort study", Crit Care Med, 41, pp.1878~1883 (2013)