Consensus Statements

Mechanical Ventilation: Beyond the ICU
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Criteria for Long-term Invasive and Noninvasive
Mechanical Ventilation Beyond the ICU

• Patients who may be candidates for discharge to a non-ICU site include:
• Patients with absent or severely impaired spontaneous breathing efforts, including (1) those with central hypoventilation secondary to inadequate central respiratory drive, eg, intracranial hemorrhage, cerebrovascular accident, central alveolar hypoventilation; and (2) those with severe respiratory muscle failure, eg, high (cervical) spinal cord injury.
• Patients who have had acute respiratory failure and remain stable on long-term mechanical ventilation but who fail repeated attempts to wean from mechanical ventilation, eg, previously well persons who required mechanical ventilation for a severe illness or trauma, and chronically ill patients who required mechanical ventilation for a superimposed acute illness and require prolonged ventilation after the acute illness.
• Patients with chronic disorders who have recurrent episodes of respiratory failure that require ICU treatment and mechanical ventilation, eg, those with severe COPD, kyphoscoliosis, or slowly progressive neuromuscular disorders.

Table 1 lists indications for both invasive and noninvasive long-term ventilation beyond the ICU.

Table 1—Indications for Mechanical Ventilation Beyond the ICU

Indications for NIV Patient has chronic stable or slowly progressive respiratory failure: Significant daytime CO2 retention (> 50 mm Hg) with appropriately compensated pH or Mild daytime or nocturnal CO2 retention (45 to 50 mm Hg) with symptoms attributable to hypoventilation (eg, morning headaches, restless sleep, nightmares, enuresis, daytime hypersomnolence, etc) Significant nocturnal hypoventilation or oxygen desaturation The following conditions have been met: Patient has had optimal medical therapy for underlying respiratory disorders Patient is able to protect airway and clear secretions adequately Patient's reversible contributing factors have been treated (eg, obstructive sleep apnea, hypothyroidism, congestive heart failure, severe electrolyte disturbance). The diagnosis is appropriate (see Table 2) and may include the following: Neuromuscular disorders Chest wall deformity Central hypoventilation syndrome or obesity hypoventilation Obstructive sleep apnea, and a failure to improve with nasal CPAP COPD, with severe hypercapnia or nocturnal desaturation (tentative indication)*

Indications for invasive ventilation Patient meets indications for NIV and has the following: Uncontrollable airway secretions despite use of noninvasive expiratory aids; or Impaired swallowing leading to chronic aspiration and repeated pneumonias Patient has persistent symptomatic respiratory insufficiency and fails to tolerate or improve with NIV Patient needs round-the-clock (> 20 h) ventilatory support because of severely weakened or paralyzed respiratory muscles (eg, quadriplegia due to high spinal cord lesions or end-stage neuromuscular disease) and patient or provider prefers invasive ventilation.

*However, some conferees strongly prefer NIV, even when the patient has a need for continuous ventilatory support, as long as upper airway function is intact.

Table 2 lists medical conditions that are appropriate for long-term mechanical ventilation beyond the ICU.

Table 2— Medical Conditions Appropriate for Long-term Mechanical Ventilation Beyond the ICU

CNS disorders Arnold-Chiari malformation CNS trauma Cerebrovascular disorders Congenital and acquired central control of breathing disorders Myelomeningocele Spinal cord traumatic injuries

Neuromuscular disorders ALS Congenital childhood hypotonias Guillain-Barr³ syndrome Infant botulism Muscular dystrophies Myasthenia gravis Phrenic nerve paralysis Polio and postpolio sequelae Spinal muscular atrophy Myotonic dystrophy

Skeletal disorders Kyphoscoliosis Thoracic wall deformities Thoracoplasty

Cardiovascular disorders Acquired heart diseases Congenital heart diseases

Respiratory disorders Upper airway Pierre Robin syndrome Tracheomalacia Vocal cord paralysis Lower respiratory tract BPD COPD Complications of acute lung injury Cystic fibrosis Complications of infectious pneumonias Pulmonary fibrotic diseases

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