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Mechanical Ventilation: Beyond the ICU

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Long-term Mechanical Ventilation:
Who, When, and Where

Who

The patient's physician and respiratory care team determine (1) the need for long-term ventilatory assistance, and (2) the type of mechanical ventilation, both technique and equipment, best for the patient after discharge from the ICU.

These determinations are based on (1) the patient's current illness and past medical history, (2) complete medical assessment, and (3) tests of daytime, and sometimes of nighttime, breathing efficiency and ability to breathe without help.

Patients who benefit from long-term mechanical ventilation are those whose medical conditions would become unstable if they were removed from mechanical ventilation. They might have recurrent or chronic conditions that make it more difficult for the patient to carry out activities of daily living.

When

Medical criteria determine when a patient can be discharged from the ICU on long-term mechanical ventilation to a site outside the ICU. However, other considerations also are important. Successful discharge on long-term mechanical ventilation is more likely when:

the patient is highly motivated to accept the responsibility to make long-term ventilation work;
the patient may be able to independently do some activities of daily living;
the patient is able to communicate with caregivers and give them direction;
the patient and his/her family understand all available options for long-term ventilation;
the family is able and willing to participate in long-term care;
financial resources are available for mechanical ventilation equipment and caregiver assistance such as nursing services; and
medical and respiratory care professionals are available to monitor and supervise long-term care.

Where

The optimal location for long-term ventilator-assisted individuals may be with the family in the home. In the home, the patient's quality of life is likely to be better than at any other location. Costs of care are usually lower when the patient is at home, but insurance coverage of home-care costs must be evaluated on an individual basis to determine if adequate reimbursement is available. Usually, the cost of home care must be less than the cost of a long-term care facility in order for benefits to apply.

Home is not the only site for patients to receive long-term mechanical ventilation. Other non-hospital sites may be appropriate for the patient's needs and resources. The appropriate site for long-term mechanical ventilation is one in which all of the patient's needs—medical care, respiratory care, psychological support, and rehabilitation—can be met by available resources. A site other than the home may be more appropriate for some patients.

The choice of a site for long-term mechanical ventilation is a joint responsibility of the patient, patient's family, and patient's physician, with consultation from other members of the respiratory care team—respiratory therapist, nurse, social worker, case manager, and benefits manager.

Types of Facilities That May Be Considered:

For patients who can leave the ICU but still require hospitalization:

Specialized respiratory care unit of the hospital
General medical/surgical unit of the hospital

For patients who can leave the hospital but have special needs for care, monitoring, or rehabilitation:

Subacute care unit of the hospital
Long-term care hospital
Rehabilitation hospital

For patients capable of some degree of independent living:

Skilled nursing facility
Congregate living center
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