Long Mechanical Ventilation

Long Mechanical Ventilation May Mean Loss of Independence

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Older patients can have functional and cognitive difficulties.

Critically ill patients who have been mechanically ventilated for more than a week are at high risk for functional impairment and death by 1 year after hospital discharge, particularly the oldest patients and those with the longest hospital stays, according to a study presented here.

Among patients who were older than 66 and were treated in the intensive care unit (ICU) for 2 weeks or more, 40% died within the first year, 29% were readmitted to the ICU, and activities such as dressing, bathing, and climbing stairs remained severely restricted, according to Claudia dos Santos, MD, of the University of Toronto.

“Patients who survive mechanical ventilation in the ICU have a long road ahead and can have functional and cognitive difficulties as well as mood disorders, and also have a high mortality risk,” she said during a presentation on high impact clinical trials in critical care at the American Thoracic Society annual meeting.

The Canadian RECOVER program, which began in 2007, is a prospective cohort study that is evaluating outcomes after ICU discharge to help clinicians risk-stratify patients so that rehabilitation can be tailored to their needs.

As part of this program, the researchers, led by Margaret Herridge, MD, of the Toronto General Research Institute, followed 391 patients who were mechanically ventilated for at least a week in the ICU and survived for 7 days after discharge.

Mean age was 58, 69% were men, and mean APACHE II score was 25. Median time spent on the mechanical ventilator was 16 days, mean ICU stay was 22 days, and mean hospital stay was 29 days.

Disability was assessed using the Functional Independence Measure (FIM), which is widely used in rehabilitation settings to document improvement after an intervention, Dos Santos explained. Scores below 40 indicate total dependence and complete inability with self-care activities, 50 suggests significant dependence, and 90 indicates partial independence. A score of 126 is normal.

Recursive partitioning analysis classified patients into four disability risk groups, with the lowest being young, with short length of stay (younger than 42 and hospitalized for less than 2 weeks), and the highest being older than 66 and a length of stay of 14 days or more.

At day 7, the mean FIM score was 54. Among the lowest-risk group, mean score was 107, but in the highest-risk group it was 44, rising only to 66 by 2 weeks. “These patients were very close to being completely dependent,” she said.

FIM scores overall had improved by 1 year, averaging 110, but they still had not normalized, she noted.

Also at day 7, 60% of patients were unable to walk. By 1 year, walk distances increased from 24% to 75% of predicted.

Symptoms of depression rated on the Beck Depression Inventory, where a score of 21 indicates clinically relevant depression, remained at 17 at 6 and 12 months. “This didn’t get better,” she said.

 While several of the outcomes — including mortality and ICU readmission — were worse for the older, long-hospital-stay group, hospital readmissions in general were high for all groups, ranging from 36% to 43%.

An additional analysis indicated that FIM score, Charlson comorbidity score, and age were independent predictors of death by 1 year.

“Stratification of patients into these risk groups can help guide decisions by clinicians and family members on rehabilitation after discharge,” she concluded.