Age, Duration of Mechanical Ventilation, and Outcomes of Patients Who Are Critically Ill

doi:10.1378/chest.09-0515

Chest

Volume 136, Issue 3, September 2009, Pages 759-764

https://doi.org/10.1378/chest.09-0515 Get rights and content

Background

Age and duration of mechanical ventilation (MV) are strongly associated with mortality and hospital discharge disposition.

Methods

Electronic administrative records from a 425-bed community teaching hospital were obtained for 9,912 patients who were admitted to hospital ICUs between 2003 and 2008. Risk estimates of age and duration of MV for in-hospital mortality and discharge to home vs extended-care facilities (ECFs) also were obtained.

Results

Of 9,912 patients, 37 were discharged to hospice care, and 668 were < 18 years of age. Of the remaining 9,207 patients, 4,238 received invasive MV. Mortality or hospital discharge to ECFs increased consistently for each decade of age > 65 years and as the duration of MV increased. Although only 11.7% of patients < 65 years age who received MV for 1 or 2 days died during hospitalization, the mortality rate increased to 72.1% for patients > 85 years of age who had received MV for > 7 days. For patients requiring MV for ≥ 7 days, < 10% of the ≥ 65 years of age and < 5% of patients ≥ 85 years of age survived to be discharged home from the hospital. Multivariate logistic regression analyses showed that age > 65 years and duration of MV remained significantly associated with outcomes, even after adjustment for hospital discharge diagnoses (Charlson scores).

Conclusions

This study suggests that age and duration of MV are strongly associated with mortality and posthospital disposition. If confirmed, the simple combination of age and duration of MV provides prognostic information that could be used with trajectory of illness and in the context of patients' values to inform end-of-life discussions with patients or their surrogates during a trial of critical care.

Section snippets

Materials and Methods

This retrospective cohort study conducted at Bridgeport Hospital, Yale New Haven-Health (Bridgeport, CT), a 425-bed community teaching hospital. The Institutional Review Board approved the study, waiving the requirement of informed consent for this retrospective review of computerized administrative medical records. Bridgeport Hospital has a total of 37 critical care beds within its medical, surgical, and burn ICUs. Each ICU is staffed with one nurse for every two patients, and care is

Results

A total of 9,207 patients were included in the analysis. The median age of the patients was 65 years, and 43% were women. A total of 4,238 patients (46%) received MV, with a median duration of 2 days (25th to 75th percentile, 2 to 6 days). The median age of patients requiring MV was older than that of patients who did not require MV (67 vs 63 years, respectively; p < 0.05), and the male/female gender ratio was similar in both groups. Cardiovascular and pulmonary primary conditions were more

Discussion

To our knowledge, this study is the first to examine whether a simple combination of patient age and DMV data, which are readily available to clinicians at bedside, provide useful prognostic information for families and clinicians in their decision making regarding care of patients who are acutely ill. These epidemiologic data were derived from 5 years of hospital ICU admissions at a community teaching hospital and suggest that advanced age and prolonged duration of MV significantly decrease

Acknowledgments

Author contributions: Dr. Feng gathered data, performed statistical analyses, and helped to write the manuscript. Dr. Amoateng-Adjepong assisted in statistical analyses and in writing the manuscript. Dr. Kaufman helped to write the manuscript. Dr. Gheorghe helped to gather data and participated in writing the manuscript. Dr. Manthous conceived the question and helped to write the manuscript.

Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts

References (0)

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2021, Journal of Theoretical Biology
Citation Excerpt :
A 2003–2008 study conducted at Bridgeport Hospital reported that 4,238 out of 9,912 (42.8%) patients received MV for a median of two days. Mortality or discharge to extended-care facilities increased for each decade of age greater than 65 years (Feng et al., 2009). Most recently, severe forms of COVID-19, a highly infectious respiratory disease caused by the novel coronavirus SARS-CoV-2, can lead to respiratory failure and death (Lai et al., 2020).
Despite the benefits of mechanical ventilators, prolonged or misuse of ventilators may lead to ventilation-associated/ventilation-induced lung injury (VILI). Lung insults, such as respiratory infections and lung injuries, can damage the pulmonary epithelium, with the most severe cases needing mechanical ventilation for effective breathing and survival. Damaged epithelial cells within the alveoli trigger a local immune response. A key immune cell is the macrophage, which can differentiate into a spectrum of phenotypes ranging from pro- to anti-inflammatory. To gain a greater understanding of the mechanisms of the immune response to VILI and post-ventilation outcomes, we developed a mathematical model of interactions between the immune system and site of damage while accounting for macrophage phenotype. Through Latin hypercube sampling we generated a collection of parameter sets that are associated with a numerical steady state. We then simulated ventilation-induced damage using these steady state values as the initial conditions in order to evaluate how baseline immune state and lung health affect outcomes. We used a variety of methods to analyze the resulting parameter sets, transients, and outcomes, including a random forest decision tree algorithm and parameter sensitivity with eFAST. Analysis shows that parameters and properties of transients related to epithelial repair and M1 activation are important factors. Using the results of this analysis, we hypothesized interventions and used these treatment strategies to modulate the response to ventilation for particular parameters sets.
Healthcare costs of ICU survivors are higher before and after ICU admission compared to a population based control group: A descriptive study combining healthcare insurance data and data from a Dutch national quality registry
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This difference in healthcare costs can be due to the fact that older patients are less likely to undergo major surgery or dialysis [23]. Though, after discharge older people are more likely to be readmitted and are more dependent of long-term care facilities, nursing homes or rehabilitation centres compared to younger people [24-26]. ICU patients in our study had a high prevalence of chronic conditions compared to the total Dutch population [1].
To identify subgroups of ICU patients with high healthcare utilization for healthcare expenditure management purposes such as prevention and targeted care.
We conducted a descriptive cohort study, combining a national health insurance claims database and a national quality registry database for ICUs. Claims data in the timeframe 2012–2014 were combined with the clinical data of ICU patients admitted to an ICU during 2013. A population based control group was created based on the ICU population.
56,760 ICU patients and 75,232 controls from the general population were included. Median healthcare costs per day alive for the ICU population were significantly higher during the year before (€8.9 (IQR €2.4; €32.1)) and the year after ICU admission (€15.4 (IQR €5.4; €51.2)) compared to the control group ((€2.8 (IQR €0.7; €8.8) and €3.1 (IQR €0.8; €10.1)). ICU patients with more chronic conditions had significantly higher healthcare costs before and after ICU admission compared to ICU patients with less chronic conditions.
ICU patients have three to five times higher healthcare costs per day alive compared to a control population. Our findings can be used to optimize the healthcare trajectories of ICU patients with high healthcare utilization after discharge.
Is failure to awaken and wean malpractice?
2016, Journal of Critical Care
Respiratory failure is among the most common primary causes of or complications of critical illness, and although mechanical ventilation can be lifesaving, it also engenders substantial risk of morbidity and mortality to patients. Three decades of research suggests that the duration of invasive mechanical ventilation can be reduced substantially, reducing morbidity and mortality. Mean duration of ventilation reported in recent international studies suggests a quality chasm in management of this common critical illness.
This is a selective review of the literature and synthesis with precepts of medical professionalism and ethics.
To the extent that daily wake-up-and-breathe reduces morbidity, mortality, and length of stay, failure to deploy this strategy is, by definition, malpractice (ie, poor practice). Practical measures are offered to close this quality chasm.
Outcome of mechanically ventilated patients initially denied admission to an intensive care unit and subsequently admitted
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Citation Excerpt :
The most striking feature of the current study is that patients who were denied ICU admission and subsequently admitted did not tend to benefit from ICU admission when it occurred. The actual benefit from ICU admission may have been diminished due to other factors that were found to be significantly associated with adverse outcomes such as duration of mechanical ventilation [14], length of hospital stay [15], rate of failed extubations [16], and occurrence of VAP and nosocomial bacteremia [17,18], all of which were highest among this group of patients. In addition, the mean length of stay before transfer to the ICU was 3.9 days, delayed admission to ICU has been associated with significant increase in overall hospital mortality [19].
The outcome of mechanically ventilated patients initially denied admission to an intensive care unit (ICU) and subsequently admitted is unclear. We compared outcomes of patients denied ICU admission and subsequently admitted, to those of patients admitted to the ICU and to patients refused ICU admission. The medical records of all the patients who were subjected to mechanical ventilation for at least 24 h over a 4 year period (2010–2014) were reviewed. Of 707 patients (757 admissions), 124 (18%) were initially denied ICU admission and subsequently admitted. Multivariate stepwise logistic regression analysis showed significant association with death of: age, length of stay, nursing home residency, duration of mechanical ventilation, previous admission with mechanical ventilation, cause for mechanical ventilation, rate of failed extubations, associated morbidity (previous cerebrovascular accident, dementia, chronic renal failure), and occurrence of nosocomial bacteremia. The odds for death among patients denied ICU admission and subsequently transferred to the ICU compared to patients admitted directly to the ICU was 3.6 (95% CI: 1.9–6.7) (P < 0.0001). The odds for death among patients refused ICU admission compared to those who were initially denied and subsequently admitted were not statistically significant (OR = 1.7, 95% CI: 0.8–3.8). In conclusion, patients denied ICU admission and subsequently admitted face a considerable risk of morbidity and mortality. Their odds of death are nearly three times those admitted directly to the ICU. Late admission to the ICU does not appear to provide benefit compared to patients who remain in general medicine wards.
Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association
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Original ResearchCritical Care MedicineAge, Duration of Mechanical Ventilation, and Outcomes of Patients Who Are Critically Ill

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Original Research
Critical Care Medicine
Age, Duration of Mechanical Ventilation, and Outcomes of Patients Who Are Critically Ill