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Health related quality of life (QoL)in patients recovering from long-term ICU-stay after difficult weaning(prolonged MV)
Prof. Dr. Bernd Schönhofer
Dpt of respiratory and critical care medicine
Krankenhaus Oststadt-Heidehaus
Klinikum Region Hannover
Germany
Contents
Background
ICU-associated issues influencing QoL
QoL after discharge
Strategies to improve QoL after prolonged MV
Some open questions
Technology and improved levels of care have increased patients“survivors of catastrophic illness”.
These patients commonly require prolonged and difficult weaning.
McIntyre NR, et al. CHEST 2005; 128:3937–3954
Management of Patients Requiring PMV Consensus Conference
• Exceeding a specific number of days of MV (range 2-29 days)• Receiving a tracheostomy for PMV• Exceeding a specific number of days in ICU (range 4-14 days)• Different definitions for prolonged ICU stay in community (10 d) or teaching hospitals (21 d)
McIntyre NR, et al. CHEST 2005; 128:3937–3954
“PMV” - Arbitrary definitions
• ARDS Rubenfeld NEJM 2005
• Crit illness PNP or ICU-AP De Jonghe JAMA 2002
• Trachestomy Frutos-Vivar CCM 2005
• Age Wesley Ann Inter Med 2002
• Comorbidities Chelluri CCM 2004
• Premorbid functional status Carson CCM 1999
Risk factors for PMV
2002 225.2 /100.000 Patients
Cox CE, et al. Critical Care Medicine 2004; 32: 2219-2226
1993 143.9 /100.000 Patients
Increase in PMV in North Carolina, 1993-2002
Increasing incidence of difficult weaning
Spicher and WhiteArch Intern Med
1987
GraceyChest 1992
DouglasCCM 2002
CombesCCM 2003
EngorenChest2003
Cumulative 1-year survival 30 %Hospital survival about 50%
Curr Opin Crit Care 2006; 12: 405-411
Schönhofer B, et al. Intensive Care Med 2002; 32:908-916
Survival of mechanically ventilated patients admitted to a specialised weaning center
Contents
Background
ICU-associated issues influencing QoL
QoL after discharge
Strategies to improve QoL after prolonged MV
Some open questions
QoL-relevant issues in the ICU
Relatives
Sedation &analgesia
Environment& sleep
StaffNurse
Physicians
Psychololgical &
Spiritual careDelirium
Pharmaco-therapy
Mechanicalventilation
Rotondi AJ, et al. CCM, 2002; 30:746
n=150 patients
50 did not remember100 did remember
Patient‘s recollections of stressful experiences while receiving PMV in an ICU
• Remembered ETT (n=75)– Pain and discomfort: 68%– Anxiety about ETT: 68%
• Remembered ICU stay (n=97)– Feeling fearful: 44%– Being in pain: 39%– Feeling terror or panic: 32%
Physical deconditioning and muscle weakness after PMV
De Jonghe et al, JAMA 2002; 288: 2859-2867
Contents
Background
Disease- and ICU-associated issues influencing QoL
QoL after discharge
Strategies to improve QoL after prolonged MV
Some open questions
SF-36Ware, Boston 1993
SIPBergner, Med Care 1981
NHPHunt, Soc Sci Med 1981
Uses 36 items to measure eight QOL domains:• physical functioning • role limitations due to physical problems• bodily pain• general health perceptions • energy/vitality • social functioning• role limitations due to emotional problems• mental health
Uses 136 questions to evaluate twelve QOL domains:• work• recreation• emotional behavior• alertness• home management,• sleep• body care• eating, • ambulation• mobility• communication,• social interaction
Evaluates subjectivefunctional status with 38 yes/no statements in six domains:• physical mobility• pain• sleep• energy• emotional reactions• social isolation
MV < 96 h
Survival and quality of life: Short-term vs. long-term ventilator patients Douglas SL, et al. CCM 2002;30:2655-62
MV > 96 h
bett
er
QoL
w
ors
e
2-Months Mortality and Functional Status of Critically Ill Adult Patients Receiving PMV
• 817 patients • Mean duration of MV: 9 days• At 2 months:
– Mortality 43%– Functional status deteriorated & declined– 35% of survivors were at risk for clinical depression– 78% of survivors had a caregiver
Chelluri L, et al. Chest 2002; 121: 549-558
Stressful memories and psychological distress in MV adult ICU patients – a 2-month follow-up study
• 313 Patients, intubated > 24 h• 2-months follow up : 226 Patients• High symptom levels of PTSD: 8,4 %
• Conclusion: Extremely stressful experiences on the ICU are associated with Posttraumatic stress disorder (PTSD)
• Risk factors:– Female sex– Agitation– Extreme fear during ICU stay
Samuelson KA, et al Acta Anaesthesiol Scand. 2007; 51:671-8
Posttraumatic stress disorder following intensive care: a hypothesis generating study of diversity in care
Jones C, et al. Intensive Care Med. 2007;33:978-985
Physical restraint
Sedation
Previous psychological problems
PTSD
Delusional memories
PF: physical functioningRP: role physical
SF
-36
• Quality of life of ARDS survivors remains persistently lower than in healthy population
1 to 3 yrs after ICU discharge
FVC (% predicted)
6-minute walk (% predicted)
Return to work (%)
117 ARDS pts21 days MV
Herridge et al, NEJM 2003; 348: 683-693
Functional outcome in PMV depends on diagnosis!
Quality of life in survivors after PMV
Chatila, et al CCM 2001; 737-742
bett
er
QoL
wors
e 44 ALI patients25 days MV in ICU14 days MV in VRU
Sickness Impact Profile (SIP)
> 6 mo discharged from ICU
• MV > 14 d
• 93% successfully weaned
• 51% NIV
Health-related quality of life after PMV
Euteneuer et al, Respir Med 2006;100:477-486
Health-related quality of life after PMVRespir Med 2006;100:477-486
wors
e
QoL
b
ett
er
SF-36 Score (0 = worst)
All NMD COPD mixed Thoracic-restrictive
PCS = Physical Component SummaryMCS = Mental Component Summary
**P < 0,01 *P < 0,05 compared to standard group
**
****
***
*
Health-related quality of life after PMVRespir Med 2006;100:477-486
ARDS
Curr Opin Crit Care 200%; 11: 369-375
Hopkins RO, et al. Chest 2006;130:869-878
Long-term neurocognitive function after critical illness.
Premorbid characteristicsAge / Gender / Disease /
Pre-existing Cognitive impairments
Critical Illness / ICU treatment
Sedatives + Analgetics
Hypotension
Hypoxemia
Glucose dysregulation
Metabolic derangements
Development of delirium
Long termNeurocognitive impairments
ICU SyndromeICU Psychosis
Postoperative delirium
15 ARDS pts, 15 pts controls ( age & sex matched)47 days MVCT scan 16 days after ARDS onset
Control ARDS
At 1 yr, 50% pts with significant memory impairment
Hopkins et al, Brain Injury, 2006; 20: 263-271
Brain atrophy and cognitive impairment
74 ARDS pts28 days MV
Neurocognitive disorders
• Verbal memory • Attention/Concentration
2 yrs after ICU discharge
Hopkins et al, AJRCCM 2005; 171; 340-347
wors
e
QoL
b
ett
er
Mob : Physical mobility; Soc: Social isolation; Emo: emotional reaction
37 days MV
3 yrs after ICU discharge
Combes et al, CCM 2003; 31
bett
er
QoL
wors
e
French Nottingham Health Profile score
46 ARDS pts26 days MV
8 yrs after ICU discharge
Severe posttraumatic stress disorder (23% pts)Intense fear – helplessness – anxiety persisting reexperiencing
• Related to the duration of MV, but not to the ARDS severity• Process of traumatization - weaning itself - threatened respiration without mechanical support - feeling of suffucation
Kapfhammer et al, Am J Psychiatry 2004; 161: 45-52
Location after discharge from weaning unit
Schönhofer et al, Intensive Care Medicine 2002; 28: 908
0
10
20
30
40
50
60
Home Hospital Nursinghome
Rehab
[%]
Nursing Home (n=16)
Rehab (n=11)
Home (n=17)
p
Physical SIP score 52,2 51,9 29,4 .004
Psychosocial SIP score 37,4 21,6 21,3 .016
Hospital Readmission among Long-term Ventilator Patients
Douglas SL, et al. CHEST 2001;120:1278-1286
Contents
Background
Disease- and ICU-associated issues influencing QoL
QoL after discharge-long-term ICU-stay-ARDS-PTSD
Strategies to improve QoL after PMV
Some open questions
ICU Care
Medical
Nursing
Early Rehab
Respiratory
Discharge planning
Respir care Physician Social Services Relatives
Post acuteSetting
Home
Nursery home
Rehabilitation
LTMV Facility
Strategies to improve QoL after PMV
Quality of life
[...] This suggests the potential for improved symptom management, which could contribute to a less stressful ICU stay
and improved patient outcomes.
Patient‘s recollections of stressful experiences while receiving PMV in an ICU
Rotondi AJ, et al. CCM, 2002; 30:746
Time (hours)
Pro
ba
bili
ty t
o r
em
ain
un
de
r M
V
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 100 200 300 400 500 600 700 800 900 1000 1100
p<0.0001
Vitacca M. Am J Respir Crit Care Med 2001; 164: 225-230
Weaning centre: High expertise in weaning problems
Davidson JE, et al. CCM 2007; 35:605-622
[...]Many people have strong attachments to their pets...
The patient-centered ICU: American College of Critical Care Medicine Task Force 2004-2005.
Effects of music therapy on anxiety in ventilator-dependent patients
Music therapy is an effective intervention in decreasing anxiety in ventilator-dependent patients and its use should be incorporated into the care of mechanically ventilated patients.
Heart Lung 2001; 30: 376-87
Admission Discharge
Motor strength
p
Upper limb score
1,9 3,6 < 0,001
Lower limb score
1,5 2,7 < 0,001
FIM score
supine to sit 1,0 3,0 < 0,001
Sit to stand 1,0 3,0 < 0,001
CCM 2005; 39:
Impact of whole-body rehabilitation in patients receiving PMV
Martin UJ, et al. CCM, 2005; 33:2259-65
For pts ventilated for > 3 days
Disease management program Team: - advanced practice nurses - a geriatrician - pulmonologistOngoing care coordinationFamily supportTeachingMonitoring of therapies
Fewer days of rehospitalization Less depression in caregivers Cost savings for the hospital
Daly et al, Chest 2005; 128: 507-517
Contents
Background
Disease- and ICU-associated issues influencing QoL
QoL after discharge-long-term ICU-stay-ARDS-PTSD
Strategies to improve QoL after prolonged MV
Some open questions
Is there an effect of burnout syndrome of the staff on patints‘ QoL after PMV ?
Embriaco, et al. AJRCCM 2007; 175:686-692Poncet, et al, AJRCCM 2007; 175:698-704
Burnout
No burnout
Is there an effect of relatives with Post-traumatic Stress Symptoms on pats‘ QoL after PMV ?
PTSS in Family Members of ICU PatientsAzoulay, et al. AJRCCM 2005;171: 987-94
all(284)
notenough
time
infoincomlete
Info too complex
• After PMV survivors tend to have physical and
mental impairments in the long-term
• Minority is discharged directly to home and often
hospital readmission is required
Conclusions (I)
Conclusions (II)
• A post-PMV follow-up is needed:Assess patients‘ level of anxiety and perception of fear
Identify patients at risk of psychological distress
• Professional discharge management and care after ICULength of time may vary with patient‘s condition
• Anti-PTSD and -burnout strategies also for staff and relatives