Respiratory Failure

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Lung Failure Across the Life Span

Respiratory Failure After the Intensive Care Unit Marilyn McCord, RN, MSN, CCRN

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most cases, the development of acute respiratory failure (RF) results in admission to the intensive care unit (ICU). About one half of patients admitted to an ICU with another diagnosis develop RF as a complication.6 The goals of treatment in the ICU are to correct the underlying cause of failure, avoid further complications, and when stable, transfer the patient to a less intensive site of care. Discharge home is the ultimate goal that most patients and families expect to achieve. This outcome is not always easily achievable, however, and may involve multiple sites of care before discharge home can occur. Discharge home may not be an option in some cases. Although short-term mortality from RF has decreased in recent years, it is still a major cause of death. 6 Approximately 150,000 patients per year in the United States are diagnosed with acute RF; about 27% succumb to their pulmonary disease process. 19 Advances in medical care and technology have improved mortality rates; however, many patients still need continued acute and perhaps lengthy subacute care. This article examines the care of the patient with RF after the critical illness phase, including a discussion of the multiple sites of care and the responsibility of the patient care team in preparing the patient and family prior to transitioning care. Respiratoryfailure is both a diagnosis and a general term. It is the pulmonary system's inability to ventilate the alveoli and to oxygenate blood and tissues. 18 The process of ventilation and oxygenation is needed for the intake and utilization of

From the Department of Patient Care Services, Sinai Hospital of Baltimore, Baltimore, Maryland

oxygen and for eliminating the body of carbon dioxide, a waste product of metabolism. Failure of this process can be acute or chronic, resulting in respiratory acidosis, hypoxemia, and tissue hypoxia. Diagnostic criteria exist, vary depending on the source, and do not clearly define the condition causing failure. The generally accepted criteria are a Paco2 greater than 50 mm Hg and a Pao 2 of less than 50 mm Hg while breathing room air. RF is sometimes referred to as "hypercapnic" RF, because pump failure causes retention of carbon dioxide. Hypercapnic failure may occur with or without hypoxemia. Pump failure results in a ventilation-perfusion mismatch and can be caused by conditions affecting the nervous system, abnormalities of the thoracic cage, or the respiratory muscles, which ultimately result in carbon dioxide retention. Multiple diseases, conditions, and complications can lead to this end point, including chronic obstructive pulmonary disease, neuromuscular diseases such as amyotrophic lateral sclerosis and muscular dystrophy (MD), chest cage deformity or disease, central ventilatory drive impairment in sleep apnea, drug overdose, anesthesia, and other conditions such as pneumonia, pulmonary embolism, and central nervous system injury or disease. RF may also occur as a result of hypoxemic-related problems found in restrictive lung diseases such as fibrosis, pleural effusions, pulmonary edema, aspiration, near-drowning, and infection. RF occurs in conjunction with, secondary to, or in response to a primary event or disease such as those already listed. Acute and chronic RF are differentiated based on the. rapidity or abruptness

CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 11 I Number 4 I December 1999

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of occurrence as reflected in the pH value of the arterial blood gas (ABG). Acute RF occurs quickly, not allowing time for compensation to affect pH. In acute failure , the pH is usually less than 7.30. The hypercapnic and hypoxic changes are deviations from the patient's baseline. Chronic RF develops over weeks or months, allowing compensatory mechanisms an opportunity to prevent significant tissue problems caused by hypoxia.13 Chronic RF may develop as a sequela to acute RF. The kidneys retain bicarbonate (HC0 3-) in response to the increase in H+ ions, and the pH is driven back toward normal (Table 1). RF can occur in both the young and the old, in previously healthy individuals, and in those who are in a fragile state of health. As Table 2 demonstrates, presentation and symptoms can vary markedly among individuals. As RF is the failure of the system to maintain adequate alveolar ventilation and oxygenation, implementation of artificial ventilation is often the treatment of choice. Ventilation may be provided noninvasively with a mask and pressure or volume support or with intubation and pressure or volume mechanical ventilation. The latter is more commonly implemented. Noninvasive ventilation has been used as an alternative to traditional intubation and volume mechanical ventilation with a decrease in ventilator-associated complications such as pneumonia.17 Other options for noninvasive treatment of RF are bi-level positive airway pressure (Bi-PAP) or continuous positive airway pressure (CPAP). The decision to intubate and ventilate generally is based on the degree of ABG abnormality, symptom presentation, and the patient's response to less invasive interventions. The goals of artificial ventilation are to support the mechanism of oxygenation and ventilation, avoid further complications, and allow correction of the underlying cause until the cause of failure resolves or results in death.7• 13• 14 Although the goal of the critical care phase is stabilizing the individual and treating the cause of failure , the recovery and convalescent

Factor

The patient and the family frequently find themselves in the position of making difficult decisions

t < 7.30

7.35-7.45 Within normal parameters as a result of compensation t > 50 mm Hg t <50 mm Hg t hemoglobin/hematocrit t > 28 mEq/L Compensatory mechanism of HC03- retention and W excretion to drive pH back toward normal

t HC03 - (bicarbonate)

t

Chronic Respiratory Failure

No compensatory changes

t > 50 mm

= Decreased;

Making the Difficult Decisions

Acute Respiratory Failure

pH

!

phase can be prolonged and unpredictable, often with minimal or no functional improvement. During the critical illness episode, respiratory and skeletal muscles can become weak, and malnutrition may occur unless nutrition is provided enterally or parenterally.17 Interventions commonly used, including the endotracheal tube, mechanical ventilation, enteral feeding, and particular medications, place the patient at risk for the development of nosocomial ventilator-associated pneumonia.10 Although the highest risk for ventilator-associated pneumonia is in the ICU, the risk continues to be present regardless of setting. When the duration of mechanical ventilation exceeds 7 days, 5% of those patients remain unweanable after 4 weeks. 13 It has been estimated that as many as 25% of patients receiving mechanical ventilation encounter problems in the weaning process, especially if they are elderly. This is a result of age-related changes in the pulmonary system such as the loss of elasticity in the lung parenchyma, less distensible pulmonary vessels, decreased surfactant, chest wall stiffness, and decrease in respiratory muscle mass. 2• 20 These changes contribute to decreased lung compliance. When RF accompanies chronic restrictive or obstructive lung disease, failure to wean from mechanical ventilation is common. 17 When weaning difficulties occur in the ICU, the plan of care generally focuses on stabilizing the patient for transitioning from the more costly ICU to an alternative less costly site for continued care. Frequently, patients and families are not prepared to leave the ICU, as they continue to perceive the condition to be critical. Although not critical at this time, the patient continues to be at risk for complications (Table 3).

Hg

<50 mm Hg

Within normal limits, 22-28 mEq/L or slightly t

= increased.

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Table 2

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SYMPTOMS OF RESPIRATORY FAILURE

Presentation

Symptoms

i

Failure to adequately ventilate

Paco2 pH Headache Confusion or other change in mental status/behavior Tachypnea, RR> 30 j Work of breathing, use of accessory muscles Paradoxic breathing Tremor, asterixis ! Pao2 and saturation (Spo2) ! Spo2 Tachycardia, heart rate 20-30 beats per minute (BPM) over baseline Hypertension or hypotension Dyspnea, gasping , nasal flaring , accessory muscles Anxiety and agitation, altered mental status Cyanosis

!

Failure to oxygenate arterial blood Failure to oxygenate tissues

in an urgent or emergent period. A common complaint among family members is not being kept informed by the medical staff regarding the condition of the loved one. It is not uncommon for families to make multiple calls to the attending physician or staff nurse or to wait in the hospital for long hours hoping to interact with the medical

Table 3

team. When a patient has multiple subspecialties consulting on the case, the flow and consistency of infonnation can be even more disjointed. If the patient and family do not have an understanding of the condition, they may be overwhelmed and unable to cope with changes such as transfer to another level of care.

COMPLICATIONS IN RESPIRATORY FAILURE

Complication

Prevention

Preventing oxygen desaturation during care

Monitor saturation (Spo2) Increase fraction of inspired oxygen administration during activities Hyperoxygenate before, during , and after suctioning In-line suction catheters to eliminate disconnection for suctioning (on ventilator) Handwashing Aseptic technique when suctioning Aseptic technique when manipulating the airway Changing respiratory equipment per hospital policy Frequent oral care (every 4 h) HOB j 30 degrees with enteral feedings Changing of peripheral intravenous and central lines per policy or use of peripherally inserted central catheter Remove Foley catheter if possible Physical therapy consult, out-of-bed activities, chair, ambulation Frequent repositioning , ROM if on bedrest Splints if indicated Psychiatric referral Cheerful environment Medications Nutrition consult for enteral or parenteral nutrition if unable to take oral ly Monitor I & 0 , report imbalances IMV ventilation when tolerated

Nosocomial pneumonia

Nosocomial infections Immobility and deconditioning

Depression Inadequate nutrition Fluid imbalance (generally positive)

HOB = Head of bed; I & 0 = intake and output; IMV = intermittent mandatory ventilation; ROM = range of motion.

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Early communication and preparation of the patient and family regarding current status, prognosis, and future care are important. This can be accomplished in frequent family meetings, where the physicians discuss status, current issues, prognosis, and planning for future care. Case managers (facility and insurer), clinical nurse specialists, social workers, and staff nurses also participate in these meetings. Because of the large number of individuals who may attend a family conference, the meeting is generally not held in the patient's room. Information discussed must be shared with the patient if mental status permits, and a mechanism for communication needs to be established. The following conceptual model for patient and family counseling and education is based in part on the theoretic frameworks discussed in Irving Janis' book, Short-Term Counseling, 9 and in Richard Lazarus and Susan Folkman's book, Stress, Appraisal and Coping. 12 The structure of the meeting is fundamental for the session to be meaningful and not to add further frustration for the family. It is important that the number of people identified with the hospital be limited to avoid a confrontational situation. One individual from the medical team should be the leader of the meeting. Establishing a short-term counseling relationship with the patient and family can help the family to progress through the decision-making process. A cornerstone in developing this therapeutic relationship is to provide noncontingent acceptance of the patient's and family's beliefs and values. This helps to establish motivating power among the decision makers. The patient care team members should not volunteer their personal and often judgmental beliefs. The team should provide positive feedback and neither criticism nor blame. It is important to listen to the family members to determine their appraisal of the situation. They may need time to ventilate frustrations, both past and present. The ability to cope and move toward decision making depends on their appraisal of the situation. For example, a family may perceive a patient in a comatose state as improving when told that the individual is being weaned from the ventilator. In reality, the ventilator is only one aspect of care needed and when functional recovery is minimal, the individual is continually at risk for a variety of complications. When discussing the current events, it can be helpful to take a verbal walk back through the individual's life to determine how current events fit with past events. For example, a family describes how the patient has suffered a series of major insults over the last 10 years, resulting in a low level of functional capability. The current status is another insult in the progressive decline. By replaying the past events, the reality of the current situation is made clearer. Reality orientation is providing information using words that the family can understand and that paint an accurate picture of the current status. Scenarios

of probability are discussed to illustrate the most likely outcomes of the current situation. Anticipatory problem solving provides the effect and consequences of the various outcomes and decisions. This discussion may result in the family developing more effective coping strategies. The reality in this scenario is that the functional status of this patient will not return to the prehospital situation. This individual most likely requires long-term care and may well develop acute infections and other problems necessitating a return to the acute hospital setting. If withdrawal decisions are being considered, it is important to release the family member from feelings of responsibility and guilt. If an advanced directive exists, it should provide guidance for the wishes and intent of the individual. The surrogate decision maker is then only acting as the mouthpiece for the patient, stating what the patient would want if able to communicate. As the time on mechanical ventilation lengthens, complications occur and hope for functional recovery diminishes, especially when there is a profound change in mental status; thought is frequently given to verbal or written advanced directives. When status and prognosis are discussed, consideration should be given to all options so that a truly informed decision can be made. During the time that prognosis is discussed and the plan of care is agreed on, the issues regarding transitioning of care can be introduced. It is helpful when these discussions can include a representative or case manager from the patient's insurer, particularly when the choice of long-term care facilities is limited by insurer contracts. Patients and families are generally sensitive regarding moving to another facility. Most patients and families do not understand the complex health care system and the numerous levels of care available. Families should be encouraged to visit the referral facilities early before the final decision is made to transfer the patient.

Transitioning Care: After the Intensive Care Unit Most of the commonly accepted modes of ventilation employed with volume ventilation can be provided in alternative levels of care such as medical-surgical units and skilled nursing facilities. Assist-control (AC) provides for maximal support by controlling the tidal volume and setting a minimum number of breaths (generally 8 to 18 breaths per minute). The ventilator delivers all patient initiated or assisted breaths at the preset tidal volume. Synchronized intermittent mandatory ventilation provides the same controlled tidal volume during the preset number of breaths; however, any breaths that the patient takes over this number

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are of a volume that the patient alone is able to generate. Continuous positive airway pressure (CPAP) provides pressure in the system, but all breaths are of a rate and volume determined by the patient. Pressure support ventilation (PSV) is a pressure-assisted augmentation that provides a constant preset pressure during spontaneous unassisted inspiration to make inspiration easier. Positive end-expiratory pressure is a supportive therapy used to recruit atelectatic units and increase functional residual capacity. This facilitates better gas transfer and allows the lowest oxygen supplementation to be used. Many interventions instituted in the ICU to treat or minimize damage to the lungs are rarely implemented outside the ICU. These interventions include proning, extracorporeal mem7 brane oxygenation, intravascular oxygenator, nitric oxide, sedation, and neuromuscular blockade. 7•15• 19 As mentioned previously, a complicating factor in recovery is deconditioned respiratory and skeletal muscles. Inactivity because of critical illness contributes to the deconditioned muscles of both the upper and lower extremities. When comorbidity and increasing age are added, the recovery process can become even more complicated. These conditions lead to poor performance of even the most basic activities of daily living.16 Fatigue and shortness of breath are the two most common complaints when minimal rehabilitation is initiated. The road to recovery now becomes a more complex and lengthy one. Continuum of Care

Although initial mechanical ventilatory support occurs in a critical care unit in most cases, the financial burden of this level of care often necessitates an exploration of alternative sites. Currently, pressure exists from managed care and utilization review regarding the high cost of care for patients with complex medical requirements, resulting in more rapid discharge from acute care hospitals. 13 The continuum of care available is related to organizational structure and policies, availability of resources within and outside an organization, insurer stipulations, and geography. In some community hospitals, patients requiring mechanical ventilation are only cared for in the ICU. Patients in other facilities may transfer to a step-down or medicalsurgical unit before placement in a skilled nursing facility or discharge home. In some areas of the country, there are no accessible alternatives to the acute hospital within a given geographic location. Many new terms have emerged over the last 20 years to describe the multiple levels of care that can be provided, including high-acuity, transitional care, postacute, specialty hospital, extended care, subacute, and residential health care facilities. In preparation for continued care, many changes may have to be made. Patients who have required

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mechanical ventilation for more than 2 weeks generally have received a tracheostomy tube to replace the endotracheal tube. Initial enteral feeding through a nasogastic tube and the continued artificial airway usually necessitate the placement of a gastrostomy tube. Long-term mechanical ventilation and increased age also increase the risk of feeding aspiration. 7 In many of the settings outside the critical care unit, the same modes of ventilation and weaning techniques are continued. The completion of the weaning process may not be achievable within the acute care hospital setting as a result of the pressure for shorter lengths of stay and transfer to alternative sites of care. Ongoing nursing and transdisciplinary care continues to focus on improving oxygenation and ventilation, increasing strength and endurance, and participating in the activities of daily living. Patients are usually classified as ventilator dependent when they are unable to be weaned after a period of 4 weeks. 13 Weaning may be defined as the process of assisting patients to breathe spontaneously without mechanical ventilation support.11 Weaning from mechanical ventilation remains a priority regardless of the setting as long as potential exists. Active weaning often occurs, which results in the patient no longer requiring mechanical ventilation. In some cases, however, the process occurs more passively by decreasing the support provided by the mechanical ventilator rather than active weaning. In either case, the team needs to determine tolerance by assessing vital signs, dyspnea, use of accessory muscles, and other specific preset criteria. Intermediate Care Units

Intermediate care, step-down, high-acuity, and definitive observation units are some of the multiple terms used to describe care areas between the ICU and traditional medical-surgical units in the acute care hospital. Some of the same technology used in the ICU may be provided, including mechanical ventilation, hemodynamic and telemetry monitoring, and some intravenous vasoactive medications. Nurse-to-patient ratios are usually between the 1 : 2 ratio of the ICU and the 1 : 4-8 ratio of the general floor. Frequently, the ratio in an intermediate care unit is 1: 3 or 1: 4. One advantage of this type of unit is the ability to decompress the ICU. Stable but resource-intensive patients can be cared for in the intermediate care unit until the time that they can be managed on the general floor or transferred to a skilled nursing facility or long-term care facility . Nurses in these units are either critical care nurses or have received additional education (e.g. , telemetry and ventilator management) and training based on the patient population.

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Medical-Surgical Units

Medical-surgical units have been successful in providing care to patients requiring mechanical ventilator support with or without telemetry monitoring. The interventions described previously are generally not available. Either special ventilator units are created or the patient is assimilated into the general floor mix. Nurses are educated and trained in ventilator management and telemetry. Although the cost may be less to care for the patient on a unit outside of the ICU, most insurers are looking for continued cost reductions. Patients may be able to be weaned in the acute hospital, but once the patient no longer needs the ICU, many insurers are expecting transfer to the lowest cost alternative site of care for continued weaning and rehabilitation. The medicalsurgical unit may act as a transitional pivot as medical stability is achieved and interventions in preparation for discharge are completed (e.g., insertion of percutaneous endoscopic gastrostomy [PEG] tubes or peripherally inserted central catheters [PICC]). The family and patient receive counseling and education so that they can participate as informed consumers in the decisions that lie ahead. The most pressing of these decisions is the site of ongoing care when the patient is deemed to be medically stable. Many if not most families are not prepared to understand the variety of facilities available. Communication is a vital link to ensure a successful transition for the patient and family. Ideally, this process should begin early in the disease process and ICU stay when it is believed that weaning may be a prolonged process. Although the outcome may be uncertain, the patient and family can be introduced to the most probable scenarios for the immediate and distant future, including the options discussed below. Subacute and Skilled Nursing Facilities

Pressure to contain health care costs has resulted in subacute care being a viable and often preferred alternative to the traditional acute care hospital. 16 Implementation of diagnosis-related groups in the 1980s combined with the growth of managed care was the impetus to develop more cost-effective sites of care for the continued treatment of patients with complex medical conditions and rehabilitation needs.8 Third-party payers have placed increasing emphasis on reducing the financial cost of required medical care by insisting on earlier discharge from acute hospitals to these lower-cost facilities. 13 Hospitals may be penalized for the continued acute stay through the denial of payment. The number of such facilities that provide care for the patient requiring ventilator support has greatly expanded since 1986. 13 These facilities have a multitude of names such as extended care facilities, skilled nursing facilities, subacute facilities or units,

transitional care units, and even nursing homes. Some hospitals have found it beneficial to create subacute units within existing hospital walls. These hospitals are able to provide a continuum of care and maintain their population at a reduced cost. The intensity of care is less, but all services are usually available. In some cases, this hospital setting provides a few extra days in preparation for home discharge. In subacute and skilled nursing facilities, care is designed to be provided to stable individuals on a short-term basis with or without rehabilitation interventions. The care is determined to be skilled under Medicare guidelines. The skilled care includes intravenous therapy with total parenteral nutrition or antibiotics, intramuscular injections, care for stage III and IV wounds, restorative therapy, and initial phases of many interventions such as suctioning, tracheostomy care, tube feeding with a new PEG, and skilled therapy by physical therapists. Such care is too complex for the conventional nursing home. Most facilities attempt to have a multidisciplinary team approach to the care provided. Rehabilitation therapies (physical therapy, occupational therapy, speech-language pathology, respiratory and recreational therapy) are provided at the subacute or skilled nursing facility's level of care. Such a facility may have multiple units or levels of care such as a custodial or nursing home, dementia unit, and ventilator unit. Although diagnosis-related groups affected the payment system to the acute hospital in the 1980s, until recently, there was favorable reimbursement to the subacute facilities for the care provided by Medicare and managed care organizations. Just as the acute hospital had to adjust to prospective Medicare reimbursement, however, now so must the subacute or skilled nursing facility. A new Medicare prospective reimbursement began in July of 1998 with a 4-year phase-in plan. Reimbursement changes became necessary after the passage of the Balanced Budget Act of 1997 (HR 2015), which cut $116 billion from Medicare and $15 billion from Medicaid. 8 Changes made primarily affect subacute and skilled nursing facilities. The rates paid are determined by the acuity of the patient at the time of review for transfer, and reimbursement is determined by case mix. Patients are evaluated using tools that determine the intensity of service. The prospective payment system involves the setting of rates in advance with no settlement between the cost of care provided and the rate paid. Reimbursement rates are now lower than before, and for many complex patients, such as those requiring mechanical ventilatory support and intravenous therapy, the rates may not cover t11e costs of care. If it is determined at the time of referral that weaning is unlikely or is going to be a prolonged process, some facilities may not accept the patient because of the fixed rate paid.

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Chronic Care Facilities

Chronic care facilities , long-term care hospitals, and specialty hospitals are facilities that serve the patient who requires more intensive interventions, monitoring, and resources than can be provided in the traditional subacute unit as a result of a complex medical condition and multisystemic involvement. 8 Long-term care facilities also began emerging during the 1980s. Reimbursement to this type of facility may be excluded from Medicare prospective payment system (PPS) rate adjustments but may come under a new payment cap. Patients admitted to a long-term care facility must meet the Health Care Financing Administration guidelines of a length of stay expected to exceed 25 days. 8 Typical patient populations admitted to this type of facility are ventilator-dependent patients or those receiving dialysis, complex IV regimens, and significant wound management. Laboratory and radiographic diagnostic testing is more readily available than in the sub-acute and skilled nursing facilities . Physician intervention is required more frequently than in a subacute unit, often a minimum of three visits per week or daily. Generally, this means that the care is billed at a lower rate than at the acute hospital but at a higher rate than at a skilled nursing facility. In some areas of the country, this level of care is able to bill on hospital Medicare days. Medicare hospital days coverage includes 60 days covered in full, 30 days subject to copayment, and 60 lifetime reserve days, also subject to copayment. Situations occur when Medicare hospital days benefits are exhausted. The patient and family then need to seek assistance from the Medicaid system, which may mean spending down assets to qualify unless costs are privately paid or covered under a secondary insurance policy. The clock is partially reset, however, if the individual is discharged from the facility and not hospitalized for 30 days. This procedure can be quite disturbing to a family. The 1990s have seen a significant marketing compaign by both subacute and long-term care facilities promoting themselves as an alternative when neither the hospital nor home is the right choice for the patient. Most facilities offer a full range of medical, nursing, and therapeutic services. It is up to the consumer during a visit to the facility to discuss staffing, programs, and services. Supportive services found in acute hospitals are frequently available on-site, including pharmacy, laboratory, radiology, hemodialysis, infusion therapy, and nutritional specialists. Most facilities market particular programs such as ventilator management and weaning, brain injury care terminal care and Alzheimer care. Personal servlces, such as a hairdressing or barbering, manicure, laundry, telephone, and television services, may be available for a fee. Room accommodations are usually semiprivate. The choice of facility may

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be limited by an insurer. The extent to which care is covered depends on the type of service required, level of care needed, and the patient's insurance benefit package. Home

Home is usually the most desired discharge location. For the ventilator-dependent patient or the patient with severe respiratory and functional impairment, however, this may not be realistic for the spouse or family members because of financial, physical, and emotional reasons. Education and counseling are needed so that the family realizes what care at home involves. The physical appearance of the home changes with the addition of multiple pieces of equipment and supplies. Living rooms often are transformed into hospital rooms. Care must be taken by all members living in the home not to trip over cords or bump into equipment. The additional noise created by the machines may be difficult for the family members, especially during the night. The alarm of a ventilator at 2:00 AM can be shocking in an otherwise quiet environment. Weaning at home is unlikely, and the physical care can be labor-intensive and financially costly. Machines used for home ventilation are simpler, without the weaning modes and adjunctive settings of a hospital ventilator. Although there are patients and families who choose to return home, this option carries a heavy physical, emotional, and financial burden. Equipment, including the ventilator, is usually obtainable through insurance when durable medical equipment coverage exists, but copayment may be required. Equipment and supply costs can range from several hundred dollars to more than $1000 per month. Equipment required for home mechanical ventilation includes the following: -Mechanical ventilator, back-up is ideal -Two to three complete circuits - Battery and charger -Humidification system -Secondary alarms -Oxygen (stationary and portable) -Suction machine with suction catheters -Manual resuscitator (ambu bag) -Communication system (intercom or baby monitor) -Hospital electrical bed -Wheelchair with ventilator/ battery tray -Additional tracheostomy tubes -Commode -Miscellaneous supplies Shift care by a licensed nurse is generally not a benefit offered by insurance. Therefore, family members must commit to intensive education and the necessity of providing 24-hour round-the-dock care in the home or pay for another person (either

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professional or a trained lay person) to provide the care. Financially, the provision of shift care by a trained registered nurse or licensed practical nurse in the home may prove to be too expensive. Obtaining and retaining lay people as caregivers is achievable and less costly, but it may result in a revolving door of hiring and training. For example, to cover from 11:00 PM to 7:00 AM so that the family caregiver can sleep may cost $25 per hour for licensed nursing care versus $10 per hour for 8 hours of care by a lay caregiver, which translates into: -$200 per shift versus $80 per shift -$1400 per week versus $560 per week -$6000 per month versus $2400 per month -$73,000 per year versus $29,205 per year Other types of living arrangements are also possible, but availability is geographically driven. Assisted living, group home, or congregate living facilities that can accommodate an individual using a mechanical ventilator are occasionally available. These types of living arrangements may be difficult to find, however, and also financially cumbersome and limiting. CASE HISTORY 1

]. M. was 19 years old when he developed acute RF as a sequela to Duchenne's muscular dystrophy (MD). As is typical for this particular type of MD, symptoms of RF developed when he was in his late teens. An appointment was made with the primary, care physician, because]. M.'s mother noticed that his lips were bluish, he was more difficult, to arouse in the morning, and he usually complained of a morning headache upon rising. Upon assessment by his primary care physician, an ABG was drawn that revealed a pH of 7.26, Paco2 of 76 mm Hg, Pao2 of 43 mm Hg, HC03of 26 mEq/ L, and arterial blood saturation with oxygen (Saoz) of 70% on room air. These values were diagnostic of acute RF. As RF is the expected end point of this particular disease process, immediate counseling was done to review the options and the benefits and burdens of each option. The patient, supported by his parents, chose lifesustaining interventions, including mechanical ventilation, knowing this would be a life-long process. He was admitted to the ICU, intubated, and placed on mechanical ventilation. A tracheotomy was performed 3 days later. For]. M. and his family, the implementation of a life-supporting intervention such as mechanical ventilation did not alter or diminish his quality of life. It is not uncommon when dealing with an individual who has a significant debilitating disease to find that the quality of life with mechanical ventilation is acceptable. At the time that]. M. made his deci-

sion, care of a ventilator patient was restricted in this hospital to the ICU. The family immediately began intensive education, training, and preparation for his discharge. Family members, including his parents and two siblings, were trained in tracheostomy care and ventilatory management, and he was successfully discharged home 3 weeks after admission. At the time, this patient's insurance had a program for ventilatordependent patients that allowed for some shift care, easing the caregiving burden on the family. Partly because the patient's family was already providing a high level of care CJ. M. was wheelchair bound since the age of 9 years), training to manage the technology he now needed was not overwhelming. Because his RF was solely a result of the inability to ventilate, the implementation of mechanical ventilation was all that was needed to support the functions of ventilation and oxygenation. Oxygenation was not a concern once the ventilation problem was corrected; therefore, supplemental oxygen was not needed. He was able to ventilate well with a cuffless tracheostomy tube, allowing for communication. His ability to swallow was unaffected, and he was able to continue on a regular diet. Hobbies that he enjoyed, especially listening to music and singing, could be continued. Modifications were made to his electric wheelchair to accommodate the ventilator and battery, and he was not home bound. ]. M. successfully remained at home without any acute hospitalizations for a period of 9 years before his death, which occurred suddenly, again as a result of acute RF possibly related to a mucous plug. CASE HISTORY 2

Mr. B. is a 57-year-old man who was transferred to the pulmonary unit from the ICU after a 37-day hospitalization in the ICU following coronary bypass surgery. This was the third such surgery for this gentleman. Mr. B. had undergone his first coronary artery bypass graft in 1983 and had a revision 10 years later. Several months prior to admission, he underwent heart catheterization, which revealed severe disease and an ejection fraction of 30%. His past medical history included atrial fibrillation, insulin-dependent diabetes, chronic obstructive pulmonary disease, asbestosis, and the use of continuous oxygen at 5 L at home for the past several years. Mr. B. was admitted to the hospital with unstable angina and a resulting decrease in blood pressure. Based on the current situation, a decision was made to attempt another bypass surgery. Following surgery, he suffered cardiac arrest and was placed again on cardiopulmonary bypass. He developed shock and was main-

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tained on mechanical ventilation and multiple vasopressors, including dopamine, epinephrine, and NeoSynephrine. Eventually, he was weaned from these medications. Upon transfer to the pulmonary unit, he was placed on a flexicare bed, and the toes on both of his feet were necrotic. It was determined that perfusion to the toes was compromised from the surgery and vasopressor support. Although the toes were necrotic, they were not infected, and based on the diagnosis of dry gangrene, amputation was not imminently needed. He was maintained on mechanical ventilation for RF. Admission ventilator settings to the pulmonary unit were CPAP with 25-cm pressure support ventilation (PSV) and a fraction of inspired oxygen (F1o:z) of 35%. His minute ventilation remained at about 15 L, indicating a continued need for ventilatory support. A family meeting was held with the patient's wife and children, attending physician (who was also the pulmonologist), intern, case manager, and social worker. The patient's current medical status was discussed along with the prognosis at this time. Transitioning of care was also discussed. Choices of facilities were limited by insurance contracts. The family accepted the plan of care and cooperated with touring the facilities. Although they accepted the plan of care, there was a belief among the family members that Mr. B would return home soon. They were hopeful for a recovery. Reality orientation was provided in terms of what was likely to occur in the immediate future. As a result of the circulatory problem in Mr. B.'s legs, ambulation would not be realistic. The possibility of a future amputation existed. If the patient was able to be weaned from the ventilator, rehabilitation would focus on training the family for bed to wheelchair transfers. A PEG had been placed because of difficulty in swallowing and repeated swallowing test failures. Through the process of preparation for eventual discharge, the patient was able to tolerate the gradual decrease of pressure support of 2 cm of water per day. At the point where the PSV was decreased to 10 cm, Mr. B. was no longer able to tolerate 24 hours on the CP AP setting.

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An increase in the respiratory rate to 38 breaths

per minute and documented hypoxemia by ABG necessitated AC ventilation at night and during some daytime hours. After touring the possible facilities , the family made a choice. The subacute facility chosen, however, delayed in providing specific acceptance of the patient for several days, as it appeared that weaning from the ventilator would be more time-consuming than originally thought. Unfortunately, the patient developed progression of the renal insufficiency that had begun in the ICU. His urine output dropped to less than 200 mL every 8 hours, and his blood urea nitrogen and creatinine levels were rising. While still on the pulmonary unit, dopamine was started at a renal perfusion dose of 3 µ,g / kg / min to increase kidney perfusion. Within 2 days, he developed a change in mental status and hypotension (systolic blood pressure < 90 mm Hg), necessitating a return to the ICU. He stayed in the ICU for 1 week and then was transferred again to the pulmonary unit. At this time, the patient and family were counseled regarding the poor prognosis, and a decision was made not to resuscitate in case of a cardiac event. All other therapies were continued. Mr. B. continued to be alert, aware of his surroundings, and interactive with his family. His RF now necessitated full ventilator support on AC of 12. An ileus, which developed during his prior stay on the pulmonary unit, was unresolved and total parenteral nutrition was initiated. After 2 weeks, his renal insufficiency progressed again to acute renal failure. He was no longer responsive to dopamine and developed a metabolic acidosis. Because of the multiple organ involvement and poor prognosis, he was not considered for hemodialysis. Just 1 day before his death, he verbalized his desire to return home. Through the continual action of the medical care team with compassionate information sharing and counseling, the wife was able to accept that death was to be the outcome of this event. The patient's plan of care focused on comfort. Although he was maintained on ventilatory support, intravenous fluids, including the total parenteral nutrition, were discontinued, and he died within 12 hours.

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SUMMARY RF is a unique situation. It is specific in diagnosis and yet, at the same time, broad in concept. It can be acutely life threatening or chronic in p resentation and need for intervention. Patients are cared for in ICUs, medical-surgical floors, and nursing homes as well as at home. When RF is a complicating condition of an already hospitalized patient, the road to recovery may be long and complicated. It is important that the health care team provides education and counseling so that the patient and family can cope with the changing events and the potentially long road to recovery. Outcome data from all the sites of care are currently lacking for a comparative analysis of the most effective site. All the sites of care discussed in this article are cost-effective alternatives to the ICU, but there is a lack of standards and evidence of measurable outcomes such as the quality and cost relationship. Outcome data are needed to document the cost of care and the relationship of that cost to specific outcomes such as final discharge disposition, survival, complications, and quality of life. Health care providers have a much clearer image of tl1e care that can be provided in the multiple sites available. Unfortunately, patients and families do not have that same level of understanding. For many patients and families, regardless of what the facility is called, it is not the acute hospital, and that is where they wish to remain until discharge home. Clarification and standardization are needed regarding the tern1inology used to describe the various sites of care. It is important that integrated health care institutions provide education and counseling to patients and families regarding the continuum of care and the many alternatives along that path.

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RESPIRATORY FAILURE 20. Sexton D: Nursing Care of the Respiratory Patient. Norwalk, CT, Appleton & Lange, 1990 21. Tejeda M, Boix ], Alverez F, et al: Comparison of pressure support ventilation and assist-control ventilation in the treatment of respiratory failure. Chest 111:1322, 1997

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22. Thompson L: Failure to wean: Exploring the influence of age-related pulmonary changes. Critical Care Nursing Clinics of North America 8:7, 1996 23. Votto], Brancifort], Scalise P, et al: COPD and other diseases in chronically ventilated patients in a prolonged respiratory care unit. Chest 113:86, 1998 Address reprint requests to Marilyn McCord, RN, MSN, CCRN Department of Patient Care Services Sinai Hospital of Baltimore 2401 West Belvedere Avenue Baltimore, MD 21215