5583.ppt

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

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r M

V

0.0

0.1

0.2

0.3

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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