7.1 Chronic Critical Illness

Respiratory failure is a common indication for admission to the ICU. The clinical context combined with shared decision-making largely determine the treatment course for respiratory failure. Advances in critical care medicine and a more protocolized approach to ICU care have allowed patients to more frequently survive the acute phase of their illness. Those patients who remain dependent on mechanical ventilation develop a condition referred to as chronic critical illness (CCI); an increasingly common trend in the modern ICU. Described by Nelson et al,¹ the hallmark feature of CCI is prolonged respiratory failure with dependence on mechanical ventilation. Patients with CCI are concomitantly affected by skin breakdown, malnutrition, anasarca, cognitive dysfunction, and profound neuromuscular weakness.¹

CCI is particularly taxing on the United States health-care system with annual costs estimated to exceed $20 billion.² Patients with chronic respiratory failure often require prolonged ICU care and greater hospital lengths of stay. Given their significant comorbid conditions, these patients rarely transfer to a general medical ward. Lower nurse-to-patient ratios unique to the ICU are important for optimal pulmonary hygiene, such as frequent suctioning and help with mucus clearance. The increased need for nursing and respiratory therapists contributes to expensive hospitalizations. When patients are eventually discharged, they often require rehospitalization. As an example, patients with CCI have exceedingly high readmission rates, with an estimated 40% chance of readmission after hospital discharge.³

Despite surviving the initial, acute insult of a critical illness, there is notable morbidity and mortality among the CCI population. Yearly mortality among patients with CCI is estimated to be 40%–50%, which exceeds that of many malignancies.^4–6 More specifically, age and prehospital functional status are robust predictors of death after 1 year.⁷ One study of long-term acute care (LTAC) patients requiring prolonged mechanical ventilation demonstrated only a 5% likelihood of being alive after 1 year if older than 75 years, or older than 65 years with poor functional status.⁷

7.2 Tracheostomy

The ICU clinician must carefully counsel patients and surrogate decision makers regarding the decision to pursue tracheostomy. Although a surgical airway may enable a patient to transfer out of the ICU, it poses significant challenges. Postoperative pain, bleeding, and surgical site infection are acute complications from a tracheostomy procedure. The long-term sequela include difficulties with speech and oral intake, fistula formation, tracheal stenosis, and the social stigmata of a chronic illness.

The ICU clinician is tasked with counseling patients or surrogate decision makers about the risks and benefits of tracheostomy. In our experience, the ICU clinician may not fully consider the complex long-term outpatient care and follow-up required for a patient with a tracheostomy. Questionnaires given to patients with a tracheostomy or their surrogate decision makers suggest more comprehensive counseling is necessary before proceeding with a surgical airway. Specifically, 80% of respondents reported receiving no information regarding services that may be needed after discharge, and 69% received no information regarding the possibility of death within 1 year.⁸ Therefore, the ICU clinician should carefully explain the risks, benefits, potential complications, and overall prognosis to each patient and their family members before further considering tracheostomy placement.

There are several suggested advantages to tracheostomy. Ideally, patients can liberate from continuous sedatives that are often necessary to alleviate discomfort from the endotracheal tube. Another advantage is improved oral hygiene. The orogastric tube, commonly accompanying the intubated ICU patient, is simultaneously removed with the endotracheal tube after tracheostomy. This enables easier access for removing secretions with a suction catheter and allows the patient to cough. Last, pending improvement in the patient’s respiratory status and a reduction in ventilation requirements, patients can begin working with a speech pathologist to trial a speaking valve, such as the Passy–Muir valve; the ability to communicate after a prolonged endotracheal intubation is highly valued by patients and families alike.⁹

Such benefits have, however, not been demonstrated consistently in the literature, and the ideal timing for a tracheostomy remains unclear. There have been many randomized trials and systematic reviews comparing early (defined as fewer than 10 days of endotracheal intubation) versus late (defined as more than 10 days of endotracheal intubation) tracheostomy placement. The clinical trials and systematic reviews generally demonstrate similar mortality rates, duration of mechanical ventilation, ICU length of stay, and sedation requirements between early and late tracheostomy patients.^10–13

The largest randomized clinical trial, the TracMan trial, showed no difference in mortality, antibiotic use, or ICU length of stay in patients randomized to early versus late tracheostomy.¹⁴ This trial highlights the lack of clear evidence for pursuing an early tracheostomy. It is our practice to individualize the timing of a tracheostomy in each patient. If prolonged mechanical ventilation is anticipated after 1 week, we recommend beginning discussions with patients or surrogate decision makers to avoid the complications related to prolonged endotracheal intubation.

7.3 Post-ICU Disposition

We consider two disposition options for Mr. Smith (our case patient), who has been diagnosed with ventilatory dependence. Outside of the ICU, patients can potentially transfer care to an LTAC, skilled nursing facility, inpatient rehabilitation center, chronic ventilator facility, or directly home. Ventilation requirements, coexisting medical problems, nursing needs, and proximity to patient’s family influence disposition from the ICU.

In the first scenario, Mr. Smith can proceed with the tracheostomy and seek placement in a LTAC facility, defined by the Centers for Medicare and Medicaid Services as an acute care hospital with a mean length of stay of at least 25 days. Historically, patients would remain in an inpatient setting for the duration of their illness. The recent surge in the number and availability of LTACs have changed this paradigm of care.¹⁵ In many ways, LTACs serve as step-down units from the ICU. LTAC physicians examine patients, make changes to help wean from the mechanical ventilation, and treat illnesses such as pneumonia with antibiotics. Patients also work with physical therapists to regain muscle mass and strength that was inevitably lost during their recent ICU admission. However, despite comprehensive medical care, patients residing in a LTAC after critical illness have a high mortality rate. These patients are medically complex with low physiologic reserve. One study noted the 1-year mortality after LTAC admission from an ICU to be as high as 52.2%.¹⁵ The major downside to a facility-based approach is the potential distance and isolation from family. Coexisting medical problems can severely limit available LTAC placement options. The complex interplay between private medical insurance and Medicare or Medicaid may also limit LTAC availability.

Another option would be for Mr. Smith to proceed with the tracheostomy and return home. This path is now possible, given the new technology and advancements in chronic ventilation management. Returning home is oftentimes a major goal for ICU patients; the downside is the high degree of care required by family members and financial strain. Patients on mechanical ventilation require continuous care by family members, because insurance will rarely cover skilled private duty nursing. Caregivers must receive specialized training before hospital discharge for tracheostomy and ventilatory management. This intense care regimen is emotionally and physically exhausting. Caregivers of patients with CCI are at risk for depression and poor physical health.^{16, 17} Interestingly, caregivers of patients residing in a facility, such as LTAC, reported higher levels of depression and emotional overload compared with caregivers of patients living at home.¹⁸

With either approach – transfer to a facility or discharge home – patients need comprehensive medical care and rehabilitation. CCI after discharge from the ICU entails ventilator weaning, functional recovery, mental health, nutritional support, and close monitoring for development of infections.