Long-term mortality and quality of life after prolonged mechanical ventilation*

ObjectiveTo describe and identify factors associated with mortality rate and quality of life 1 yr after prolonged mechanical ventilation. DesignProspective, observational cohort study with patient recruitment over 26 months and follow-up for 1 yr. SettingIntensive care units at a tertiary care university hospital. PatientsAdult patients receiving prolonged mechanical ventilation. InterventionsNone. Measurements and Main ResultsWe measured mortality rate and functional status, defined as the inability to perform instrumental activities of daily living (IADLs) 1 yr following prolonged mechanical ventilation. The study enrolled 817 patients. Their median age was 65 yrs, 46% were women, and 44% were alive at 1 yr. Median ages at baseline of 1-yr survivors and nonsurvivors were 53 and 71 yrs, respectively. At the time of admission to the hospital, survivors had fewer comorbidities, lower severity of illness score, and less dependence compared with nonsurvivors. Severity of illness on admission to the intensive care unit and prehospitalization functional status had a significant association with short-term mortality rate, whereas age and comorbidities were related to long-term mortality. Fifty-seven percent of the surviving patients needed caregiver assistance at 1 yr of follow-up. The odds of having IADL dependence at 1-yr among survivors was greater in older patients (odds ratio 1.04 for 1-yr increase in age) and those with IADL dependence before hospitalization (odds ratio 2.27). ConclusionsMortality rate after prolonged mechanical ventilation is high. Long-term mortality rate is associated with older age and poor prehospitalization functional status. Many survivors needed assistance after discharge from the hospital, and more than half still required caregiver assistance at 1 yr. Interventions providing support for caregivers and patients may improve the functional status and quality of life of both groups and thus need to be evaluated.

[1]  I. L. Cohen,et al.  Mechanical ventilation for the elderly patient in intensive care : incremental charges and benefits , 1993 .

[2]  Elizabeth H Bradley,et al.  Understanding the treatment preferences of seriously ill patients. , 2002, The New England journal of medicine.

[3]  A. Barusch,et al.  Depressive Symptoms in the Frail Elderly: Physical and Psycho-Social Correlates , 1999, International journal of aging & human development.

[4]  M. Matthay,et al.  Health-related quality of life after acute lung injury. , 1999, Critical care medicine.

[5]  M. Engoren,et al.  Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery , 2000, Critical care medicine.

[6]  E. Ruokonen,et al.  Quality of life after prolonged intensive care. , 1999, Critical care medicine.

[7]  C. Behrendt.  Acute respiratory failure in the United States: incidence and 31-day survival. , 2000, Chest.

[8]  S. Katz,et al.  STUDIES OF ILLNESS IN THE AGED. THE INDEX OF ADL: A STANDARDIZED MEASURE OF BIOLOGICAL AND PSYCHOSOCIAL FUNCTION. , 1963, JAMA.

[9]  G. Wahl,et al.  Respiratory failure in the elderly. Analysis of outcome after treatment with mechanical ventilation. , 1993, Archives of internal medicine.

[10]  E. Guthrie,et al.  Survival, morbidity, and quality of life after discharge from intensive care , 2000, Critical care medicine.

[11]  M. Lawton,et al.  Assessment of older people: self-maintaining and instrumental activities of daily living. , 1969, The Gerontologist.

[12]  W. Knaus,et al.  Predicting Future Functional Status for Seriously Ill Hospitalized Adults: The SUPPORT Prognostic Model , 1995, Annals of Internal Medicine.

[13]  E. Andresen,et al.  Assessing the health status of older adults , 1997 .

[14]  M. Silverman,et al.  Intensive care for critically ill elderly: mortality, costs, and quality of life. Review of the literature. , 1995, Archives of internal medicine.

[15]  G. Snider.  Historical perspective on mechanical ventilation: from simple life support system to ethical dilemma. , 1989, The American review of respiratory disease.

[16]  E. Ely,et al.  Mechanical Ventilation in a Cohort of Elderly Patients Admitted to an Intensive Care Unit , 1999, Annals of Internal Medicine.

[17]  I. L. Cohen,et al.  Clinical and economic outcome of mechanically ventilated patients in New York State during 1993: analysis of 10,473 cases under DRG 475. , 1998, Chest.

[18]  M. Frass,et al.  Influence of age on outcome of mechanically ventilated patients in an intensive care unit , 1992, Critical care medicine.

[19]  Robert Gray,et al.  Flexible Methods for Analyzing Survival Data Using Splines, with Applications to Breast Cancer Prognosis , 1992 .

[20]  S. Epstein,et al.  Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome. , 1998, American journal of respiratory and critical care medicine.

[21]  T. Noseworthy,et al.  Quality of life measures before and one year after admission to an intensive care unit. , 1995, Critical care medicine.

[22]  D. Hosmer,et al.  Applied Logistic Regression , 1991 .

[23]  V. Fuchs,et al.  Health Care for the Elderly: How Much? Who Will Pay for it? , 1998, Health affairs.

[24]  John E. Ware,et al.  SF-36 Health Survey. , 1990 .

[25]  P. Grambsch,et al.  Proportional hazards tests and diagnostics based on weighted residuals , 1994 .

[26]  J. Lubitz,et al.  Three decades of health care use by the elderly, 1965-1998. , 2001, Health affairs.

[27]  J. Stauffer,et al.  Survival following mechanical ventilation for acute respiratory failure in adult men. , 1993, Chest.

[28]  L. Radloff.  The CES-D Scale , 1977 .

[29]  S. Wisniewski,et al.  How patients feel about prolonged mechanical ventilation 1 yr later* , 2002, Critical care medicine.

[30]  W. Katon,et al.  Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. , 1997, JAMA.

[31]  I. L. Cohen,et al.  Investigating the impact of age on outcome of mechanical ventilation using a population of 41,848 patients from a statewide database. , 1995, Chest.

[32]  D. Wagner,et al.  Economics of prolonged mechanical ventilation. , 1989, The American review of respiratory disease.

[33]  G P Samsa,et al.  Comparing Proxy and Patients' Perceptions of Patients' Functional Status: Results from an Outpatient Geriatric Clinic , 1992, Journal of the American Geriatrics Society.

[34]  A Gafni,et al.  Frequency and methodologic rigor of quality-of-life assessments in the critical care literature. , 1998, Critical care medicine.

[35]  J. Timsit,et al.  Outcome, functional autonomy, and quality of life of elderly patients with a long-term intensive care unit stay , 2000, Critical care medicine.

[36]  J Tsevat,et al.  Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. , 2000, The American journal of medicine.

[37]  M R Pinsky,et al.  Long-term outcome of critically ill elderly patients requiring intensive care. , 1993, JAMA.

[38]  Salvador Benito,et al.  Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. , 2002, JAMA.

[39]  D.,et al.  Regression Models and Life-Tables , 2022 .

[40]  M. Bullinger,et al.  Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome. , 1998, Critical care medicine.

[41]  W. Knaus,et al.  The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. , 1991, Chest.

[42]  C. Mackenzie,et al.  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. , 1987, Journal of chronic diseases.