The weaning of long-term mechanical ventilator–supported patients
In the early 1950s, New York’s Goldwater Memorial Hospital opened its first ventilator unit in response to polio epidemics. You may remember pictures of the children of that era being ventilated by iron lungs. Now, nearly 60 years later, Coler-Goldwater Specialty Hospital and Nursing Facility on Roosevelt Island proudly maintains a national leadership role in prolonged mechanical ventilator services and weaning programs, and is a forerunner in the provision of respiratory care.
Goldwater Memorial Hospital merged with Coler Memorial Hospital in 1996, and now Coler-Goldwater has 627 long-term acute care hospital beds and 1,389 nursing facility beds. We have two campuses on the northern and southern tips of Roosevelt Island, with breathtaking views of Manhattan Island. Although the campuses are a mile apart, they are considered and operated as a single administrative entity. The goal of our long-term mechanical ventilator program has always been to enhance the quality of life of the patients, with meticulous attention to their physiological, medical, and nutritional status. Freedom from ventilator support clearly improves quality of life, as well as allows for much greater (if not complete) independence and discharge to a less restrictive level of care, including discharge home. Over the years, the mechanical ventilators have evolved, and the most modern ventilators are continually added to Coler-Goldwater’s resources.
Our ventilator unit patients receive state-of-the-art treatment with round-the-clock availability of qualified respiratory care practitioners. The Coler-Goldwater Department of Medicine has initiated a weaning program for long-term ventilator patients in which the approach is to gently “sever the cord” of dependence between patient and ventilator. The department has a major section for pulmonary medicine with approximately 180 beds for patients requiring long-term mechanical ventilation, as well as other pulmonary problems. There are 3.5 full-time pulmonologists in the department who, along with other clinical roles, select ventilator-supported patients for weaning and guide the weaning process itself. Technical support for the ventilators and respiratory care is provided by 46 licensed respiratory care practitioners who also provide other specialized clinical care for our patients. All patients within the department, including the ventilator-supported patients, are cared for by interdisciplinary teams of internists, nurses, nutritionists, and social work staff. Other disciplines such as psychiatry, psychology, and rehabilitation therapies are included when clinically necessary. The teams meet once a week to review the clinical and changing needs of the patients.
From 2001 through 2005, 832 patients requiring prolonged mechanical ventilation were admitted from both public and private acute care hospitals, almost all within New York City. All of these patients were considered to be either difficult or impossible to wean from ventilator support at their previous hospital. Although 95% of the patients had been on mechanical ventilator support for at least two weeks before admission to Coler-Goldwater, most patients had been on a ventilator for more than four weeks, with close to 10% having been on a ventilator for more than three months, and a few for more than a year or longer. The criterion for admission to our long-term ventilator program has been very simple: The patients required continuing mechanical ventilation beyond the acute hospital stay. The medical reason for long-term ventilation was not a consideration in acceptance to the program, nor was the possibility of being weaned or not.
These patients ranged in ages from 18 to 105 with an average age of 68. There were slightly more men (55%) than women (45%).
The Weaning Program
All the patients admitted on a mechanical ventilator were assessed by one of the pulmonologists to see if an attempt to wean the patient from the ventilator was warranted. For weaning to be attempted, the patients needed to be medically stable, be able to trigger the ventilator, and have pulmonary functions measured from the ventilator that met recognized criteria for weaning. Those patients who met all these weaning criteria were transferred to a 10-bed unit with a staff specialized in the management of the weaning process. Daily assessments by the pulmonologists and experienced internists, respiratory therapists, and nursing staff were made, and adjustments to the ventilator settings, amount of time free from the ventilator, etc., were made as clinically indicated. In general, 70% of patients were in the active weaning process for less than two weeks before being successfully weaned. There were, however, very few patients who required up to six weeks for successful weaning.
Successful weaning in our program has been defined as no less than four continuous weeks free from all ventilator support. There is general acceptance that one week free from a ventilator is considered to be successful weaning; however, the standard at Coler-Goldwater is more rigorous. Four weeks was chosen as the criterion for success because these patients, unlike the patients in acute care hospitals, have been on ventilator support for long periods before weaning attempts at Coler-Goldwater.
Roughly 40% of the patients admitted to the program during these years met the weaning criteria, and there was an attempt to wean them. One-third of all the patients admitted to the hospital on a mechanical ventilator for long-term care have been successfully weaned. Interestingly, the length of time on a ventilator did not influence the success of weaning attempts. What is most encouraging for older patients is that those in their 70s, 80s, and 90s who met the weaning criteria were just as likely to be weaned as younger patients. The successfully weaned patients were generally transferred to our inpatient rehabilitation program for active cardiopulmonary rehabilitation in preparation for discharge to a community setting, including home. Throughout, the care provided to these patients has included a major focus on the quality of life and its enhancement. Special techniques for communication were used as needed, as well as individualized recreational therapy.
What distinguishes Coler-Goldwater as a national leader in the care of ventilator-dependent patients is our meticulous attention to all the aspects of patient care. Coler-Goldwater is clearly dedicated to the management of these clinically difficult patients. The overall guiding principle of the ventilator program is that each of our patients has a potential for an enhanced quality of life. This is maximally achieved through complete freedom from ventilator support but remains the goal for those who continue to require some or total ventilator support.
For more information, contact Medical Director Yolanda Bruno, MD, MPA, at (212) 848-6300, or visit https://www.nyc.gov/coler-goldwater. To send your comments to the authors and editors, please e-mail firstname.lastname@example.org.
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