Report on Mechanical Ventilation

Question: Write a Report on Mechanical Ventilation

Answer:

Introduction

Artificial ventilation or more technically known as mechanical ventilation is a framework of system which is used to aid or replace spontaneous respiration in humans. This typically is composed of a machine known as ventilator and also can depict breathing assisted by certified nurses, anaesthesiologist, physicians, paramedic, EMT etc (Esteban, et al., 2008). This mechanical ventilation maybe invasive or otherwise, and can be of two types – positive pressure as well as negative pressure (TAAST, 2018). Hence, this mechanical ventilation helps patients to breath by either assisting in inhalation of oxygen, and or exhalation of carbon dioxide and can be set up both in homes as well as healthcare settings. 
For the purpose of this report, we would focus on the framework of mechanical ventilation, and highlight on its impact on the society at large and healthcare industry. We would explore the usage data and statistics and aim to leave an impact on the cultural and socio economic aspects of using Mechanical Ventilators (MV). The scope of this paper is to provide the reader with a brief yet comprehensive account of MVs and its broad ramifications and also the future trends. 

Analysis

Impact of MV in healthcare of US 

Generally, mechanical ventilation is used when the patient spontaneously cannot respire and needs additional help to maintain the level of gases in the blood and reduce the breathing work. MV cannot itself cure a disease, and it has several complications associated. Though it is considered as a life saving intervention, it is also associated with a number of potential complications, namely, airway injuries, ventilator-associated pneumonia, pneumothorax, atrophy in the diaphragm, oxygen toxicity etc (Kalil, et al., 2016).

Usage Data of MV

As per data retrieved in 2005, 790,257 hospitalizations in United States alone had to be given mechanical ventilation, which depicts 2.7 episodes of MV per 1000 population (The American Association for the Surgery of Trauma, 2018). The estimated national costs were 27 billion representing 12% of the total hospital costs. But these figures correspond to hospital related MV uses. As per Macintyre, the use of positive pressure MV is widely used in United States, and about 1 to 3 million patients per year are estimated to receive such support of MV outside the operating room. Traditionally, MVs have been associated in settings of Intensive Care Units only, but with time, a clear trend can be observed to expand the venues to a number of sub-acute facilities, facilities of long term care and even home. With the number of elderly population on the rise, and as more aggressive surgical treatments and immunosuppressive therapies are developed, the number of such MV uses is likely to witness a global upward trend in future (Macintyre, 2016). Along with this, the increasing awareness about extensive outbreaks of various respiration related pandemics led to a number of government agencies to arrange for more number of MVs in case it is required during emergencies. 

Costs

Nonoyama et al, conducted a study on the utilization and costs of home mechanical ventilation found that, the healthcare costs for HMV users were associated with family caregiving or publicly supported. The median healthcare cost was $ 5275 with 58% of it being publicly funded, and 39% being family caregiving and the rest from third party insurances or from pockets. For invasively ventilated, the median costs were $ 8733 and for non-invasively ventilated the costs were $ 3925 per month. These healthcare costs are extremely high and understanding them for the HMV users along with ICU users will help the policy makers to optimize the resource allocations, and facilitating individuals to live at home while at the same time minimizing the burden of the caregivers (Nonoyama, et al., 2018). 

Other Statistics

As per a study by Meltzer et al, where the outbreak of avian influenza in 2013, let US officials to visit their contingency plans on account of such a outbreak in their country, it was found that additional 7000 to 11,000 ventilators would be required to avert approximate number of deaths of 35k - 55k (Meltzer,  et al., 2015). However, it was found that presence of MVs are not only liable for averting such deaths, but presence of trained staff, the easy accessibility to emergency supplies, and timely ability to match access to the ventilators for critical ill patients all are responsible for managing an impending pandemic.

Socioeconomic Impact 

In United States alone, more than a million individuals receive MVs when admitted to ICUS, and though usually for a few days, approximately 10% to 34% of them require prolonged (> 21 days) of MV care. As per 2015, there were more than 100,000 PMV cases half of which are Medicare beneficiaries. Unfortunately, this PMV care is very expensive and the overall outcome often is not satisfactory. It was found that the very cost effectiveness of such PMV reduced dramatically based on the age of the patient and the probability of poor long and short term outcomes. Though on paper this appears to be really bad, as the economy has to bear the weight of such heavy expenditure when the outcome is negative, still deciding amongst patients as to who should be prioritized for PMV care and who not, is a very tough ethical call on the healthcare workers. Identifying the patients who are likely to most have a favourable outcome, and thus lowering the intensity of care for appropriate patients and effectively reducing  the readmissions should be the future strategies and priorities of healthcare in improving the PMV’s value (Cox, et al., 2009). 

Cultural Aspects 

One aspect is established through this paper, that is, the cost of Mechanical Ventilation is extremely high – irrespective of whether it is used in ICU setting or home setting. Hence, deciding when to discontinue a MV not only is a dilemma which plagues the healthcare workers but also the members of the family. Discontinuing the MV is one of the most challenging aspects of ICY management and a significant portion of the time thus spent on such ventilator is dedicated to weaning the patient from the system. Both the premature extubation as well as delayed extubation are associated with adverse outcomes and the timing of such extubation is critical. This extubation procedure in itself is complex as a number of ethical dilemmas are associated with it – whether to allowing a peaceful death to descend on the patient, or whether to keep the struggle on. Generally the family of the patient takes the call, and such decisions depend on the cultural values and norms they possess. Hence, stopping the use of an artificial life support system is extremely complex as a number of factors are associated to such. The healthcare workers and families struggle with the load of religious, moral and other concerns regarding the removal of such life support. This terminal weaning is a very stressful task, but ideally protocols and procedures should be in place which will help the healthcare facilities along with the patient parties to take a decision and improve on the situation. Ideally, the four health care ethics pillars should be looked upon for such – beneficence and non-maleficence, the patient preference, the quality of life and lastly the contextual features (Keene, et al., 2006). 

Conclusion

Mechanical ventilation is an innovation in the field of medicine and science which is used to assist patients to sustain life and it has distinctly brought about changes in the process of treatment. But respiratory therapists, healthcare workers and families of patients all face ethical concerns when performing the terminal weaning. The final decision should be taken based on the four principles of health care ethics – beneficence and also non-maleficence, the preference of the patients, the quality of life and lastly, contextual features. 

Bibliography

Cox, E., Carson, S., Govert, A., Chelluri, L., & Sanders, G. (2009). An Economic Evaluation of Prolonged Mechanical Ventilation. Critical Care Medicine , 8, 1918 - 1927.
Esteban, A., Ferguson, N., Meade, M., Frutos-Vivar, F., Apezteguia, C., Brochard, L., et al. (2008). Evolution of mechanical ventilation in response to clinical research. American journal of respiratory and critical care medicine , 177 (2), 170 - 177.
Kalil, A., Metersky, M., Klompas, M., Muscedere, J., Sweeney, D., Palmer, L., et al. (2016). Management of adults with hospital acquired and ventilator associated pneumonia : 2016 clinical practice guidelines by the Infectious Disease Society of America and the American Thoracic Society. Clinical Infectious Diseases , 63 (5), 61-111.
Keene, S., Samples, D., Masini, D., & Byington, R. (2006). Ethical concerns that arise from terminal weaning procedures of a ventilator dependent patient a respiratory therapists perspective. The Internet Journal of Law, Healthcare and Ethics. , 4 (2), 92-97.
Macintyre, N. (2016). Mechanical Ventilation. In V. Broaddus, J. Mason, D. Ernst, E. King, C. Lazarus, F. Murray, et al., Textbook of Respiratory Medicine. US: Elsevier.
Meltzer, I., Patel, A., Ajao, A., Scott, V., & Koonin, M. (2015). Estimates of the Demand for Mechanical VEntilation in the United States during an Influenza Pandemic. Clinical Infectious Diseases , 11 (5), 52 - 57.
Nonoyama, M., McKim, D., Road, J., Guerriere, D., Coyte, P., Wasilewski, M., et al. (2018). Healthcare Utilization and costs of home mechanical ventilation. Thorax , 311-376.
The American Association for the Surgery of Trauma. (2018). Mechanical Ventilation in the Intensive Care Unit. Retrieved February 21, 2018, from The American Association for the Surgery of Trauma: http://www.aast.org/GeneralInformation/mechanicalventilation.aspx

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