Being placed on a ventilator or intubated is an intensive and invasive medical procedure that involves inserting a tube down the throat and into the windpipe to assist with breathing. While this can be a life-saving intervention for some critically ill patients, being intubated for too long also carries significant risks.
Why intubation may be needed
Some of the main reasons a doctor may recommend intubation and mechanical ventilation include:
- Respiratory failure – Conditions like pneumonia, COPD, pulmonary edema can impair oxygen exchange in the lungs.
- Cardiac arrest – CPR and artificial ventilation are needed to get oxygen to vital organs like the brain.
- Anesthesia for surgery – Intubation provides a protected airway and allows delivery of inhaled anesthetics.
- Severe trauma – Car accidents, gunshot wounds, burns can all impair breathing.
Without mechanical assistance, these conditions could quickly become fatal due to lack of oxygen (hypoxia). The ventilator takes over the work of breathing and can be life-saving in the short-term.
Risks of prolonged intubation
While intubation is sometimes necessary, there are many risks associated with remaining on mechanical ventilation for long periods of time. Some of these include:
- Ventilator-associated pneumonia – The breathing tube allows bacteria access to the lungs, putting the patient at high risk of developing pneumonia.
- Other infections – Being on a ventilator compromises the immune system and increases infection risk overall.
- Lung damage – The high levels of oxygen and pressure from mechanical ventilation can damage delicate lung tissue.
- Respiratory muscle weakness – The lack of use can cause the diaphragm and breathing muscles to weaken and atrophy.
- Sinusitis – The breathing tube can obstruct sinus drainage leading to infection.
- Trauma to the larynx – The tube rubbing against the vocal cords for extended periods can cause damage and scarring.
- Gastrointestinal issues – Poor mobility and medication side effects frequently lead to symptoms like nausea, constipation, diarrhea.
The risks go up the longer someone requires ventilation. Studies show that complications affect nearly half of all patients ventilated for more than 4 days.
Effects of prolonged intubation
Many of the complications of extended intubation are severe and life-threatening. But even if the patient survives, prolonged intubation can also have lasting effects.
Physical effects
- Vocal cord damage – Intubation tubes can cause scarring of the larynx and vocal cords leading to hoarseness or loss of voice.
- Swallowing problems – Damage to the throat muscles and nerves can impair swallowing leading to aspiration.
- Respiratory impairment – Lung damage from ventilation can cause long-term reductions in lung function.
- Critical illness myopathy – Muscle wasting occurs from lack of use and corticosteroid medications.
- Contractures – Immobility leads to stiff, frozen joints from lack of movement.
- Pressure ulcers – Being immobile also increases risk of painful bed sores.
Mental effects
- Delirium – Sedatives, lack of natural sleep/wake cycles contribute to acute confusion and agitation.
- PTSD – Many patients report trauma associated with difficulty breathing, pain, inability to communicate.
- Depression – Resulting from profound weakness, isolation, and dependence on life support.
- Cognitive impairment – Hypoxia, sedation may impact memory, thinking, executive function.
How long can a person safely be on a ventilator?
There is no single answer for how long someone can be safely ventilated. The risks tend to go up with increased duration, but there are many factors at play:
- Underlying health status – Young, previously healthy patients tend to tolerate ventilation better than the elderly or those with multiple chronic conditions.
- Cause of respiratory failure – Reversible conditions like pneumonia or asthma may require shorter ventilation than end-stage COPD or lung cancer.
- Other organ function – Presence of sepsis, kidney failure, cardiac issues can limit ventilator time.
- Medications – Heavy sedation increases complications like delirium.
- Ventilator settings – Lower pressures, volumes may reduce lung trauma versus higher settings.
There are cases of people being ventilated for months at a time, but generally risks increase after:
- 48 hours
- 4 days
- 7-10 days
- 14+ days
At these milestones, doctors will closely assess if ongoing ventilation is appropriate or potentially prolonging suffering.
How ventilation time is reduced
To help patients come off the ventilator as quickly and safely as possible, doctors use various strategies:
- Treating underlying illness – This may include antibiotics for infection, diuresis for heart failure, surgery to stop bleeding, etc.
- Daily assessment of readiness – Checking if oxygenation and vital parameters are adequate for breathing trials.
- Minimizing sedation – Lightening sedation helps evaluate neurological status and preserves muscle strength.
- Progressive ventilator weaning – Gradually reducing ventilator settings allows respiratory muscles to adapt.
- Physical and occupational therapy – Moving and exercising helps maintain muscle conditioning needed for breathing.
- Proper nutrition – Adequate calories and protein can help prevent muscle wasting while ventilated.
These strategies aim to ensure the patient is receiving the minimum ventilator support needed so liberation from ventilation can occur as quickly as possible.
What happens when ventilation is withdrawn?
The process of withdrawing life-sustaining ventilation or allowing natural death to occur is medically and ethically complex. It involves assessing prognosis and any reasonable hope of recovery. If a patient is determined to be dying and unlikely to survive off the ventilator, the treatment is transitioned to comfort measures only.
In terminal weaning, ventilator settings are not immediately withdrawn. Gradual reduction of oxygen, pressure support, and sedation are titrated to prevent sensations of breathlessness and anxiety as demise occurs. Medications are given to provide comfort and pain relief. Time is allowed for loved ones to be present and participate in honoring rituals. Withdrawal of artificial nutrition and hydration may also be ethically appropriate in dying patients.
While ethically and emotionally difficult, withdrawal of ventilation and other life-sustaining measures prevents prolonged dying and allows natural death to occur in a more peaceful, dignified manner.
Key statistics on prolonged mechanical ventilation
Some key statistics highlighting concerns related to excessive ventilation include:
- 20% of patients ventilated for 2 days cannot be weaned off within the next month
- Approximately 300,000 Americans require prolonged mechanical ventilation every year
- Prolonged ventilation is associated with higher mortality rates
- 1 in 5 patients on ventilators for 4+ days develop ventilator-associated pneumonia
- Muscle strength declines by 30-50% within 1 week of intubation
| Duration of Ventilation | Complication Rates |
|---|---|
| Less than 48 hours | 10-20% |
| 2-4 days | 15-25% |
| 1-2 weeks | 50-75% |
| More than 3 weeks | Over 85% |
As shown, the percentage of patients experiencing serious complications rises significantly the longer ventilation is continued. This is why doctors constantly weigh the benefits and burdens to avoid unnecessarily prolonged intubation.
Financial costs
Prolonged ventilation also incurs substantial financial costs. Estimates indicate that:
- Each day spent ventilated in the ICU costs $2,000-4,000.
- 30 days on a ventilator could incur $100,000 in hospital charges.
- Regular ventilation accounts for about 40% of all ICU expenses.
- Medicare spends over $27 billion annually on patients requiring prolonged ventilation.
The daily costs of ICU care and ventilation far exceed most other hospital treatments. While not the primary factor, the high expense of prolonged intubation is relevant in decisions about transitioning to other goals of care when there is little or no prospect of recovery.
Preventing complications of prolonged intubation
While sometimes necessary, steps can be taken to try to minimize risks when intubation cannot be avoided or may be needed for an extended period. Some strategies include:
- Minimizing sedation to allow patients to participate in care, preserve muscle strength.
- Humidifying and warming air delivered through the breathing tube.
- Frequent oral hygiene to reduce bacterial colonization.
- Repositioning and range-of-motion exercises to prevent contractures.
- Using specialized tubes to allow speech, preserve swallowing.
- Meticulous skin care to prevent pressure ulcers.
- Adequate pain control for procedures, airway discomfort.
- Early enteral feeding to provide nutrition, prevent atrophy.
While these interventions cannot eliminate complications entirely, they can help reduce some of the risks and impacts.
Conclusion
Mechanical ventilation can be life-preserving for critically ill patients with respiratory failure. However, remaining intubated and on a ventilator for prolonged periods also carries substantial risks of complications, side effects, and reduced quality of life. As duration increases, the chance of mortality and morbidity rises as well. Doctors balance these factors closely when determining optimal ventilation timeframes and recognizing when ongoing life support may be medically futile or promoting undue suffering. While sometimes unavoidable, efforts are made to minimize intubation time through watchful, proactive medical management and re-evaluation to transition patients off ventilators as soon as safely possible.