The Survival Outcomes of Patients Requiring Prolonged Mechanical Ventilation (2024)

2.1. Participants

The current retrospective, single-center study included all patients who required prolonged mechanical ventilation and were admitted to the RCC between 1 January 2012, and 31 December 2017 Patients were eligible for RCC admission if they met the Taiwan national health insurance requirements [2].

2.2. Data Collection

Data on patients requiring PMV were collected, including age, sex, comorbidities, causes of acute respiratory failure leading to PMV, receipt of a tracheostomy or not, weaning status, discharge conditions, and long-term outcomes. Survival rates were recorded at one-year, two-year, three-year, four-year, and five-year intervals, with the five-year survival rate calculated using the Kaplan–Meier estimate of the survivor method. To assess long-term survival, I reviewed the medical records of all outpatient visits for each patient until 31 December 2018, to determine whether they had passed away, and issued a death certificate for deceased patients until 31 December 2018.

2.3. Outcomes Measure

The main outcome is to investigate the five-year survival rate of PMV patients using the Kaplan–Meier estimate of the survivor method. The secondary outcome is to investigate the factors that influence the five-year survival rate among all PMV patients, successfully weaned PMV patients, patients discharged after successfully weaned from patients (discharged PMV patients), and ventilator-dependent PMV patients (RCW patients).

2.4. Statistical Analysis

The Kaplan–Meier method was utilized to estimate the cumulative probability of survival over the long-term follow-up period for all PMV patients, those who successfully weaned from PMV, patients discharged after successfully weaned from PMV (discharged PMV patients), and ventilator-dependent PMV patients (RCW patients). Additionally, the Cox proportional hazards model was employed to determine any relationships among the survival rates of the four groups. To compare the survival rates among the four groups, the Log-rank test was utilized.

Table 1

Clinical variables and tracheostomy of 403 patients requiring prolonged mechanical ventilation.

Table 2

The survival time of 403 prolonged mechanical ventilation patients.

4.1. The One-Year Survival Rate of PMV Patients

The one-year survival rate of 403 PMV patients in this study was 24.3%. I found that PMV patients without comorbidities (p = 0.002, odds ratio (OR) = 3.645, 95% confidence interval 1.607–8.266) had a better one-year survival rate. However, patients over 75 years old (p = 0.005, OR = 0.464, 95% confidence interval 0.270–0.795), those with end-stage renal disease (ESRD) (p = 0.040, OR = 0.275, 95% confidence interval 0.080–0.941), and those with four or more comorbidities (p = 0.021, OR = 0.180, 95% confidence interval 0.042–0.773) had poorer one-year survival rates [2]. Other studies have reported the one-year survival rate of PMV patients to range from 37.2% to 61% (Table 3) [9,10,11,12,13,14,15,16,17]. Factors associated with a poor one-year survival rate include older age, failure to wean, high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and ESRD comorbidity. Carson et al. reported that patients over 65 years old had a poorer one-year survival rate than younger patients [14], which was consistent with my finding that patients over 75 years old had a poorer survival rate. In addition, thrombocytopenia, requiring vasopressors, and ESRD were also found to be associated with poor one-year survival rates [14]. Lin et al. reported that younger age and absence of liver cirrhosis were associated with a better one-year survival rate [16], while Huang et al. found that congestive heart failure, ESRD, malignancy, and liver cirrhosis were factors related to a poor one-year survival rate. However, PMV patients who had undergone tracheostomy had a favorable one-year survival rate [17]. My findings were consistent with the variables reported in the literature regarding factors influencing the one-year survival rate of PMV patients.

4.2. The One-Year Survival Rate of Patients Discharged after Successfully Weaned from PMV (Discharged PMV Patients)

Several studies have shown that the one-year survival rate of patients discharged after successfully weaned from PMV varies between 44.6% and 66.9% (see Table 4) [18,19,20,21,22,23]. Factors associated with a poor one-year survival rate in these patients include older age, failure to wean, high APACHE II score, high Simplified Acute Physiology score, and low body mass index. In this study, the one-year survival rate of 157 patients discharged after successfully weaned from PMV was 50.3%. I found that patients with no comorbidities (p = 0.035, OR = 5.203, 95% confidence interval 1.127–24.028) and those who underwent tracheostomy (p = 0.005, OR = 4.439, 95% confidence interval 1.551–12.701) had better one-year survival rates. However, patients over the age of 85 had a poorer one-year survival rate (p = 0.004, OR = 0.028, 95% confidence interval 0.084–0.616), as did those with four or more comorbidities (p = 0.013, OR = 0.099, 95% confidence interval 0.016–0.608) [23].

4.3. Five-Year Survival Rate of PMV Patients

Limited research has investigated the five-year survival rate of patients receiving PMV. A statistical analysis of the five-year survival rate indicated a significant difference between 403 PMV patients and 243 patients who were successfully weaned from PMV (p = 0.001, HR = 1.374). Patients who were successfully weaned from PMV had a better five-year survival rate than those who received PMV. Therefore, successfully weaned from mechanical ventilation can impact the long-term survival of patients requiring PMV. Of the 303 PMV patients discharged from our RCC, 243 were successfully weaned and 60 remained ventilator-dependent. The group of 243 successfully weaned patients included 157 discharged PMV patients and 86 PMV patients who passed away while in the ward. The statistical analysis of the five-year survival rate showed no significant difference between the 243 successfully weaned patients and the 60 ventilator-dependent patients (p = 0.575, HR = 0.920). The five-year survival rate of 60 ventilator-dependent patients was similar to that of 243 successfully weaned patients. However, a significant difference was found in the five-year survival rate between 157 discharged PMV patients and 60 ventilator-dependent PMV patients (p < 0.001, HR = 1.965). Ventilator-dependent patients had a worse five-year survival rate than discharged PMV patients. Moreover, the long-term use of invasive ventilators did not increase the five-year survival rate of ventilator-dependent PMV patients.

4.4. Five-Year Survival Rate of Discharged PMV Patients

Schönhofer et al. found that the one-year and three-year survival rates for 293 discharged PMV patients were 49.4% and 38.1%, respectively [18]. Davis et al. reported higher survival rates among 457 discharged PMV patients with one-year, three-year, and five-year survival rates of 65%, 41%, and 29%, respectively [20]. Warnke et al. also found higher survival rates among 597 discharged PMV patients from a weaning center, with one-year, three-year, and five-year survival rates of 66.5%, 47.3%, and 37.1%, respectively [22]. In the present study of patients discharged after successfully weaned from PMV, I found survival rates of 50.3% at one year, 38.6% at three years, and 32.6% at five years. Comparing my results to those of other studies, I found that patients of this study had a worse five-year survival rate than Warnke’s case series, but similar rates to those reported by Schönhofer et al.

My earlier study also identified factors associated with poor survival rates among successfully weaned from PMV patients. Patients with ESRD, four or more comorbidities, and those who did not undergo tracheostomy had lower survival rates [23]. Tracheostomy was associated with a lower risk of in-hospital mortality in the study by Combes et al. [24]. Tracheostomy has several benefits for PMV patients, including a more tolerable airway, improved suctioning, the potential for oral feeding, enhanced communication, increased ambulation, and easier pulmonary toilet and oral hygiene. Therefore, tracheostomy is advised for RCC patients who cannot be weaned from the ventilator in the near future. However, the majority of patients and their families are often hesitant to undergo the procedure due to concerns about complications and scarring. In 2017, we implemented a program to address these concerns, resulting in only 37 PMV patients (9.7%) undergoing tracheostomy during the three-year study period [25]. Nonetheless, when successfully weaned PMV patients have fewer comorbidities and no ESRD, tracheostomy is strongly advised to improve their long-term survival.

4.5. Improving the Long-Term Survival Outcomes of PMV Patients

PMV is associated with poor long-term survival outcomes, and urgent action is needed to increase the proportion of patients who are successfully weaned from invasive ventilators. To achieve this, it is recommended that each RCC in Taiwan develop standard guidelines for ventilator weaning. Additionally, PMV patients with fewer comorbidities and no ESRD comorbidity may benefit from tracheostomy, as these patients tend to have better five-year survival rates. Several studies have shown that the use of noninvasive ventilation can improve survival rates for PMV patients. For example, Davies et al. found that their ventilator-dependent PMV patients who received nocturnal noninvasive ventilation had better one-year survival rates [20]. Similarly, Warnke et al. reported that patients who were discharged with a noninvasive mechanical ventilator had higher five-year survival rates than those discharged with an invasive mechanical ventilator [22]. Therefore, eligible PMV patients who require invasive mechanical ventilation should be switched to noninvasive mechanical ventilation to improve their long-term survival outcomes.

4.6. Clinical Outcomes in COVID-19 Patients Requiring Mechanical Ventilation

In a study of hospitalized COVID-19 patients in the UK, 9% required invasive mechanical ventilation [26]. A study from China reported that 2.3% of COVID-19 patients underwent invasive mechanical ventilation [8]. Gao et al. reported in their study that approximately one-fifth of hospitalized COVID-19 patients developed respiratory failure requiring mechanical ventilation [27]. Another study reported that 25% of patients with severe COVID-19 disease required mechanical ventilation [28]. According to Grasselli’s study, hospitalized COVID-19 patients requiring invasive mechanical ventilation had a significant mortality rate [29]. Between 1 January 2022, and 31 December 2022, ninety-three hospitalized COVID-19 adult patients with acute hypoxemic respiratory failure required admission to the intensive care unit in our hospital, as well as invasive mechanical ventilation. Patients with acute hypoxemic respiratory failure were divided into four groups based on their outcomes: nonsurviving in the ICU (n = 34), surviving in the ICU (n = 26), nonsurviving in RCC (n = 14), and surviving in RCC (n = 19). The incidence of PMV in COVID-19–related acute hypoxemic respiratory failure was 35.5%. The ICU mortality rate was 36.6%, the in-hospital mortality rate was 51.6%, and the RCC mortality rate was 42.4%. In a Chinese study of 191 hospitalized COVID-19 patients, 54 of the patients passed away.

Comorbidity was present in 91 (48%) patients, with hypertension (58 patients), diabetes (36 patients), and coronary heart disease (15 patients). Older age was associated with in-hospital mortality [30]. In our series, the mean age of the 48 nonsurviving patients was 76.4 years, and the mean age of the 45 surviving patients was 73.3 years. Comorbidities were present in 90 (96.8%) patients, with hypertension (48 (51.6%) patients), diabetes (45 (48.4%) patients), neurologic disease (34 (36.6%) patients), chronic kidney disease (27 (29%) patients), and coronary heart disease (19 (20.4%) patients).

Patients with COVID-19 are more likely to have bacterial secondary infections, some of which can be fatal. Rawson et al. found that 8% of 806 hospitalized COVID-19 patients experienced coinfection [31]. According to a study by Musuuza et al., 19% of COVID-19 patients developed secondary infections, which were associated with a poor outcome. The three most common bacteria identified among patients with superinfections were Acinetobacter spp., Pseudomonas aeruginosa, and Escherichia coli [32]. There were 33 COVID-19-related PMV patients in our series, and the most common cause for patients requiring PMV was superinfection, including 29 cases of pneumonia and 2 cases of sepsis. Among those with superinfections, the four most frequently identified bacteria were Pseudomonas aeruginosa (12 cases), Acinetobacter baumannii (10 cases), Klebsiella pneumonia (7 cases), and methicillin-resistant Staphylococcus aureus (5 cases). In a study by Melamed et al., 355 patients with COVID-19-associated respiratory failure, 86 (24%) required PMV (defined as >17 days of ventilator support), and the mortality rate was 46.5%. The mortality rates between the PMV group and in the patients requiring shorter mechanical ventilation (mortality rate: 43.1%) were not significantly different [33]. In the study of Bergman et al. 606 patients required mechanical ventilation for COVID-19 pneumonia, and the in-hospital mortality rate was 40.3%. Patients with intubations lasting longer than 21 days had a lower in-hospital mortality rate of 25.7%. In the first 21 days following intubation, the majority of mechanically ventilated patients with COVID-19 pneumonia died in the hospital [34]. There is little reported clinical experience with PMV in patients with COVID-19-associated respiratory failure in the literature. Additional studies will be conducted to provide clinical evidence and establish associations with COVID-19-associated respiratory failure patients on PMV.

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