Intermediate Respiratory Care Units M. Ferrer and A. Torres

M. Ferrer and A. Torres

Introduction

Unlike the situation in North America, respiratory physicians in most European countries have not been involved in critical care medicine until recently [1], since both specialties have developed separately over time. This separate development has been particularly clear in Spain, due to the following circumstances [2]: 1) When intensive care medicine began in Spain, Spanish pulmonary physicians did not have a strategic vision of the future, unlike cardiologists, who demanded and assumed responsibility for the coronary units; 2) historically, pulmonary physicians have shown little interest in the care of critically ill respiratory patients; and 3) specialists in intensive care medicine have defended their specialty and have avoided others entering it.

In the USA, respiratory specialists have been running respiratory intensive care units (ICUs) since the 1960s [3] and, since the late 1980s, other units with lower lev- els of resources called non-invasive respiratory care units, intermediate respiratory care units or high dependency units (HDUs) [4, 5]. Despite some concerns in defin- ing these units [6], their effectiveness, both in medical and in economic terms, has already been described [7, 8]. The experiences reported suggest that it is possible to provide effective care for patients with acute on chronic respiratory failure and/or those requiring prolonged mechanical ventilation outside the general ICU, and at a lower cost. In Europe, respiratory care units have only been developed relatively recently [9], but there has been a rapid increase in numbers in recent years [10].

European intermediate respiratory care units tend to serve as specialized single organ units at an intermediate level of care between the ICU and general ward, but their characteristics are not homogeneous.

Several circumstances have contributed to this development. The administrative organs of the medical societies for pulmonary medicine, such as the Respiratory Intensive Care Assembly of the European Respiratory Society (ERS) have shown a growing interest in patients with severe respiratory conditions. In addition, European intensive care physicians are progressively open to the involvement of other specialists in the management of these patients. This has been demonstrated by the creation of a joint consensus document, the appointment of pulmonary medicine specialists for ICUs and, in general, a more open strategic view, which has probably been generated by the problems of growth and the aging of the medical staff. Finally, the training pro- grams of residents in pulmonary medicine are being reviewed, placing greater impor- tance on training in critical care respiratory medicine for postgraduate formation.

The recent report by a Working Group of the ERS [11] elaborated by specialists in

pulmonary medicine, anesthesiology, and intensive care medicine stratifies the

Table 1. Levels of care for acute respiratory patients [11].

Level 0 May be treated in a conventional hospital ward

Level 1 Patients with a risk of clinical deterioration or who come from higher levels of care.

Level 2 Patients requiring care for failure of a single organ (respiratory) or for postoperative care, or those from a higher level of care.

Level 3 Patients requiring advanced or basic respiratory support with failure of at least 2 organs.

Fig. 1. Model of integration of the Respiratory Medicine specialties in the care of critically ill patients as proposed by the report of the Euro- pean Respiratory Society. Adapted from [11].

grades of medical care to critically ill patients into several levels, justifies why it would be easy for specialists in pulmonary medicine to adapt to one of these levels (Table 1), and describes the difficulties of integration which underline the absence of the specialty of pulmonary medicine in the process agreed upon in Europe for the development of critical care medicine. The document by the ERS proposes a model of integration of critically ill patient care for specialists in pulmonary medi- cine (Fig. 1), with the intermediate respiratory care unit being of special relevance in this model.

The present chapter will review the most relevant characteristics of intermediate respiratory care units, with emphasis on the definition, organization, and selection criteria.

Definition and Justification for Intermediate Respiratory Care Units

An intermediate respiratory care unit is defined as an area of monitoring and treat-

ment of patients with acute respiratory insufficiency or acute episodes caused by a

primarily respiratory disease. The objective of this unit is basically to provide ade-

quate and correct cardiorespiratory monitoring and/or treatment with non-invasive

mechanical ventilation (NIV) for patients with respiratory insufficiency. Likewise,

the intermediate respiratory care unit allows continuous monitoring of post-thoracic

surgery patients or those receiving mechanical ventilation through tracheotomy, and the management of critically ill patients with difficulty in withdrawal of invasive mechanical ventilation. Non-invasive monitoring techniques and NIV should be the main therapeutic option.

The intermediate respiratory care units are designed to offer respiratory patients an intermediate grade of care between the ICU and conventional hospitalization.

The first document referring to the needs and functions of the intermediate respira- tory care unit in hospitals proposed the creation of these units for both non-invasive monitoring of severe respiratory patients and to achieve better withdrawal of mechanical ventilatory support [4]. These units have received different names but their activity may be summarized as care for: 1) patients requiring NIV due to acute respiratory insufficiency or acute episodes; 2) patients discharged from an ICU requiring a period of intermediate surveillance; and 3) prolonged weaning with tra- cheotomy and, if in a medical-surgical unit, patients during the postoperative period following thoracic surgery. The arguments for defending these units are: 1) they are units which require fewer resources for patients who, in another case, would remain in the ICU or would be badly attended in a conventional hospitalization ward; 2) they can provide care for patients with chronic obstructive pulmonary disease (COPD) who may require prolonged withdrawal from artificial ventilation; 3) many of the patients admitted to the intermediate respiratory care unit may be treated with NIV; and 4) the cost/efficacy of NIV has been clearly demonstrated.

NIV is, and should be, the main justification for the presence of these units. This type of mechanical ventilation has shown to be effective in acute hypercapnic respi- ratory insufficiency in COPD [12;13] and in some types of patients with acute hyp- oxemia and non-hypercapnia (acute pulmonary edema, immunosuppressed patients, post-thoracic surgery) as well as in the withdrawal of artificial ventilation in patients with chronic respiratory diseases [14 – 16]. In all these cases, NIV effec- tively prevents nosocomial respiratory infection, which is one of the most frequent and severe complications of invasive mechanical ventilation.

A key argument in favor of the need for intermediate respiratory care units arises from the consideration that many of the patients who are admitted to a traditional ICU do not require or do not benefit from the high level of care and the monitoring provided by the personnel in these units. Nonetheless, these patients cannot be ade- quately managed in a conventional hospital ward; thus, the intermediate respiratory care unit is the appropriate setting for their treatment. Indeed, the clinical features of intermediate care area patients are similar to those of less severely ill ICU moni- toring patients [17]. Some have undertaken the development of these units based on the reduction of the overload in the ICU, without a decline in the quality of care pro- vided to the respiratory patients.

It has been estimated that up to 40 % of patients admitted to an ICU do not

require invasive mechanical ventilation. Likewise, only 40 % of patients with acute

respiratory insufficiency due to lung disease require invasive mechanical ventilation

[18 – 22]. In a study on 99 Italian ICUs, COPD was the most common chronic under-

lying disease in patients admitted to an ICU and the most frequent cause of admis-

sion was cardiopulmonary monitoring [23]. In relation to this study, it may be con-

cluded that the resources available in the ICU for carrying out functions such as

monitoring and treatment of patients with acute chronic respiratory insufficiency in

whom invasive mechanical ventilation is not indicated are over or inappropriately

used. Moreover, when these patients require invasive mechanical ventilation, up to

60 % of the duration of ventilation is used in its withdrawal [23 – 26].

Several studies have suggested that the transfer of patients from the ICU to the intermediate respiratory care unit or direct admission to these units of patients in whom the probability of requiring intensive care is low may be an effective way to reduce costs and improve the use of general ICUs [7]. It has been demonstrated that 40 % of patients in medical ICUs and 30 % of those in surgical ICUs are admitted with the sole objective of performing continuous 24 hour monitoring and not for carrying out specific therapeutic procedures. The mission of the intermediate respi- ratory care unit would be not only to reduce healthcare costs but also to favor a more efficient use of the existing resources in the ICU. The correct use of the inter- mediate respiratory care unit makes the availability of free beds in the general ICU possible and, thereby, facilitates more appropriate use of the general ICU. In addi- tion, an intermediate respiratory care unit offers patients who cannot be admitted to the general ICU an alternative to the potentially insufficient care of a conventional hospital bed [7, 8, 20].

The above considerations justify the creation of the intermediate respiratory care unit whose essential objective is to provide the best quality healthcare together with:

1) reduced needs for healthcare personnel, particularly of nursing and auxiliary staff, and reduced consumption of technical and healthcare resources [7]; 2) better use of ICU resources, with this unit being reserved for patients truly requiring inten- sive treatment [8]; and 3) the possibility of earlier ICU discharge of patients who have overcome the acute phase of their disease but who still require medical or spe- cialized nursing care or NIV for facilitating weaning, all of which are aspects which cannot be provided in conventional hospital areas.

In addition to the factors related to the consumption of healthcare resources, other advantages should be considered such as providing more privacy to the patient, greater comfort in regard to reduced use of equipment, less environmental distortion (noise and lights), and a more flexible visiting schedule for members of the family. All of these aspects make the intermediate respiratory care unit a more ideal setting for the care of this type of patient, contributing to their improvement and facilitating hospital discharge, particularly in patients requiring continued ven- tilatory support at home [10, 27].

In summary, intermediate respiratory care units reduce hospital costs, reduce mean ICU stay and occupation, without increasing the mean hospital stay, improve patient and family satisfaction and do not have a negative impact on the final out- come of the process. Thus, intermediate respiratory care units are structured with a very favorable cost/effectiveness relationship if applied to patients requiring special- ized respiratory care [28].

Fortunately, pulmonary medicine has been implicated in the use of NIV from the introduction of this technique. Thus, pulmonary physicians working in hospital medicine are familiar with the technique and know when and how to apply it. None- theless, in general there are insufficient human resources and space; that is, interme- diate respiratory care units are not generally available.

Criteria for Admission to an Intermediate Respiratory Care Unit

The decision to admit a patient to an intermediate respiratory care unit should be

individualized, taking into account the age, co-morbidities, and the wishes of the

patient. Patients with very severe respiratory insufficiency with a high probability of

requiring invasive mechanical ventilation and those with other severe non-respira-

tory organ dysfunction should be considered for admission to an ICU. On the other hand, patients with acute or acute-on-chronic respiratory failure not fulfilling deter- mined criteria of severity may be admitted to a conventional hospital ward. Patients fulfilling any of the following criteria should be considered for admission to an intermediate respiratory care unit:

) Transfer of patients from the ICU who, following stabilization, continue to depend on invasive mechanical ventilation after unsuccessful disconnection from the ventilator by NIV or tracheotomy, with the aim of progressing with the disconnection and/or programming home mechanical ventilation. The patients should be conscious, hemodynamically stable, with no evidence of sepsis, and should have stable renal function without cardiac arrhythmia or uncontrolled bleeding.

) Transfer of patients from the ICU who, after having become stabilized following a severe clinical process or who have required prolonged invasive mechanical ventilation, require nursing care and/or physiotherapy as an intermediate step to conventional hospitalization.

) Use of NIV for the treatment of acute or acute-on-chronic respiratory failure.

) Severe respiratory insufficiency which, although not requiring ventilatory sup- port, does require non-invasive monitoring.

) Patients after thoracic surgery with pneumonectomy or with a foreseen signifi- cant reduction in postoperative pulmonary function, relevant comorbidity, or age over 70 years, or when relevant medical respiratory complications appear during the postoperative period. In these patients, the above mentioned criteria indicated for identifying patients requiring ICU admission should be considered.

) Life-threatening hemoptysis.

Localization and Design of Intermediate Respiratory Care Units

There are currently no guidelines or standards on the best location and design or constitution of these units in hospitals [10, 23, 27, 29]. Since these are respiratory patients whose main treatment is the application of NIV [29, 30], the medical per- sonnel in charge should be a specialists in pulmonary medicine and functional dependence should be to a Department of Pulmonary Medicine, similar to the rela- tionship of Coronary Care Units with the Department of Cardiology.

Taking this into account several models for the location of intermediate respira- tory care units in a hospital have been proposed [27].

) Independent location: This has the advantage of greater functional indepen- dence and of providing adequate support to a large group of patients as case- mix will be better controlled. This location should have good access to the Department of Pulmonary Medicine and/or the ICU. The most important limi- tation is the loss of efficiency when the intermediate respiratory care unit is small or when the units are large and have low indexes of occupation, as well as less flexibility and integration of personnel and accessory spaces which may lead to higher costs.

) Parallel model: An intermediate respiratory care unit adjacent to the ICU. This pro-

vides greater privacy to the patients and allows greater flexibility in regard to both

the availability of equipment and healthcare staff rotation with the ICU. The limita-

tions are the lack of occupation if the intermediate respiratory care unit is large.

) Integrated model: An intermediate respiratory care unit integrated within the ICU or in the pulmonary medicine ward with a more or less specific area pro- vides the advantage of continuity of care to the patient within the same unit, facilitating transfers based on a worsening or improvement in the patient’s con- dition as well as a greater flexibility and integration of the medical, nursing, physiotherapy, auxiliary, and administrative personnel. It has the restriction that the work loads vary greatly with respect to complexity, making an adjust- ment in nursing staff needs necessary. Other limitations may be high equip- ment costs per bed and training of healthcare personnel.

One variant of this last model would be an intermediate respiratory care unit adjacent to and functionally integrated with a sleep disorder laboratory. These areas have resources for respiratory monitoring which are normally not occu- pied during the day. Given the specialization of the intermediate respiratory care unit in NIV, these areas could be used as ‘day hospitals’ for the initiation of home mechanical ventilation in some chronic patients and those who are already receiving chronic ventilation and require monitoring for identifying and eventually solving problems which arise at home. At the same time, some of the monitoring resources available in the sleep disorders laboratory could be used in patients admitted to the intermediate respiratory care unit [10]. The model would facilitate the unification of NIV in acute situations and home mechanical ventilation.

Although the model of integration of the intermediate respiratory care unit in the pulmonary medicine ward is the most common model [29], location will largely depend on the characteristics of each center.

Physical Structure and Size

The area available for beds should be double or more than those used in conven- tional hospital wards [10, 31]. Therefore, an open structure (without partitions between the beds) and a central nursing control station, similar to that in most ICUs, provides greater facility of movement and a better view and care than a closed structure (with partitions). However, the latter provides greater patient and family comfort and privacy, as well as better infectious control measures, particularly in limiting the spread of multi-drug resistant respiratory pathogens. Indeed, one of the advantages of the intermediate respiratory care unit over the ICU is the greater patient contact with the family [32]. If the latter design is chosen, it is advisable to ensure continued visualization of the patients from the nursing station, whether direct (a partially glass partition) or with a closed video and audio circuit. Since some patients require wheelchairs for mobility, it is advisable to allow sufficient space for maneuvering of these chairs.

The number of beds in the unit should allow for the needs of the reference area

of the hospital. The number of patients who would benefit from NIV and/or moni-

toring whould be taken into account, being larger during some periods of the year

that during others. On the other hand, NIV should also be performed in the pulmo-

nary medicine ward and in the ICU, depending on the disease severity of the

patients [10, 13]. Small units (for example three beds) lose some of the cost savings

in terms of personnel and infrastructure compared to a conventional ICU [27]. This

increase in cost may be covered by integrating the intermediate respiratory care unit

in a pulmonary medicine ward. Since NIV has shown to be useful in acute respira-

tory insufficiency in immunosuppressed patients [33], a room with infrastructure for patient isolation may be useful.

The use of ventilation and monitoring requires a greater number of electrical connections, gas outlets (oxygen, compressed air) and vacuum, monitor supports, respirators or drip stands etc. than in a conventional ward. A specific system includ- ing all of these requisites at the head of the bed would be useful.

The nursing station should have a structure which allows direct patient supervi- sion as well as monitoring of physiologic parameters. It is also necessary to have an area for office work and another for administrative functions [34]. Other necessary areas are offices for the physicians, the secretary, pharmacy, storeroom, and files, which may be shared in integrated models.

Staffing

These units should be attended by a professional multidisciplinary team, which should be directed by specialists in pulmonary medicine. Likewise, it is necessary to have someone to coordinate and supervise the nursing staff. There should be one physician per six patients [35]. It is not necessary to have medical personnel in the intermediate respiratory care unit 24 hours a day but a physician on duty should be physically available in the hospital [27, 29]. In general, the care provided during the evening and night could be integrated within the medical duties of the pulmonary medicine ward. Nursing staff on each shift should consider one nurse for 3 to 4 patients [10] with 24 h nursing presence and care in the intermediate respiratory care unit. Likewise, personnel from physiotherapy are also necessary with one per- son for 6 beds, ideally with morning and afternoon shifts. Nursing and physiother- apy personnel should have experience in the management of ventilators, nebulizers, and oxygen therapy, as well as the placement of masks and the control of patients with severe respiratory insufficiency. Nursing auxiliaries are necessary, especially for patient mobilization and posture changes.

Material Needs

The materials required for these units depend on many factors including the specific characteristics of each hospital. These requisites may be grouped into the following schema: infrastructure and furnishings, monitoring and diagnostic equipment, equipment for respiratory therapy, and equipment for thoracic surgery patients.

Infrastructure and furnishings

It is advisable to have a nursing station for all the unit’s documents, including the clinical histories of the patients, and at least one computer. Likewise, dressing carts and a unidose medication system as well as a cart with equipment for tracheal intu- bation and cardiopulmonary resuscitation are required. The latter should also include medication for emergency situations. The beds should, ideally, be electric to allow posture changes. Similarly, anti-sloughing mattresses should be provided. The rooms should have the following:

) Auxiliary bars beside the beds for the placement of fungible material used in patient care.

) Wall connections for oxygen and pressurized air as well as vacuum outlets.

A minimum of two oxygen and pressurized air and three vacuum outlets per

patient are advisable. The vacuum outlets should be able to be connected to aspi- rators and pleural drainage systems and should, therefore, have the correspond- ing fungible material. Likewise, there should be a manual resuscitation bag.

) An acoustic warning system and/or interphone connected to the nursing station.

) An auxiliary table and telephone with exterior connection.

) Preferably functional armchairs to allow patients to be seated if possible.

The units should have at least one patient-lift/crane to raise patients from bed as well as architectonically barrier-free bathrooms. There should also be enough pumps for intravenous infusion and administration of nutrition.

Monitoring and diagnostic equipment

As a general norm, invasive monitoring should be reserved for the ICU and non-invasive monitoring for the intermediate respiratory care unit. The essential monitoring required for NIV is pulse-oximetry and arterial blood gases after the initiation of ventilation or following changes in ventilatory parameters [30]. Respi- ratory frequency is another important parameter [36]. At the same time, continu- ous electrocardiogram (EKG) and non-invasive arterial pressure monitoring, as well as monitoring of ventilator pressure and flow in ventilated patients, are neces- sary.

Apart from NIV parameters, capnography at the end of expiration, transcutane- ous carbon dioxide pressure (PCO

), measurement of the ventilatory pattern, maxi- mum inspiratory pressure, neuromuscular impulse by occlusion pressure of the air- way (Po.1), dynamic pulmonary volume, and peak flow may be monitored.

Respiratory therapy equipment

Since NIV is one of the main reasons for the intermediate respiratory care unit, there should be both pressure-cycled as well as volumetric ventilators. Among oth- ers, these ventilators should have an internal and/or external electric battery to facil- itate patient transportation. Continuous positive airway pressure (CPAP) apparatus is also necessary for spontaneous respiration. Likewise, all the fungible material nec- essary for NIV should be available:

) Complete tubing, including the exhalation ports in the case of ventilators with- out a separated circuit for inspiration and expiration, and oxygen connections when the ventilators do not use pressurized oxygen and bacterial filters.

) Nasal, nasal-oral, or complete facial masks of different sizes and shapes to adapt to the face of each patient should be available. Likewise, harnesses for maintaining the mask on the patient’s head are necessary, especially when the patients require home mechanical ventilation.

Since a significant proportion of patients require tracheal intubation and invasive mechanical ventilation, there should be at least one ventilator of this type to main- tain patients until they are transferred to an ICU. As in the previous section, fungi- ble material such as tubing, endotracheal tubes etc. should be available.

For the care of patients with a tracheotomy, different sized cannulas are necessary

with a balloon which may be inflated by pressure or with a sponge inside, with or

without fenestration, to allow phonation. In addition, silver cannulas should be

available for patients not requiring ventilation. Other material needed by patients

with a tracheotomy includes stoma dilators for cannula changes, and cleaning

brushes for internal cannulas or phonation valves.

Humidification is another important aspect of respiratory therapy. Humidifiers usually use hot water, although heat and moisture exchangers are appropriate for patients with tracheotomy. Similarly, aerosol therapy requires nebulizers and their accessories. Nebulizers may be pneumatic, to generate larger particles which are deposited in the bronchial tree, or ultrasonic to create smaller particles able to reach the pulmonary parenchyma.

Equipment for thoracic surgery patients

Specific equipment for these patients includes pleural drainage together with spe- cific sealing systems and aspiration of the pleural cavity, which may be either open or closed.

Interaction of the Intermediate Respiratory Care Unit with Other Departments or Units

Intensive Care Units

The aging of the population with the consequent increase in patients with chronic diseases together with greater knowledge of the pathophysiology of many processes leads to greater therapeutic efficacy, increasing the need for more beds in the ICU [26]. If we consider that the objective of the ICU should be to provide high quality healthcare, then it must be understood that the intermediate respiratory care unit and the ICU should complement each other. Some time ago it was indicated that the intermediate respiratory care unit should optimize the use of healthcare resources by reducing the number of admissions in the already overworked ICU without compromising the quality of care provided [4]. This is based on the fact that around 40 % of ICU admissions do not receive intensive treatment, particularly invasive mechanical ventilation, thus, this group of patients would benefit from admission to the intermediate respiratory care unit, especially those with acute respiratory insufficiency due to lung disease. Since these patients are treated with NIV or with CPAP, more effective care may be provided by the intermediate respi- ratory care unit without reducing the quality of care given [10] while, at the same time, more beds remain free in the ICU for patients with multiorgan failure and/or indications for endotracheal intubation. Thus, it has been reported that the closure of an intermediate respiratory care unit leads to a greater rate of admissions to the ICU of patients with diseases of less severity as measured by the APACHE II score [8].

Chronic patients who have recovered from an exacerbation of their disease but who still require nursing care or monitoring may also benefit from the intermediate respiratory care unit as may individuals who are difficult to wean from the ventilator after recovering from the acute phase of their disease process. This type of action cannot be easily provided in a general hospital ward and, therefore, the ICU stay for these patients is often unnecessarily prolonged [10].

In summary, the following are determined situations in which the ICU may bene- fit from the activity of an intermediate respiratory care unit:

) Admission for acute exacerbations of a chronic respiratory disease [37], partic- ularly COPD, requiring NIV

) Acute or acute-on-chronic respiratory failure with prolonged ICU stay, moti-

vated by the need for ventilation after recovery from the acute episode.

) Neuromuscular patients for a NIV schedule or in more advanced stages for tracheotomy as invasive mechanical ventilatory support.

) Patients with ventilator weaning difficulties who may benefit from NIV.

) Patients with complex diseases who, on ICU discharge, may benefit from better monitoring in the intermediate respiratory care unit compared to that provided in a general hospital ward, thereby, allowing earlier identification of patients with greater risk and reducing the mortality in this subgroup [11, 37].

) Greater homogeneity of the case-mix in the ICU so that the ICU does not receive admissions with low scores on the severity scales (SAPS, APACHE) [27].

Another advantage of the intermediate respiratory care unit in the management of these patients is the greater comfort and privacy provided in comparison with the ICU. The intermediate respiratory care unit allows a more normal life with greater family contact.

Department of Thoracic Surgery

The opening of an intermediate respiratory care unit is always beneficial for the Department of Thoracic Surgery since these units are covered with a better nurse- patient relationship and greater possibilities of non-invasive monitoring for hemo- dynamically stable postoperative patients discharged from the ICU or from the areas of postoperative recovery early following extubation. A 24 – 48 h stay in the interme- diate respiratory care unit facilitates stabilization of the patient, thanks to the use of respiratory physiotherapy and, in many cases, NIV. Intermediate respiratory care units are even more effective after upper airway surgery in which ICU stay may be uneventfully shortened. These areas are also useful for performing tracheotomies in neuromuscular patients and for the use of laser in tracheal stenosis. Moreover, the intermediate respiratory care unit can provide a greater union of the specialties of Pulmonary Medicine and Thoracic Surgery when the two Departments share the intermediate respiratory care unit as a hospital resource.

Other Departments

The intermediate respiratory care unit may be useful for the Departments of Otorhi-

nolaryngology, Internal Medicine, and even the Department of Pulmonary Medicine

since the use of NIV and non-invasive monitoring as well as the better nurse-patient

relationship make it possible for the intermediate respiratory care unit to be used as

a step between the ICU and general hospital wards in patients not requiring inten-

sive care but who need close monitoring not provided in conventional wards [38]. It

has been reported that the mortality of these patients was lower in general hospital

wards following opening of an intermediate respiratory care unit [39]. A reduction

in readmissions to the ICU has also been reported [40]. Likewise, some authors have

described the convenience of admission to the intermediate respiratory care unit for

several days after discharge from the ICU for patients undergoing corrective surgery

for obesity, for the management of obstructive sleep apneas that often accompany

obesity, for patients requiring airway care, and for the prevention of possible bed

sores [41].

Conclusion

Intermediate respiratory care units have been developed increasingly since the late 1980s. These units have lower levels of resources compared with ICUs, and can pro- vide effective care for patients with acute on chronic respiratory failure and/or those requiring prolonged mechanical ventilation outside the general ICU and at a lower cost. NIV should be one of the fundamental pillars for the justification of these units. Intermediate respiratory care units may also serve as step-down units from the ICU to the general or respiratory ward when patients still require nursing care, physiotherapy, and/or when withdrawal of invasive mechanical ventilation is diffi- cult and patients require NIV or ventilation through tracheostomy. Severe respira- tory insufficiency that requires non-invasive monitoring, postoperative care of tho- racic surgery patients with pneumonectomy or with a foreseen significant reduction in postoperative pulmonary function, as well as patients with life-threatening hemoptysis may also benefit from admission to an intermediate respiratory care unit. These units can be independently located, situated parallel to an ICU, or inte- grated within an ICU or respiratory ward. The units are characterized by a lower nurse to patient ratio, often 1/2.5 – 1/4, compared to ICUs. Intermediate respiratory care units are an area of respiratory medicine and should be part of the Department of Pulmonary Medicine. This requires the constant presence of physicians who are trained in the care of patients with severe respiratory insufficiency.

References

1. Roussos C, Rossi A (1996) Pulmonologists and respiratory intensive care. Eur Respir J 9:

183

2. Torres A (1999) Respiratory intensive care in Spain. Monaldi Arch Chest Dis 54:441 – 443 3. Petty TL, Lakshminarayan S, Sahn SA, Zwillich CW, Nett LM (1975) Intensive respiratory care

unit. Review of ten years’ experience. JAMA 233:34 – 37

4. Bone RC, Balk RA (1988) Noninvasive respiratory care unit. A cost effective solution for the future. Chest 93:390 – 394

5. Gracey DR, Viggiano RW, Naessens JM, Hubmayr RD, Silverstein MD, Koenig GE (1992) Out- comes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital.

Mayo Clin Proc 67:131 – 136

6. Melis RJ, Olde Rikkert MG, Parker SG, van Eijken MI (2004) What is intermediate care? BMJ 329:360 – 361

7. Elpern EH, Silver MR, Rosen RL, Bone RC (1991) The noninvasive respiratory care unit. Pat- terns of use and financial implications. Chest 99:205 – 208

8. Byrick RJ, Mazer CD, Caskennette GM (1993) Closure of an intermediate care unit. Impact on critical care utilization. Chest 104:876 – 881

9. French Multicentric Group of ICU Research (1989) Description of various types of intensive and intermediate care units in France. Intensive Care Med 15:260 – 265

10. Nava S, Confalonieri M, Rampulla C (1998) Intermediate respiratory intensive care units in Europe: a European perspective. Thorax 53:798 – 802

11. Evans T, Elliott MW, Ranieri M, et al (2002) Pulmonary medicine and (adult) critical care medicine in Europe. Eur Respir J 19:1202 – 1206

12. Brochard L, Mancebo J, Wysocki M, et al (1995) Noninvasive ventilation for acute exacerba- tions of chronic obstructive pulmonary disease. N Engl J Med 333:817 – 822

13. Plant PK, Owen JL, Elliott MW (2000) Early use of non-invasive ventilation for acute exacer- bations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet 355:1931 – 1935

14. International Consensus Conferences in Intensive Care Medicine (2001) Noninvasive positive

pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 163:283 – 291

15. Nava S, Ambrosino N, Clini E, et al (1998) Noninvasive mechanical ventilation in the weaning

of patients with respiration failure due to chronic obstructive pulmonary disease. A random- ized, controlled trial. Ann Intern Med 128:721 – 728

16. Ferrer M, Esquinas A, Arancibia F, et al (2003) Noninvasive ventilation during persistent weaning failure. A randomized controlled trial. Am J Respir Crit Care Med 168:70 – 76 17. Junker C, Zimmerman JE, Alzola C, Draper EA, Wagner DP (2002) A multicenter description

of intermediate-care patients: comparison with ICU low-risk monitor patients. Chest 121:

1253 – 1261

18. Henning RJ, McClish D, Daly B, Nearman H, Franklin C, Jackson D (1987) Clinical character- istics and resource utilization of ICU patients: implications for organization of intensive care.

Crit Care Med 15:264 – 269

19. Sage WM, Rosenthal MH, Silverman JF (1986) Is intensive care worth it? An assessment of input and outcome for the critically ill. Crit Care Med 14:777 – 782

20. Oye RK, Bellamy PE (1991) Patterns of resource consumption in medical intensive care.

Chest 99:685 – 689

21. Seneff MG, Wagner DP, Wagner RP, Zimmerman JE, Knaus WA (1995) Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 274:1852 – 1857

22. Connors AF Jr, Dawson NV, Thomas C, et al (1996) Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med 154:959 – 967

23. Confalonieri M, Gorini M, Ambrosino N, Mollica C, Corrado A, Scientific Group on Respira- tory Intensive Care of the Italian Association of Hospital Pneumonologists (2001) Respiratory intensive care units in Italy: a national census and prospective cohort study. Thorax 56:373 – 378

24. Esteban A, Alia I, Iba˜nez J, Benito S, Tobin MJ, and the Spanish Lung Failure Collaborative Group (1994) Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. Chest 106:1188 – 1193

25. Apolone G, Bertolini G, D’Amico R, et al (1996) The performance of SAPS II in a cohort of patients admitted to 99 Italian ICUs: results from GiViTI. Gruppo Italiano per la Valutazione degli interventi in Terapia Intensiva. Intensive Care Med 22:1368 – 1378

26. Vincent JL, Burchardi H (1999) Do we need intermediate care units? Intensive Care Med 25:1345 – 1349

27. Cheng DC, Byrick RJ, Knobel E (1999) Structural models for intermediate care areas. Crit Care Med 27:2266 – 2271

28. Nasraway SA, Cohen IL, Dennis RC, et al (1998) Guidelines on admission and discharge for adult intermediate care units. American College of Critical Care Medicine of the Society of Critical Care Medicine. Crit Care Med 26:607 – 610

29. Corrado A, Roussos C, Ambrosino N, et al (2002) Respiratory intermediate care units: a European survey. Eur Respir J 20:1343 – 1350

30. Elliott MW, Confalonieri M, Nava S (2002) Where to perform noninvasive ventilation? Eur Respir J 19:1159 – 1166

31. Guidelines/Practice Parameters Committee of the American College of Critical Care Medi- cine, Society of Critical Care Medicine (1995) Guidelines for intensive care unit design. Crit Care Med 23:582 – 588

32. Rudy EB, Daly BJ, Douglas S, Montenegro HD, Song R, Dyer MA (1995) Patient outcomes for the chronically critically ill: special care unit versus intensive care unit. Nurs Res 44:324 – 331 33. Hilbert G, Gruson D, Vargas F, et al (2001) Noninvasive ventilation in immunosuppressed

patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481 – 487

34. Laufman H (1986) Planning and building the ICU: problems of design, infection control and cost/benefit. In: Reis MD, Langher D (eds) The ICU: A Cost/benefit Analysis. Excerpta Medica, Amsterdam, pp 709 – 712

35. Raffin TA (1989) Intensive care unit survival of patients with systemic illness. Am Rev Respir Dis 140:S28-S35

36. Yang KL, Tobin MJ (1991) A prospective study of indexes predicting the outcome of trials of

weaning from mechanical ventilation. N Engl J Med 324:1445 – 1450

37. Goldhill DR, Sumner A (1998) Outcome of intensive care patients in a group of British inten- sive care units. Crit Care Med 26:1337 – 1345

38. Zimmerman JE, Wagner DP, Knaus WA, Williams JF, Kolakowski D, Draper EA (1995) The use of risk predictions to identify candidates for intermediate care units. Implications for intensive care utilization and cost. Chest 108:490 – 499

39. Franklin CM, Rackow EC, Mamdani B, Nightingale S, Burke G, Weil MH (1988) Decreases in mortality on a large urban medical service by facilitating access to critical care. An alterna- tive to rationing. Arch Intern Med 148:1403 – 1405

40. Fox AJ, Owen-Smith O, Spiers P (1999) The immediate impact of opening an adult high dependency unit on intensive care unit occupancy. Anaesthesia 54:280 – 283

41. Davidson JE, Callery C (2001) Care of the obesity surgery patient requiring immediate-level

care or intensive care. Obes Surg 11:93 – 97