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Is Mechanical Ventilation Always Appropriate?
Many People Ask. . .
Where Do You Turn For Answers?
How Does A Ventilator Work?
As You Think About Mechanical Ventilation. . .
What Happens If Mechanical Ventilation Isn't Used?
What Are Some Benefits Of A Ventilator?
What Are Some Burdens Of A Ventilator?
Important Words Of Caution
As You Think About Mechanical Ventilation. . .
Resources You Can Use

Is Mechanical Ventilation Always Appropriate?

Rarely are there black and white answers about whether mechanical ventilation is appropriate. The decision depends on many factors including the patient's basic state of health, chances of recovery, will to live, and the benefits and burdens of further treatment.

You can talk with your health care team if you are unsure about the appropriateness of using mechanical ventilation. They can give you information to help guide your decision.

As you think about mechanical ventilation, your head as well as your heart will help you decide.

This information is a "starting place" for conversations among patients, families, and caregivers. It can prepare you for talking with health care providers when a patient has very serious medical problems. Keep in mind that the best time to discuss these issues is before a crisis occurs.

Many People Ask. . .

• How does a ventilator work?"

• What are its benefits and burdens?

• Is a ventilator always appropriate?

• What happens if I don't want mechanical ventilation?

Where Do You Turn For Answers?

Facing decisions about using mechanical ventilation can be terribly difficult. Often, it is a time of emotional confusion and suffering for families and caregivers, as well as for patients. Your health care team can help you learn more about the benefits and burdens of using mechanical ventilation.

How Does A Ventilator Work?

A ventilator, sometimes called a respirator, is a machine that pumps air into and out of a patient's airway and lungs. It is a mechanical substitute for normal breathing. It is important to keep in mind that a ventilator is not a cure in itself: It can only "buy time" to see if the patient can resume breathing naturally. There are three ways that patients can resume breathing naturally. There are three ways that patient can receive mechanical ventilation: (1) through an endotracheal tube (2) through a tracheostomy or (3) through a face mask.

An endotracheal tube is a plastic tube passed through the patient's nose or mouth into the windpipe. The tube is connected to the breathing machine which pumps air through the tube into the patient's airway. This method is generally used for short-term ventilation.

A tracheostomy is a surgical procedure where a small opening is made in the patient's neck. A short tube is inserted through the opening directly into the patient's windpipe. The tube is connected to the breathing machine which pumps air through the tube into the patient's airway.

A patient on either kind of mechanical ventilator must either be lying in bed or sitting in a chair, and movement is restricted. While using an endotracheal tube, the patient is unable to speak or swallow.

"Non-invasive positive pressure ventilation" is a short-term technique where a mask is strapped over the patient's nose, and oxygen is pumped through the patient's nose, and oxygen is pumped through the patient's airway. This method is sometimes sued to get a hospitalized patient through a short-term, acute episode without placing the endotracheal tube or performing the tracheostomy procedure. Patients may have some ability to speak or swallow. Some individuals, however, may find the treatment uncomfortable, and it is not always successful in providing adequate ventilation.

As You Think About Mechanical Ventilation. . .

The following summaries are taken from medical journals. We encourage you to discuss these statements, and other viewpoints as well, with your health care providers.

"There are patients who enjoy life with mechanical ventilation, and their rights must be recognized. It must also be recognized by patient and family that living in a hospital or at home for months or years supported by a mechanical ventilator creates its own burdens. There can be no clear-cut guidelines in making this difficult medical decision, because the considerations are almost endless and the complexities profound."
Source: Petty T, Clinics in Ger Med 1986; 2:535-545.

In general, communication between patients and their families about end-of-life care is not very good. For example, in a 1988 study, 64% of patients said that they would not want to continue living if they had a severe heart attack that required the use of continual mechanical ventilation for survival, but only 36% of the patients' spouses accurately predicted what their loved one would want in this situation.
Source: Uhlman R, Pearlman R, and Cain K, J Gerontology 1998; 43:115-121.

88% of elderly patients in several Denver clinics said they would want short-term ventilator support if they had a sudden, severe illness or heart failure; 95% said they would not want long-term ventilator support to keep them alive, however, if their medical condition did not improve.
Source: Murphy D, Santilli S, Arch Fam Med 1998; 7:484.

After the patient is in a permanent vegetative state, a "Do Not Resuscitate" order is appropriate.
Source: Am Acad Neurology, Neurology 1995; 45:1015.

"Medical treatment that offers some hope of recovery should be distinguished from treatment that merely prolongs or suspends the dying process."
Source: Am Acad Neurology, Neurology 1989; 39:123.

What Happens If Mechanical Ventilation Isn't Used?

Patients whose lungs and breathing functions improve can sometimes be "weaned" from the ventilator and gradually begin breathing again on their own. For patients who cannot recover, stopping the ventilator leads to a natural death. Drugs and comfort measures can be used to prevent patients from experiencing pain or distress while dying.

What Are Some Benefits Of A Ventilator?

• Mechanical ventilation can save lives when used for patients recovering from a short-term illness or accident.
• During surgery, mechanical ventilation is used to keep patients breathing who have been given a general anesthetic.

What Are Some Burdens Of A Ventilator?

• Mechanical ventilation cannot restore a patient's lungs; it cannot prevent the death of a person with an incurable, fatal disease or condition; and it cannot cure a permanent coma.

• Patients on mechanical ventilators have difficulty coughing, and fluids can build up in their lungs. This greatly increases the risk of developing pneumonia.

Important Words Of Caution

Short-term "trial periods" of ventilation can sometimes show whether longer periods will lead to recovery, or just prolong the patient's dying.

As You Think About Mechanical Ventilation. . .

You can take comfort in knowing you are not alone. Other people have had to make these important decisions. It may help you to keep these questions in mind:

• "What are our goals for medical treatment?"
• "How often should we re-evaluate using mechanical ventilation?"
• "What would my loved one choose?"

Resources You Can Use

American Lung Association of Colorado
(303) 388-4327 or (800) LUNG-USA
web site address: www.lungusa.org
Offers supportive assistance and information for persons with, or those who are interested in learning more about respiratory and lung disease.

National Hospice Organization (NHO)
(800) 658-8898 or (703) 243-5900
web site address: www.nho.org
Promotes quality comfort care, pain relief, and emotional and spiritual support for dying patients and their families.

*Information on this page was created by and obtained with permission from the Colorado Collective for Medical Decisions, Inc. (CCMD), 1999, and Hospital Shared Services of Colorado.