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Intermediate Respiratory Care Units
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 levels of resources called non-invasive respiratory care units, intermediate respiratory
care units or high dependency units (HDUs) [4, 5]. Despite some concerns in defining 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 programs of residents in pulmonary medicine are being reviewed, placing greater importance 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
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M. Ferrer and A. Torres
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 European 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 medicine (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 treatment of patients with acute respiratory insufficiency or acute episodes caused by a
primarily respiratory disease. The objective of this unit is basically to provide adequate 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
Intermediate Respiratory Care Units
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 respiratory 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 tracheotomy 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 respiratory insufficiency in COPD [12;13] and in some types of patients with acute hypoxemia 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 effectively 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 adequately 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 monitoring 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 provided 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 underlying disease in patients admitted to an ICU and the most frequent cause of admission was cardiopulmonary monitoring [23]. In relation to this study, it may be concluded 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].
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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 respiratory 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 intermediate 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 addition, 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 intensive 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 specialized 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 ventilatory 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 outcome of the process. Thus, intermediate respiratory care units are structured with a
very favorable cost/effectiveness relationship if applied to patients requiring specialized 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. Nonetheless, in general there are insufficient human resources and space; that is, intermediate 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-
Intermediate Respiratory Care Units
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 determined 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 support, does require non-invasive monitoring.
) Patients after thoracic surgery with pneumonectomy or with a foreseen significant 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 personnel in charge should be a specialists in pulmonary medicine and functional
dependence should be to a Department of Pulmonary Medicine, similar to the relationship of Coronary Care Units with the Department of Cardiology.
Taking this into account several models for the location of intermediate respiratory care units in a hospital have been proposed [27].
) Independent location: This has the advantage of greater functional independence and of providing adequate support to a large group of patients as casemix will be better controlled. This location should have good access to the
Department of Pulmonary Medicine and/or the ICU. The most important limitation 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 provides 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 limitations are the lack of occupation if the intermediate respiratory care unit is large.
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) Integrated model: An intermediate respiratory care unit integrated within the
ICU or in the pulmonary medicine ward with a more or less specific area provides 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 condition 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 adjustment in nursing staff needs necessary. Other limitations may be high equipment 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 occupied 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 conventional 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 monitoring 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 pulmonary 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-
Intermediate Respiratory Care Units
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 including all of these requisites at the head of the bed would be useful.
The nursing station should have a structure which allows direct patient supervision 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 person for 6 beds, ideally with morning and afternoon shifts. Nursing and physiotherapy 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 intubation 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
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patient are advisable. The vacuum outlets should be able to be connected to aspirators and pleural drainage systems and should, therefore, have the corresponding 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]. Respiratory frequency is another important parameter [36]. At the same time, continuous electrocardiogram (EKG) and non-invasive arterial pressure monitoring, as
well as monitoring of ventilator pressure and flow in ventilated patients, are necessary.
Apart from NIV parameters, capnography at the end of expiration, transcutaneous carbon dioxide pressure (PCO2), measurement of the ventilatory pattern, maximum inspiratory pressure, neuromuscular impulse by occlusion pressure of the airway (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 others, these ventilators should have an internal and/or external electric battery to facilitate patient transportation. Continuous positive airway pressure (CPAP) apparatus
is also necessary for spontaneous respiration. Likewise, all the fungible material necessary for NIV should be available:
) Complete tubing, including the exhalation ports in the case of ventilators without 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 maintain patients until they are transferred to an ICU. As in the previous section, fungible 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.
Intermediate Respiratory Care Units
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 specific 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 respiratory 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 benefit from the activity of an intermediate respiratory care unit:
) Admission for acute exacerbations of a chronic respiratory disease [37], particularly COPD, requiring NIV
) Acute or acute-on-chronic respiratory failure with prolonged ICU stay, motivated by the need for ventilation after recovery from the acute episode.
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) 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 nursepatient relationship and greater possibilities of non-invasive monitoring for hemodynamically stable postoperative patients discharged from the ICU or from the areas
of postoperative recovery early following extubation. A 24 – 48 h stay in the intermediate 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 Otorhinolaryngology, 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 intensive 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].
Intermediate Respiratory Care Units
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 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. 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 difficult and patients require NIV or ventilation through tracheostomy. Severe respiratory insufficiency that requires non-invasive monitoring, postoperative care of thoracic 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 integrated 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.
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