The purpose of using a ventilator is to address problems such as difficulty breathing, weak breathing, no breathing, or insufficient oxygen in patients.

The following patients are prone to respiratory failure and require a ventilator:

• pneumonia

• Asthma

• Chronic obstructive pulmonary disease

• Heart failure

• coma

• stroke

• general anesthesia surgery

There is no standard answer to how long a ventilator should be used. It varies from patient to patient, even for the same disease. Due to the severity of the disease, individual personality traits, psychological factors, and many other influences, the duration of ventilator use is usually shorter. If the patient is given ventilator support due to drug poisoning, severe asthma attack, or other similar conditions, the ventilator can be discontinued once the condition improves or is eliminated. In such cases, the ventilator use time is usually shorter. However, if the inflammation leads to failure of vital organs or causes irreversible damage, the ventilator use time will be longer. If the patient's physical function or nutritional status was worse than normal before the illness, the ventilator use time will also be longer than that of a normal person.

When a patient uses a ventilator for more than 21 days, it may be necessary to consider issues related to long-term ventilator use, as there are many reasons why patients may use ventilators for extended periods.

They are mainly divided into three categories:

1. First category: Cardiopulmonary diseases, such as chronic obstructive pulmonary disease, chronic congestive heart disease, and coronary artery disease.

2. The second category: multiple organ failure caused by internal medicine or surgical problems.

3. The third category: neuromuscular diseases, including polio syndrome, spinal cord injury, muscle atrophy, amyotrophic lateral sclerosis, multiple sclerosis, bilateral diaphragmatic paralysis, and central ventilatory disorders. Neuromuscular diseases are mostly progressive diseases or cause irreversible damage. When the disease progresses to the end stage, it usually causes respiratory failure. When patients are unable to breathe on their own, they will need to rely on a ventilator for the rest of their lives.

It is usually impossible to predict how long a ventilator will be used, but what is important is whether the patient receives good care and support in terms of physical, psychological and social aspects during the period of ventilator use, so that they can return to society after being weaned off the ventilator. For patients and their families who cannot be weaned off the ventilator, they can also adapt to a life of long-term ventilator use with the support of a sound medical system.

The following nine factors must be considered when weaning off a ventilator:

1. The cause of a patient's ventilator use should be considered for weaning only when the cause affecting breathing is removed or improved.

2. The patient's physical condition has returned to its state before the use of a ventilator.

3. The duration of the critical period of the disease.

4. The state of how the body's tissues use oxygen for metabolism.

5. Respiratory load and respiratory capacity.

6. Cardiovascular function.

7. Functions of other organs in the body.

8. The longer the ventilator is used, the lower the chance of weaning.

9. Psychological factors: Some patients have come to regard the ventilator as an extension of their body, and they need to overcome their psychological barriers before weaning off the ventilator.

The primary condition for weaning from a ventilator is that the patient must be able to breathe on their own before weaning can be considered.

Once the patient has passed the acute phase and the functions of all organs have returned to normal, and the patient is able to breathe on their own, the doctor and respiratory therapist will adjust the ventilator according to the patient's condition, reducing the proportion of ventilator assistance and increasing the proportion of the patient's own breathing, so that the patient can gradually adapt to breathing on their own in ventilator support mode. Weaning from the ventilator is a gradual process. Only after a respiratory function test is passed and the test results are good can weaning from the ventilator be considered.

There are many methods for weaning from a ventilator. Usually, training is conducted during the day and the patient rests at night. The duration of training must be adjusted according to the patient's condition. The number of days of weaning training depends on the patient's response. Generally, patients who have failed to wean multiple times will require a longer weaning training period.

The timing of weaning from a ventilator is crucial; weaning too early or too late can negatively impact the patient. Weaning too early can severely damage the cardiopulmonary system, delaying recovery. The trauma of premature weaning also places a heavy psychological burden on the patient and their family; the more failures, the heavier the burden and the harder it is to wean. Conversely, weaning too late increases the risk of ventilator-related complications, such as hospital-acquired pneumonia, myocardial infarction, and death, increasing the burden on the patient, their family, and the overall healthcare and societal costs.

When a patient fails to wean off the ventilator after multiple failed attempts or when the disease worsens and the patient is unable to wean off the ventilator, the patient and their family must face the fact that they will need to use the ventilator for life, adjust their mindset, and with the help of medical staff, adapt to the various inconveniences brought about by long-term ventilator use, and minimize the patient's discomfort.

1. Advantages and disadvantages of prolonged intubation and tracheotomy

Patients with respiratory failure are intubated and connected to a ventilator for assisted breathing. The artificial airway must pass through the larynx and glottis into the trachea. Obstruction of the airway in the larynx often causes discomfort and loss of voice. Prolonged intubation can lead to the following complications: nasal pain and sinusitis may occur with nasal intubation; lip ulcers, laryngeal granulation tissue, vocal cord damage, or tracheomalacia due to excessive pressure from the endotracheal tube; and difficulty swallowing. Disadvantages of long-term intubation include difficulty swallowing, difficulty clearing oral secretions, difficulty maintaining oral hygiene, frequent halitosis, and the patient's tendency to bite the tube, leading to ventilation obstruction or ventilator alarms. Based on the aforementioned drawbacks, it is advisable to consider replacing the endotracheal tube with a tracheostomy tube. Replacing the endotracheal tube with a tracheostomy tube not only facilitates care for medical staff but also reduces the incidence of patients extubating themselves. After training and adjustment, ventilator-using patients can swallow and eat, and even speak in time with the ventilator's delivery, greatly improving the quality of life for long-term ventilator users.

2. Timing of tracheotomy

Within seven days of intubation, tracheotomy is generally not considered unless there is a respiratory abnormality or surgical need. The timing of tracheotomy is determined not only by the time of intubation but also by many other factors, such as: upper airway obstruction, need for head, neck or chest surgery, comatose or limb paralysis requiring long-term bed rest, inability to clear sputum on their own, and the possibility of aspiration pneumonia. The most important determining factors are the inability to clear sputum on their own and the need for long-term ventilator reliance. When a patient's condition progresses to the point where they need to rely on a ventilator for a long period or after multiple failed attempts to wean them off the ventilator, usually around three weeks or more after intubation, the doctor will suggest that the patient and their family consider a tracheotomy. After communication and explanation, the patient or their family will sign a consent form and choose a time when the patient's condition is stable and there is no fever, allowing the tracheotomy to be performed under general anesthesia.

Under normal use, ventilators will not cause harm. However, some common complications should be noted, including:

1. Laryngeal edema, tracheal mucosal injury.

2. If the tubing comes loose or leaks, it can cause breathing difficulties or even stop breathing.

3. Excessive pressure can cause pressure trauma to the alveoli, leading to subcutaneous emphysema or pneumothorax.

4. Too high an oxygen concentration can cause oxygen poisoning.

5. The ventilator caused pneumonia.

Not all patients on ventilators need to be admitted to the intensive care unit (ICU). Only patients on ventilators whose vital signs are unstable due to the following conditions, requiring close monitoring and intensive care, need to be admitted to the ICU, for example:

1. Patients with acute respiratory failure, respiratory distress, intermittent respiratory arrest, or severe asphyxia who require active respiratory therapy.

2. Patients with acute myocardial infarction, unstable angina, or angina.

3. Patients with acute heart failure, acute kidney failure, or acute liver failure.

4. Patients who still require adjunctive therapy after surgery or whose vital signs are unstable.

5. Patients with life-threatening arrhythmias (including those following cardiac arrest).

6. Patients in shock.

7. Patients with serious metabolic and electrolyte/water imbalances or endocrine abnormalities require close monitoring.

8. Patients with acute poisoning coma.

9. Patients with hepatic coma due to cirrhosis.

10. Patients who require enhanced medical care after thoracic surgery, cardiac surgery, and neurosurgery.

11. Patients in the acute phase of encephalopathy such as stroke, meningitis, or encephalitis, who are also experiencing impaired consciousness or coma.

12. Patients with severe epilepsy.

13. Patients whose lives are threatened by acute intracranial hypertension.

14. Patients with acute brainstem lesions.

15. Patients with sepsis or suspected sepsis and whose vital signs are unstable.

16. Newborns with high jaundice levels requiring blood transfusion.

17. Extremely premature infants with a birth weight of less than 1500 grams.

18. Other critically ill patients whose vital signs are unstable.

◎ Patients with any of the following conditions should be transferred to a respiratory care center:

(a) The ventilator has been used for more than 14 days.

(ii) All organ systems, oxygenation status, or surgical wounds are stable.

(iii) Must be transferred to a respiratory care center for home respirator care training.

(iv) Terminal cancer patients who are on a ventilator and whose attending physician has determined that they should no longer receive active treatment.

(v) Patients with degenerative muscle and nerve diseases and those with head and neck injuries who use ventilators and are deemed suitable for treatment at the respiratory care center by the physician in charge of the respiratory care center.

◎ What will happen if I don't switch?

(i) Because patients who use ventilators for a long time have poor immunity, and the intensive care unit is full of patients with high infection rates, high severity and requiring multiple monitoring devices, patients staying in the intensive care unit are not only prone to infection, but the noise generated by multiple monitoring devices and the tense atmosphere in the intensive care unit will prevent patients from relaxing and recovering both physically and mentally. At the same time, the beds in the intensive care unit cannot be used effectively, and other patients who need intensive care may lose the opportunity to be rescued because they cannot be admitted.

(ii) However, if the patient experiences any of the following conditions, they must be transferred back to the intensive care unit:

1. Shock (severe hemodynamic instability)

2. Acute myocardial infarction (AMI)

3. Other major surgical procedures

Patients who have spent more than 42 days in a respiratory care center, or more than 63 days on a ventilator, or who, according to a pulmonologist's assessment, cannot be weaned off a ventilator in the short term, should be transferred to a respiratory care ward, such as:

1. Patients who require long-term use of ventilators or are ventilator dependent.

2. Patients with terminal cancer who are on a ventilator and no longer receiving active treatment.

3. Patients who cannot be weaned off a ventilator due to conditions such as surgical wound stabilization, acute injury, chronic obstructive pulmonary disease, musculoskeletal disorders, or spinal cord injury.

4. Those without serious infection and no longer requiring intravenous antibiotics.