Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
DOI 10.1186/s12890-016-0295-0
RESEARCH ARTICLE
Open Access
Long-term outcome and health-related
quality of life in difficult-to-wean patients
with and without ventilator dependency at
ICU discharge: a retrospective cohort study
P. Depuydt1,4*, S. Oeyen1, S. De Smet2, S. De Raedt2, D. Benoit1, J. Decruyenaere1 and E. Derom3
Abstract
Background: Long-term outcome and quality of life (QOL) in patients requiring prolonged mechanical ventilation
after failure to wean in the ICU is scarcely documented. We aimed to evaluate long-term survival and QOL in
patients discharged from the ICU with a tracheostomy for difficult weaning, and with or without ventilator
dependency at ICU discharge.
Methods: We retrospectively investigated post-ICU trajectories and survival in patients requiring tracheostomy for
difficult weaning admitted to the medical ICU of a tertiary center between 1999 and 2013, discriminating between
patients who were ventilator dependent or were weaned at ICU discharge. In 2014, a QOL assessment was
done in survivors with the use of the Short Form Health Survey (SF-36) and the Severe Respiratory
Insufficiency questionnaire.
Results: A total of 114 patients was included, of whom 59 were ventilator dependent and 55 were weaned
at ICU discharge. One-year survival rates were 73 % and 69 %, respectively. Overall QOL scores for physical
functioning were low, and not significantly different between patients ventilated and those weaned at ICU
discharge; scores for social functioning and mental health were less below norm and similar between both
groups.
Conclusions: Long-term survival in patients discharged from the ICU with tracheostomy and ventilator
dependency after failure to wean was not significantly different from that of patients with tracheostomy and
weaned at ICU discharge. Despite the physical QOL scores being low in both groups, mental QOL was
acceptable. Given the intrinsic limitations of this retrospective study, prospective and preferentially multicenter
studies are required to confirm these preliminary results.
Keywords: Prolonged mechanical ventilation, Quality-of-life, Tracheostomy
Background
Mechanical ventilation following endotracheal intubation is a potentially life-saving intervention in patients
with acute respiratory failure (ARF). However, in an increasing number of patients who survive the acute phase
of critical illness, subsequent weaning from mechanical
* Correspondence: pieter.depuydt@ugent.be
1
Intensive Care Department, Ghent University Hospital, De Pintelaan 185,
Ghent 9000, Belgium
4
Heymans Institute of Pharmacology, Ghent University Hospital, De Pintelaan
185, Ghent 9000, Belgium
Full list of author information is available at the end of the article
ventilation is difficult, prolonged or may ultimately
prove to be impossible [1].
In difficult-to-wean patients, it is widespread practice
to place a tracheostomy tube to facilitate weaning,
decrease complications associated with translaryngeal
intubation and increase patient comfort, although conclusive evidence for these benefits is lacking [2, 3]. Despite this intervention, patients may remain ventilator
dependent due to pre-existing neuromuscular or respiratory illness, sequelae of the ARF event, concomitant
cardiac dysfunction, persistent paralysis or intensive care
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Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
unit (ICU)-acquired neuromuscular weakness, or a combination of these factors [4].
In patients who recover sufficiently to survive without
the close monitoring and supportive care provided in the
ICU, prolonging invasive mechanical ventilation outside
the ICU may be considered; a decision to embark on this
trajectory usually involves shared decision making between the patient, his caregivers, and the ICU and pulmonology department medical teams. However, the outcome
and, especially, the quality of life (QOL) of these patients
following ICU discharge is as yet poorly known. Yet, this
information is essential to evaluate the benefits and downsides of this complex and costly care [5].
Methods
This single-center retrospective study, conducted at
Ghent University Hospital, reports on the post-ICU
trajectory, long-term outcome and QOL in two cohorts
of patients that were discharged from the ICU with
placement of a tracheostomy because of difficult weaning: the first cohort was still dependent on mechanical
ventilation at ICU discharge, while the second cohort
was weaned in the ICU. All patients were admitted to
the Medical Intensive Care Unit (MICU) and were subsequently discharged to the Department of Respiratory
Medicine. The 14-bed MICU is part of a 66-bed ICU,
which also includes a surgical (22 beds), cardiosurgical
(10 beds) and a pediatric ICU (14 beds) and a burn unit
(6 beds). The MICU admits critically ill patients of at least
15 years old and also serves as a regional referral center
for difficult-to-wean patients. Nurse to patient ratio is 1:2.
The MICU yearly admits 700 to 800 patients, of whom
40 % require mechanical ventilation; 15 % receive mechanical ventilation for >7 days. The Department of Respiratory Medicine includes a center for home mechanical
ventilation in charge of 100 patients; in 2014, chronic
home ventilation was initiated in 19 patients, in whom 3
required invasive ventilation (i.e. with tracheostomy).
Patients who were admitted to the MICU between
1999 and 2013 were eligible for inclusion in the retrospective cohort if they had received a tracheostomy for
difficult weaning during their ICU stay and were discharged to the Department of Respiratory Medicine
while this tracheostomy was still present. Patients with
neuromuscular or pulmonary disease in whom chronic
mechanical ventilation was initiated semi-electively were
not included. They were classified as ventilated patients
if they were still dependent on mechanical ventilation
for at least part of the day at ICU discharge, and as
weaned patients if they did not require mechanical ventilation for at least 72 h at ICU discharge.
From the medical and administrative records we collected demographics, comorbidities, admission diagnosis,
Page 2 of 9
etiology of acute respiratory failure and whether patients
were admitted through the emergency department or
were referred from other hospitals. Charlson comorbidity
scores were calculated to weight comorbidities [6]. We recorded trajectories following ICU discharge and vital status at hospital discharge. In hospital survivors, we noted
whether patients still had a tracheostomy and whether or
not they still received mechanical ventilation (including
non-invasive ventilation) at the time of hospital discharge
or thereafter.
We collected survival data at the end of 2014 by consulting medical and administrative patient records and
by contacting the patient’s general or referring physician
if these records were uninformative about the patient’s
vital status. Between June and December 2014, all surviving patients were invited by phone to invite them to
participate in the QOL study, which was done by means
of the Medical Outcomes Study 36-item Short Form
Health Survey (SF-36) and the Severe Respiratory Insufficiency (SRI) questionnaire. Both surveys were completed
as paper forms sent by mail. The SF-36 questionnaire consists of 36 items measuring eight multi-item domains in
a 0–100 scale, a higher score representing a better condition: physical (PF) and social functioning (SF), role
limitations due to physical (RP) or emotional problems
(RE), mental health (MH), vitality (VT), bodily pain
(BP) and general health (GH) [7, 8]. The reliability and
validity of the SF-36 has been evaluated in the critically
ill population [9].
The SRI questionnaire has been developed to assess
health-related QOL in patients with severe chronic respiratory failure resulting from a broad spectrum of
underlying disorders. The SRI questionnaire contains 49
questions in 7 domains: respiratory, physical functioning,
sleep quality, social functioning, feelings of fear, mental
health and social functioning; a summary score is calculated over all domains. The SRI has been validated for a
broad spectrum of patients with chronic respiratory failure [10], in particular those patients requiring home
non-invasive mechanical ventilation [11].
The study was approved by the local ethical committee
(Ghent University Hospital Ethical Committee). For the
retrospective assessment, informed consent was waived,
but from patients who underwent the QOL assessment,
a signed informed consent was obtained.
Binary and categorical variables are presented as frequencies and percentages. Numerical variables are presented as mean (with standard deviation) or as median
(with interquartile range) if normally, respectively nonnormally distributed. To compare numerical values, the
Student’s T-test or Mann–Whitney-U test were used
depending on the variable distribution; for categorical
variables, the Fisher Exact test was used. Kaplan-Meier
survival probabilities were calculated and were compared
Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
Page 3 of 9
using the log-rank test. All reported p-values are twotailed and a cut-off level of 0.05 was used to conclude for
significance. All statistical analysis was performed using
SPSS 22.0 software.
Results
A total of 114 patients with a tracheostomy at ICU discharge, of whom 59 still were ventilator dependent and
55 were weaned, were included for survival analysis.
This cohort represents 1 % of all patients admitted to
the MICU, and 7 % of all MICU patients requiring
tracheostomy during the study period. Patient characteristics are detailed in Table 1. Ventilator-dependent patients had more frequently underlying neuromuscular
disease (19 % vs. 4 %, p = 0.02), and had less often
pneumonia (32 % vs. 67 %, p < 0.001) and septic shock
(2 % vs. 22 %, p < 0.001) as primary cause of acute respiratory failure as compared with weaned patients. A
Table 1 Patient characteristics
Ventilated patients (n = 59)
Weaned patients (n = 55)
p-value
Age (years)
60 (53–70)
62 (53–62)
0.43
Male gender
35 (59)
34 (62)
0.78
Smoker
18 (35)
21 (47)
0.23
Heavy drinker
11 (19)
16 (30)
0.17
Obesity
12 (20)
10 (18)
0.78
Congestive heart failure
16 (27)
12 (22)
0.51
Peripheral vascular disease
10 (17)
9 (17)
0.93
Cerebrovascular disease
3 (5)
6 (11)
0.31
Diabetes
13 (22)
12 (22)
0.68
Chronic kidney disease
6 (10)
6 (11)
0.89
Chronic liver disease
2 (3)
6 (11)
0.02
Malignancy
7 (12)
12 (22)
0.15
COPD
20 (34)
23 (42)
0.71
Restrictive lung disease
5 (8)
7 (13)
0.92
Obstructive sleep apnea syndrome
8 (14)
5 (9)
0.45
Neuromuscular disease
11 (19)
2 (4)
0.02
Charlson Index of Comorbidity
5 (4–7)
6 (4–8)
0.16
Postoperative
6 (10)
6 (11)
0.92
Acute tetraplegia
7 (12)
8 (15)
0.79
Trauma (excluding tetraplegia)
3 (5)
4 (7)
0.71
Acute neurologic failure (excluding tetraplegia)
10 (17)
1 (2)
0.06
Acute cardiac failure
6 (10)
4 (7)
0.74
Septic shock
1 (2)
12 (22)
<0.001
Pneumonia (without septic shock)
19 (32)
37 (67)
<0.001
Comorbidities
a
Main admission diagnosisb
Exacerbation of COPD or other structural lung disease
Acute on chronic hypercapnic failure at admissionc
16 (27)
10 (18)
0.26
22 (37)
12 (22)
0.07
Vasopressor therapy during ICU stay
27 (46)
35 (63)
0.48
Hemodialysis during ICU stay
9 (15)
10 (18)
0.67
Time to tracheostomy (days)
14 (8–20)
16 (10–25)
0.23
Time to ICU discharge (days)
20 (10–39)
29 (15–51)
0.17
Time to weaning (days)
-
18 (7–31)
-
Data are reported as numbers (%) or median (interquartile range)
a
Malignancy was considered cured or in remission at ICU admission in all patients
b
One patient may have multiple admission diagnoses
c
As evidence by partially compensated respiratory acidosis and underlying pulmonary or extrapulmonary disease associated with respiratory pump failure
Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
Page 4 of 9
similar number of ventilator-dependent and weaned patients (58 %) were referrals from other hospitals. Timing
and indication of tracheostomy and length-of-stay at the
ICU were not significantly different between both
groups. Length-of-stay at the pulmonology department
was significantly longer for ventilator-dependent patients
vs. weaned patients (46d vs. 29d, p = 0.004) but hospital
mortality was similar in both groups. Patient trajectories
following ICU discharge are detailed in Fig. 1. Twelve
ventilator-dependent patients were subsequently weaned
(7 during the same hospitalization episode and 5 at a
later date) and nine patients were converted to noninvasive ventilation (5 during the same hospitalization
episode and 4 at a later date). Two patients who were
weaned at ICU discharge again required ventilator
No ventilation, tracheostomy
(weaned patients)
= 55
State at
discharge from
ICU
State at
discharge from
Department of
Respiratory
Medicine
State at time of
QoL assessment
support and tracheostomy at hospital discharge (1 patient)
or at a later date (1 patient). Ventilator-dependent patients
at ICU discharge were more frequently discharged at
home directly as compared to weaned patients (45 % vs.
27 %, p = 0.05). The number of readmissions following
hospital discharge was not significantly different between
both groups.
One-year survival of patients with ventilator dependency or weaned at ICU discharge was 73 % and 69 % respectively (p = NS); Kaplan-Meier survival curves are
shown in Fig. 2. Charlson comorbidity index was significantly associated with survival in ventilator-dependent
patients (p = 0.012) but not in weaned patients. When
individual comorbidities were analyzed, chronic renal
failure (p < 0.001) and cerebrovascular disease (p = 0.05)
Deceased
= 6 (11%)
Deceased= 6
Invasive
ventilation
= 2 (4%)
Deceased= 1 (50%)
Invasive ventilation= 1 (50%)
Fig. 1 Patient trajectories following ICU discharge
Non-invasive
ventilation
=0
No ventilation,
tracheostomy
= 25 (45%)
Deceased= 12 (48%)
No ventilation, tracheostomy= 4 (16%)
No ventilation, decannulated= 9 (36%)
No ventilation,
decannulated
= 22 (40%)
Deceased= 9 (41%)
Invasive ventilation= 1 (4%)
No ventilation, decannulated= 12 (55%)
Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
Page 5 of 9
Fig. 2 Survival curves of patients with tracheostomy who were ventilator-dependent (dashed line) (n = 59) or who were weaned (full line) (n = 55)
at ICU discharge
were negatively associated with survival. Admission diagnosis and etiology of acute respiratory failure were not
related to survival. In patients with a follow-up of at
least five years, 5-years survival rates were 40 % (16/40)
for ventilator-dependent and 42 % (14/33) for weaned
patients, respectively.
QOL was assessed in 21 patients with ventilator
dependency at ICU discharge after a median of 58
(24–103) months and in 22 weaned patients after a median of 52 (40–73) months. The overall response rate was
82,5 %; 4 patients could not be contacted, 2 had moved to
an address abroad and 3 refused to participate. The 0–100
scores of the SF-36 and SRI are detailed in Fig. 3. Overall,
QOL was low. SF-36 scores in the physical domains were
low but not different between patients with ventilator
dependency or weaned at ICU discharge. GH was significantly lower in ventilator-dependent vs. weaned
patients(p = 0.04). The SF-36 scores in the more mental domains were better without significant differences
between ventilator-dependent and weaned patients.
SRI showed overall lower QOL in ventilator-dependent
vs. weaned patients (50 vs. 59, p = 0.04), with lower scores
for physical functioning and feelings of fear, but with similar scores in social functioning, relations and mental
health.
Discussion
Deciding whether or not to embark for prolonged mechanical ventilation in critically ill patients with failure to
wean in the ICU is complex, with many uncertainties regarding long-term outcome. In this monocentric study,
survival of patients who were discharged from the ICU
with tracheostomy and ventilator dependency was 73 %
at one year and 40 % at five years. As compared to tracheotomized patients who were weaned at ICU discharge,
patients with ventilator dependency had comparable survival, lower QOL in terms of physical functioning, but
similar QOL in terms of social and emotional functioning.
Our findings show that at least a selection of patients
with failure to wean can be offered a meaningful survival
with an acceptable QOL in the longer term, despite the
fact that the majority of them remain dependent on ventilator support. In our practice, patients are considered
eligible for prolonged mechanical ventilation on an individual basis and after careful interdisciplinary consultation and using shared decision involving patients and
caregivers. A prerequisite for prolonging mechanical
ventilation outside the ICU is a reasonable life expectancy with a stable or only slowly evolving underlying
illness, and absent or minimal extra-pulmonary organ
dysfunction. Additional important criteria are good
Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
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Fig. 3 Quality-of-life as measured by the SF-36 questionnaire (a) and the SRI questionnaire (b) in patients who were discharged from the ICU
with a tracheostomy (n = 43) and ventilator dependency (n = 21) or weaned (n = 22) at ICU discharge*.
*In the group of patients with ventilator dependency at ICU discharge (n=21) and at time of QOL assessment, 7 patients still required invasive
ventilation, 4 non-invasive ventilation, 1 patient had a tracheostomy without ventilation and 9 patients had no ventilation and no tracheostomy. In
the group of patients who were weaned at ICU discharge (n=22) and at time of QOL assessment, 1 required invasive ventilation, 3 patients had a
tracheostomy without ventilation, and 18 had no ventilation and no tracheostomy
social support and an acceptable QOL before the acute
event (as estimated after history-taking). There must be
willingness to proceed on a prolonged medical trajectory
with important patient and caregiver’s involvement, including revalidation, education and self-care. Recently, a
decision aid has been developed for relatives of patients
with prolonged mechanical ventilation, in which the goal
of treatment was presented as a continuum of options
ranging from maximizing life duration to maximizing
comfort. Testing this aid in a before-after study revealed
better concordance between physician and patient
caregivers and greater comprehension. While this aid
was essentially developed to assist surrogates of patients
to understand and explore the patient’s values and preferences, it could also facilitate shared decision-making
involving the patient himself: this requires however
further study [12].
The only data that have been published regarding outcome of patients requiring post-ICU mechanical ventilation come from long-term acute care (LTAC) hospitals
in the USA. In a large multicenter study of 1419 patients
referred to 23 long-term care hospitals requiring post-
Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
ICU ventilation (the Ventilation Outcomes Study) [13,
14], survival at discharge was 75 % (86 % in our study);
72 % of patients discharged alive were weaned (14 % in
our study) but only 29 % of survivors were discharged to
home (45 % in our study), the remaining being transferred to other healthcare-facilities. In addition, 1-year
survival following LTAC admission was only 30 %
(although data were missing in 18 % of patients) versus
73 % in our study. In interpreting these results, and
comparing them with our figures, one must account for
the differences that exist between countries in
organization of post-ICU care for patients dependent on
mechanical ventilation or other forms of advanced care
due to chronic critical illness. Weaning centers and
long-term care hospitals do not exist in Belgium as separate institutions, but are embedded within ICUs and
pulmonology departments certified for providing home
mechanical ventilation. As such, part of the differences
in outcome between the US study and ours are probably
related to the fact that long-term care hospitals take over
part of the weaning process in difficult-to-wean patients
from the ICU and admit patients from ICUs in an earlier
stage of their critical illness: consequently, both inhospital mortality and weaning success are higher than
in our cohort, which was a more selected group of patients that was offered prolonged ventilation after failing
a more extended weaning effort at the ICU.
Very few data exist on QOL in patients with prolonged
or chronic mechanical ventilation following acute critical
illness. In the Ventilation Outcomes Study, functional
status (as measured by Zubrod Functional Status Scores)
in LTAC hospital survivors was good (ambulatory and
self-care possible, or better) in 60 % and poor (bedridden
at least 50 % of time and no self-care) in the remaining
40 % [13]. Comparison with our data is difficult given
the different QOL scores used. No data on mental health
were provided in the Ventilation Outcomes Study.
The SRI questionnaire was originally conceived to
measure QOL in patients requiring chronic non-invasive
home ventilation [15]. In a multicenter study with 85
patients requiring non-invasive home ventilation [16],
the summary score of SRI was 61 + −15, which is 10
points higher than in our population; a similar difference
can be seen in the physical component summary of the
SF-36. On the other hand, the mental component summary score was similar in our patients. The better physical
QOL in patients receiving non-invasive home ventilation
may reflect the absence of a tracheostomy and its interference with speech and eating, but also differences in the
path leading to chronic respiratory failure. In our patient
population, the acute critical illness and its subsequent
prolonged ICU stay may have caused additional functional
and cognitive impairments that have been grouped under
the moniker of ‘chronic critical illness’ [17, 18].
Page 7 of 9
In our study, QOL measurements in domains reflecting emotional and social functioning were better than
QOL in domains representing physical functioning, and
were not different between ventilator-dependent and
weaned patients. One elegant definition of overall QOL
is to regard it as the interaction of human needs and the
subjective perception of their fulfillment. Patients may
accept conditions of dependency and physical limitation
as long as their perceived role in social relations and life
experiences in general remain substantial and meaningful. Interestingly, in the aforementioned multicenter
study of QOL in patients requiring home noninvasive
mechanical ventilation, psychological well-being and
social functioning improved between 1 month and 1 year
following the start of ventilation in a number of subgroups of patients [16]. In our study, we only measured
QOL once after a median of approximately 4 to 5 years
after ICU discharge. It is conceivable that the relatively
long time interval between the ICU admission and QOL
evaluated has permitted some form of mental adaptation
and allowed the patients to come to terms with the
chronic but stable situation of dependency. Overall SF36 scores of the patients included in the present study
are in the range of what is observed in patients with
chronic diseases as severe renal failure or heart failure in
NYHA III and IV classes [5, 19].
Limitations of the study are its monocentric and retrospective design, which may limit generalization. PostICU care is little structured in Belgium, and results may
depend on local expertise. The studied cohort was highly
heterogeneous in terms of comorbidity and cause of
acute respiratory failure and no discriminative sets of
criteria that identify a good candidate for post-ICU
mechanical ventilation can be deduced. Patients with
underlying neuromuscular disease are more prevalent in
the chronically ventilated group: the fact that these
patients experienced a slowly progressive disease course
prior to the ARF event may have favored their acceptance of the chronic mechanical ventilation.
QOL assessment was done in all patients within a
single fixed time frame, and the time between ICU
discharge and QOL assessment was variable for the individual patient. The patient numbers are too small to
allow meaningful subgroup analysis. No QOL measurement is available for the period before ICU admission,
but this is a limitation present in most studies addressing post-ICU outcomes. As such, it is difficult to distinguish the contribution of chronic ventilation in patients
whose QOL may have been severely affected by the
presence of severe underlying comorbidities. Survival
bias may be of concern, as QOL only was assessed in
patients surviving until 2014; QOL in patients deceased
before this date is likely to have been lower. Finally, the
SRI questionnaire has been developed in German
Depuydt et al. BMC Pulmonary Medicine (2016) 16:133
language but has not been validated for the Dutch
translation.
Our study is however one of the few providing longterm outcome data in patients who fail to wean from invasive mechanical ventilation in the ICU. With further
advances in critical care and with the accumulation of
comorbidities in an ageing population, this particular patient group is very likely to expand and to impose an increasing burden on our ICUs and overall healthcare
delivery. Despite the limitations mentioned above, our
data show that at least in selected patients, mechanical
ventilation prolonged outside the ICU may be a valuable
treatment, both in terms of survival and perceived QOL.
However, given the intrinsic limitations of this retrospective and monocentric study, these results should be
considered as preliminary, urging for prospective and
preferentially multicenter studies to confirm them.
Conclusion
Long-term survival in patients with tracheostomy selected for prolonging mechanical ventilation outside the
ICU after failure to wean was not significantly different
from that of patients with tracheostomy who were
weaned from mechanical ventilation in the ICU. Despite
the physical QOL scores being low in both groups, mental QOL was acceptable.
Abbreviations
ARF: Acute Respiratory Failure; ICU: Intensive Care Unit; MICU: Medical
Intensive Care Unit; PF: Physical functioning; QOL: Quality of life; SF: Social
functioning; SF-36: Medical Outcomes Study 36-item Short Form Health
Survey; SRI: Severe Respiratory Insufficiency
Acknowledgements
We thank Tom Vanacker and Chris Danneels for their help in data
acquisition.
Funding
No funding was obtained for this study.
Availability of data and materials
The data supporting the findings of the manuscript are available upon
request to the first author (Pieter Depuydt).
Authors’ contributions
PD designed and planned the study, interpreted the results and drafted the
manuscript. SO interpreted the results and revised the manuscript for
important critical content. SDS and SDR acquired the data and interpreted
the results. DB and JDC interpreted data and revised the manuscript for
important critical content. ED designed and planned the study, interpreted
results and revised the manuscript for important intellectual content. All
authors read and approved the manuscript and accept accountability for all
aspects of the work.
Authors’ information
Pieter Depuydt is pulmonologist and intensive care physician working at
the Medical Intensive Care Unit of Ghent University Hospital. Eric Derom is
pulmonologist and head of the center for home mechanical ventilation
of the Department of Respiratory Medicine of Ghent University Hospital.
Sandra Oeyen is anesthesiologist and intensive care physician working at
the Surgical Intensive Care Unit of Ghent University Hospital, with special
interest for quality-of-life following ICU admission.
Page 8 of 9
Competing interests
The authors have no financial or non-financial competing interests.
Consent for publication
Not applicable (the manuscript does not contain any individual persons
data).
Ethics approval and consent to participate
The study was approved by the local ethical committee (Ghent University
Hospital Ethical Committee). For the retrospective assessment, informed
consent was waived, but from patients who underwent the QOL assessment,
a signed informed consent was obtained.
Author details
1
Intensive Care Department, Ghent University Hospital, De Pintelaan 185,
Ghent 9000, Belgium. 2Ghent University, Sint-Pietersnieuwstraat 10, Ghent
9000, Belgium. 3Department of Respiratory Diseases, Ghent University
Hospital, De Pintelaan 185, Ghent 9000, Belgium. 4Heymans Institute of
Pharmacology, Ghent University Hospital, De Pintelaan 185, Ghent 9000,
Belgium.
Received: 30 December 2015 Accepted: 24 June 2016
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