Adding value to mechanical ventilation

http://dx.doi.org/10.1590/S1806-37132014000500002 hospitalization for patients with respiratory failure and requiring mechanical ventilation is estimated to be US$34,000, allow us to extrapolate that Brazil will spend nearly R$54.5 billion/year, considering 12% of healthcare expenditures(8) and 1.1% of the gross domestic product,9) on hospital treatment of patients with acute respiratory failure or acute exacerbation of chronic respiratory failure. The figures presented above, bearing in mind that they are the result of a simple epidemiological, mathematical, and financial exercise, draw attention to the huge impact that respiratory failure and mechanical ventilation have on heath policy in Brazil. However, it is important to remember that ventilatory support is known to be a cost-effective treatment for most patients. Studies published in recent years have shown figures ranging from US$26,000 to US$175,000 per quality-adjusted life year (QALY), depending on the etiology of respiratory failure, comorbidities, and patient age.(10) Although arbitrary, it is current practice to accept treatments resulting in US$50,000150,000/QALY as cost-effective.(11) The published recommendations(1-4) state that the results of treatment of patients with acute respiratory failure have improved greatly in recent decades, and what is most interesting is that this advance is more attributable to a better understanding of the pathophysiology of respiratory failure and to the prevention of ventilator-associated complications than to the development of new drugs or technologies. Mechanical ventilators, in their basic essence, have changed very little over this period, but the way they are used has changed completely, evolving from an aggressive strategy to correct hypoxemia and/or hypercapnia to a strategy focused on delivering a minimum alveolar ventilation to ensure gas exchange, sparing the lungs from further injury and thereby providing the time needed for lung recovery. Brazil has played a decisive role in the development of these modern concepts of mechanical ventilation, particularly in the understanding of the pathophysiology of ARDS and in being a pioneer in demonstrating the benefits of using protective ventilatory strategies. (12,13) Adding value to mechanical ventilation