Introduction

In recent decades, no branch of medicine has made more progress than intensive care. Important advances include: technological developments to overcome single-organ failure (for example, the development of respirators and extracorporeal oxygenation to treat acute lung failure); improvements in pharmacotherapy based on better understanding of the underlying pathophysiology; and new or improved monitoring systems for surveillance of organ function and to help to direct therapies.

As a consequence of these technological, diagnostic and therapeutic advances, demand for intensive care medicine has escalated continuously. Increasingly, elderly patients with multiple comorbidities are now treated in intensive care units and the boundaries of possible treatments are ever-widening. As recently as 30 years ago, patients needing invasive ventilation for more than 3 days were unlikely to survive. Today, patients requiring long-term ventilation are a common occurrence in every intensive care unit. With the expansion of mechanical ventilation and other organ-replacement techniques, large new areas of medicine have been added to classical acute intensive care. The differences between the ‘high- tech’ intensive care unit and regular wards have widened. Intermediate care units have also become established, with better monitoring and a greater therapeutic spectrum than is found in conventional wards, but without the organ-replacement techniques of the intensive care unit.

Weaning from prolonged mechanical ventilation is an important aspect of modern intensive care medicine. Specialised units have grown up in many hospitals (long-term care facilities/weaning units), and home mechanical ventilation has also expanded greatly in recent years.

New professions have developed, such as the respiratory therapist. However, the development of legal and administrative structures associated with intensive care medicine, the skills of the staff and the definitions of their job profiles have not always kept pace with the rapid changes in medical reality. Historically, the structure of intensive care medicine developed differently in different European countries. Consequently, there are variations in professional responsibility, recruitment and training of staff, career perspectives in intensive care medicine and quality standards.

With the growth of intensive care units, intensive care medicine has become economically more important for hospitals and, consequently, for the financing of the whole healthcare sector. These developments will continue, increasing the pressure to create adequate legal and administrative structures in this area. At the same time, the need for qualified specialised personnel and for internationally equivalent and mutually recognised training programmes will increase.

Standards of end-of-life care and decision-making have become an increasingly important issue in intensive care medicine, in particular in patients with end-stage respiratory failure. A European Respiratory Society task force found that in European respiratory intermediate care units and high-dependency units this is highly relevant: an end-of-life decision was taken in 21.5 % of the patients admitted.

See the entire Respiratory intensive care Chapter