Intensive care medicine is likely to be responsible for an increasing proportion of the care of hospitalised patients in nearly all medical areas in the next few years. It will be a major, if not the largest, economic factor for all hospitals. It is likely that intensive care medicine will become even more specialised (figure 2). In addition to the classical management of acute and life-threatening complex problems in conventional intensive care units, with high staffing ratios and modern technical equipment, a considerable increase is likely in the number of intermediate care units in which organ-specific problems are treated. Respiratory intermediate care units focus on respiratory failure, in an analogous fashion to coronary care units and stroke units. These wards do not have the complete infrastructure and staff of conventional intensive care units, but are much better equipped and staffed than regular wards. The leadership of individual units depends on the organ in focus, since specialised knowledge is essential for successful patient management.
The development of specialised weaning centres and long- term care facilities for patients who cannot be weaned from ventilation has important economic advantages as every long- term ventilated patient in a regular intensive care unit reduces the capacity for surgical operations, which, inevitably, are an important source of finance for hospitals. Specialised units for long-term ventilation, sometimes outside hospitals, are likely to develop further; they will care not only for the above- mentioned patients with chronic ventilatory failure, but also for patients discharged from intensive care units who cannot be weaned, and who need long-term invasive or noninvasive ventilation.
Important recent developments in intensive care include devices for extracorporeal oxygenation and removal of CO2. Extracorporeal membrane oxygenation is becoming available in highly specialised centres. CO2 removal systems are already being applied in weaning and might be useful in respiratory intermediate care units as a short-term ‘bridge’ in patients with acute on chronic respiratory failure, e.g. in patients with AE-COPD. The development of permanent extracorporeal lung replacement for the treatment of chronic respiratory insufficiency appeared to be unrealisitic until recently, but with improvements in membranes, miniaturised pump systems, and longer-lasting catheters, the artificial lung has become a realistic prospect. Intensive care medicine is thus generating new challenges for respiratory physicians, which extend their range and for which educational programmes will be necessary in order to meet the growing requirements.
As mentioned previously the organisational models of intensive care medicine differ considerably between, and sometimes within, European countries, with variation in personnel, educational standards, infrastructure and responsibilities. The overall relationship between respiratory medicine and intensive care medicine across Europe is unclear, apart from in the field of domiciliary ventilation. In some countries, respiratory medicine is only partly involved in respiratory intermediate care units, weaning centres and the initiation and management of home ventilation. Similarly, respiratory medicine is still under-represented in conventional intensive care and the subject is not part of the respiratory physician’s curriculum in all countries. Several training programmes have been developed to harmonise educational and training core curricula in intensive care in Europe. The European Society of Intensive Care Medicine (ESICM) has produced the Patient-centred Acute Care Training curriculum, an up-to-date, online, modular curriculum for intensive (critical) care medicine. This is an educational resource aimed at advancing and harmonising the quality of acute and critical care medicine training and practice. The European Board of Anaesthesiology, under the auspices of the Union Européenne des Médecins Spécialistes, has developed the Anesthesiology, Pain and Intensive Care Medicine Curriculum. Additionally the ESICM has developed the European Diploma in Intensive Care, while the European Society of Anaesthesiology has developed a European Diploma in Anaesthesiology and Intensive Care.
A respiratory critical care syllabus has been developed and published under the European Respiratory Society HERMES initiative (see chapter 36) and this will be followed by a specific curriculum and diploma. Quality indicators for staff and infrastructure need to be refined for all areas of intensive care medicine (full intensive care units, respiratory intermediate units, weaning centres, home ventilation). Respiratory physicians should be responsible for defining the criteria for the last three.
Respiratory medicine should also contribute to the standards and curricula for other professional groups involved in intensive care medicine and should be the lead speciality for defining educational standards for respiratory intermediate care units, weaning units and home ventilation.