Ventilatory strategies in intensive care: Balancing clinical outcomes and cost-effectiveness

Abstract

Ventilatory strategies shape both outcomes and healthcare expenditures in acute respiratory failure. In resource-limited settings, choosing interventions that provide the greatest value is crucial. Evidence from India indicates that non-invasive ventilation may reduce mortality, intensive care unit stay, and treatment costs to nearly one-fifth of those associated with invasive mechanical ventilation. Comparative data from other low-income and middle-income countries reinforce the importance of prioritizing scalable, protocolized strategies with favorable cost-effectiveness profiles. This editorial discusses why economic considerations are indispensable in critical care, highlights key limitations in available studies, and emphasizes that the value of ventilatory support depends heavily on context - particularly pricing, capacity constraints, and local willingness-to-pay thresholds. Strengthening multicenter economic research, especially in low-income and middle-income countries, is vital to guide policy decisions and ensure equitable, sustainable deployment of ventilatory technologies.

Key Words: Artificial respiration; Intensive care units; Cost-benefit analysis; Respiratory insufficiency; Ventilatory strategies

Core Tip: Cost-effectiveness analysis of ventilatory strategies in intensive care helps balance optimal patient outcomes with rational resource use. Evidence supports the value of lung-protective ventilation, non-invasive ventilation, and prone positioning in improving survival at relatively low cost. In contrast, prolonged mechanical ventilation is resource-intensive, offering limited incremental benefit and highlighting the need for targeted, efficient critical care interventions.

TO THE EDITOR

This article aims to provide a critical overview of the cost-effectiveness of common ventilatory strategies and their implications for intensive care unit (ICU) policy and practice, with emphasis on both clinical outcomes and economic sustainability in resource-limited settings. The growing demand for intensive care services highlights the importance of balancing technological advances with economic sustainability. Ventilatory support, one of the most frequent and resource-intensive interventions in the ICU, directly impacts not only survival but also the costs associated with prolonged hospitalization[1]. Economic analyses in critical care underscore the complexity of measuring value, given the variability in patient populations, institutional resources, and regional healthcare systems.

In critical care, cost-effectiveness analyses frequently rely on health-economic metrics such as the quality-adjusted life year, which combines survival with health-related quality of life[2]. Other important outcome measures include in-hospital and long-term mortality, as well as length of stay in both the ICU and hospital, which directly impact resource utilization and overall costs. These metrics are essential for determining whether an intervention provides sufficient clinical benefit to justify its economic burden in the intensive care setting.

Despite the high economic burden of intensive care, cost-effectiveness evaluations of ventilatory strategies remain limited and heterogeneous. The systematic review by Wilcox et al[2] underscores both the scarcity of robust analyses and the wide variability in reported incremental cost-effectiveness ratios, ranging from highly favorable values for low tidal volume ventilation to prohibitively high costs in certain populations, such as elderly patients requiring prolonged mechanical ventilation. Importantly, some interventions initially deemed cost-effective, such as activated protein C for sepsis, were later proven clinically ineffective, highlighting the danger of premature economic endorsements without strong evidence of benefit. In this context, ventilatory strategies such as lung-protective ventilation and selected use of extracorporeal membrane oxygenation emerge as examples of interventions that may deliver value when applied to appropriate populations[3]. Ultimately, integrating cost-effectiveness analysis into critical care decision-making is not merely an economic exercise, but a path toward prioritizing interventions that maximize patient outcomes while ensuring responsible allocation of scarce ICU resources. In Table 1, we summarize the cost-effectiveness of major ventilatory strategies used in the ICU, including non-invasive ventilation[4], high-flow nasal cannula[5], protective ventilation[6], extracorporeal membrane oxygenation[3], and prolonged mechanical ventilation[7,8].

Table 1 Cost-effectiveness of ventilatory strategies in the intensive care unit.

Strategy	Clinical context	Reported cost-effectiveness	Interpretation
NIV	Acute respiratory failure (COPD, cardiogenic pulmonary edema)	Reduces intubation, LOS and costs vs invasive ventilation; favorable ICER	Cost-effective when applied early in selected populations
HFNC	Hypoxemic respiratory failure	2000-3000 pounds per QALY	Highly cost-effective, especially as alternative to intubation
Protective ventilation (LTVV)	ARDS/ALI	13031 dollars per QALY vs conventional ventilation	Strong evidence of clinical and economic benefit
Prolonged mechanical ventilation	Patients requiring > 21 days of MV	36000-44000 dollars per QALY (Taiwan); often > 100000 dollars in elderly	Low cost-effectiveness; high resource burden
ECMO	Severe ARDS	43040 dollars per QALY (lifetime model)	Cost-effective in highly selected severe ARDS cases
Invasive ventilation in severe stroke	Patients ≥ 40 years old	Up to 266470 dollars per QALY	Poor cost-effectiveness; highlights limit of aggressive care
ICU admission vs ward care (severe sepsis)	Severe sepsis	3338 dollars per QALY in younger patients; higher in elderly	Very cost-effective, though benefit declines with advanced age
ICU admission vs ward care (pneumonia, sepsis, ARDS)	Severe acute illness	Variable; ICU increases survival but at higher cost	Reinforces need for population-based thresholds in critical care
ARDS rescue therapies (prone positioning, inhaled nitric oxide, ECMO)	Refractory hypoxemia	Prone positioning < 10000 dollars/QALY; nitric oxide not cost-effective	Low-cost, evidence-based interventions maximize value

Costs and incremental cost-effectiveness ratio are reported as in the original studies and are not standardized across settings, currencies, or time horizons. NIV: Non-invasive ventilation; HFNC: High-flow nasal cannula; LTVV: Low tidal volume ventilation; ECMO: Extracorporeal membrane oxygenation; ICU: Intensive care unit; ARDS: Acute respiratory distress syndrome; COPD: Chronic obstructive pulmonary disease; ALI: Acute lung injury; MV: Mechanical ventilation; LOS: Length of stay; QALY: Disability adjusted life year.

The financial burden of invasive mechanical ventilation is considerable, as demonstrated in systematic reviews, which consistently show an increase in daily ICU costs with prolonged ventilatory support[9]. These findings reinforce the need for strategies that can optimize weaning, reduce complications, and shorten the length of stay without compromising outcomes. From a policy perspective, resource allocation must be guided by both clinical effectiveness and cost-effectiveness.

In this context, evidence from Brazilian cohorts highlights the regional challenges in implementing advanced ventilatory strategies, particularly in public health systems with limited resources[10]. The heterogeneity of practices and the need for standardized protocols further complicate the assessment of true cost-effectiveness. Nevertheless, strategies such as protective ventilation and prone positioning have demonstrated not only clinical benefits but also potential economic advantages when integrated into structured protocols.

Evidence from low-income and middle-income countries shows a consistent pattern: Cost-effective strategies tend to be non-invasive and protective, while high-intensity interventions quickly exceed local willingness-to-pay thresholds. In Ethiopia, non-invasive management of critical coronavirus disease 2019 cost roughly 5514 dollars per episode vs 6500 dollars for invasive ventilation, with an incremental cost-effectiveness ratio of 4948 dollars per disability adjusted life years - surpassing the country’s 5500 dollars threshold[11]. In Colombia, extracorporeal membrane oxygenation was far more expensive than protective ventilation, reaching an incremental cost of about 177000 dollars per life saved - nearly ten times the national decision rule[12]. Indian data align with these trends, showing that non-invasive ventilation costs about one-fifth as much as invasive support while also reducing length of stay and mortality. Together, these low-income and middle-income countries findings reinforce that scalable, protocolized non-invasive support and lung-protective ventilation deliver far greater value than high-cost rescue therapies, which should remain limited to highly selected patients.

The article by Sodhi et al[13] provides a valuable contribution by exploring the relationship between ventilatory strategies and costs in critically ill patients, a topic of great relevance in the post-coronavirus disease era. The observational data from Sodhi et al[13] provide important insights into the potential benefits of non-invasive ventilation but must be interpreted carefully. Non-randomized design, absence of standardized protocols, and substantial baseline severity differences limit generalizability. Higher mortality and ICU stay in intubated patients likely reflect illness severity rather than the intrinsic effect of invasive ventilation. Future studies require multicenter designs and prospective methodology.

CONCLUSION

Cost-effectiveness findings should inform triage policies, ventilatory care bundles, and health-financing decisions. Strategies with favorable economic and clinical profiles - such as early non-invasive ventilation, prone positioning, and universal protective ventilation - should be prioritized. High-cost rescue therapies, such as extracorporeal membrane oxygenation, should remain restricted to highly selected patients within specialized centers, particularly in low-income and middle-income countries where opportunity costs are substantial.