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

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.