A 2-h T-tube trial of spontaneous breathing was used in selecting patients ready for extubation and discontinuation of mechanical ventilation. However, some doubt remains as to whether it is the most appropriate method of performing a spontaneous breathing trial. We carried out a prospective, randomized, multicenter study involving patients who had received mechanical ventilation for more than 48 h and who were considered by their physicians to be ready for weaning according to clinical criteria and standard weaning parameters. Patients were randomly assigned to undergo a 2-h trial of spontaneous breathing in one of two ways: with a T-tube system or with pressure support ventilation of 7 cm H2O. If a patient had signs of poor tolerance at any time during the trial, mechanical ventilation was reinstituted. Patients without these features at the end of the trial were extubated. Of the 246 patients assigned to the T-tube group, 192 successfully completed the trial and were extubated; 36 of them required reintubation. Of the 238 patients in the group receiving pressure support ventilation, 205 were extubated and 38 of them required reintubation. The percentage of patients who remained extubated after 48 h was not different between the two groups (63% T-tube, 70% pressure support ventilation, p = 0.14). The percentage of patients falling the trial was significantly higher when the T-tube was used (22 versus 14%, p = 0.03). Clinical evolution during the trial was not different in patients reintubated and successfully extubated. ICU mortality among reintubated patients was significantly higher than in successfully extubated patients (27 versus 2.6%, p < 0.001). Spontaneous breathing trials with pressure support or T-tube are suitable methods for successful discontinuation of ventilator support in patients without problems to resume spontaneous breathing.

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OBJECTIVE To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health.METHODS The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care unit beds. The results were plotted against Ministry of Health parameters. Data were obtained from the State Regulation Center from 2010 to 2011.RESULTS There were 33,101 medical requests for 268 regulated intensive care unit beds in Rio de Janeiro. With an average length of stay in regulated ICUs of 11.3 days, there would be a need for 595 active beds to ensure system stability and 628 beds to ensure a maximum waiting time of six hours. Deducting current abandonment rates due to clinical improvement (25.8%), these figures fall to 441 and 417. With an average length of stay of 6.5 days, the number of required beds would be 342 and 366, respectively; deducting abandonment rates, 254 and 275. The Brazilian Ministry of Health establishes a parameter of 118 to 353 beds. Although the number of regulated beds is within the recommended range, an increase in beds of 122.0% is required to guarantee system stability and of 134.0% for a maximum waiting time of six hours.CONCLUSIONS Adequate bed estimation must consider reasons for limited timely access and patient flow management in a scenario that associates prioritization of requests with the lowest average length of stay.

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ObjectivesTo determine the optimal number of adult intensive care unit beds to reduce patient's queue waiting time and to propose policy strategies.MethodsMultimethodological approach: (a) quantitative time series and queueing theory were used to predict the demand and estimate intensive care unit beds in different scenarios; (b) qualitative focus group and content analysis were used to explore physicians' attitudes and provide insights into their behaviors and belief-driven healthcare delivery changes.ResultsA total of 33,101 requests for 268 regulated intensive care unit beds in one year resulted in 25% admissions, 55% queue abandonment and 20% deaths. Maintaining current intensive care unit arrival and exit rates, there would need 628 beds to ensure a maximum wait time of six hours. A reduction of the current abandonment rates due to clinical improvement or the average intensive care unit length of stay would decrease the number of beds to 471 and 366, respectively. If both were reduced, the number would reach 275 beds. The interviews generated 3 main themes: (1) the doctor's conflict: fair, legal, ethical and shared priorities in the decision-making process; (2) a failure of access: invisible queues and a lack of infrastructure; and (3) societal drama: deterioration of public policies and health care networks.ConclusionThe queue should be treated as a complex societal problem with a multifactorial origin requiring integrated solutions. Improving intensive care unit protocols and reengineering the general wards may decrease the length of stay. It is essential to redefine and consolidate the regulatory centers to organize the queue and provide available resources in a timely manner, by using priority criteria, working with stakeholders to guarantee clinical governance and network organization.