Protocol-Driven Ventilator Weaning Reduces Use of Mechanical Ventilation, Rate of Early Reintubation, and Ventilator-Associated Pneumonia

Dries, David J.; McGonigal, Michael D.; Malian, Michael S.; Bor, Barbara J.; Sullivan, Christopher J.

doi:10.1097/01.ta.0000124462.61495.45

Cited by 116 publications

(50 citation statements)

References 38 publications

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“…Observational studies from both medical and surgical ICUs have reported that spontaneous breathing trials and targeted/daily sedation interruptions (irrespective of other VAP prevention measures) reduced the prevalence of VAP from ϳ15 to 5%. This corresponded with a decrease in the mean duration of mechanical ventilation to fewer than 5 d. 105,106 In another study, targeted sedation reduced the average duration of mechanical ventilation from 10.3 to 4.4 d with a corresponding trend toward reduced VAP from 20.4 to 8.3% (P ϭ .10). 107 …”

Section: Weaning and Sedation Strategiesmentioning

confidence: 90%

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Kallet

2015

Respir Care

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SummaryVentilator-associated pneumonia (VAP) is an acquired infection related primarily to the consequences of prolonged endotracheal intubation. It is considered the most important infectious challenge in the critical care setting. Preventable complications of hospital care are considered an important source of wasted health-care costs believed to consume up to 47% of annual expenditures in the United States. Whether VAP is preventable has become a highly contentious debate since public reporting commenced a decade ago. This selective review focuses on specific aspects of this debate, including the inherent vagaries in the diagnosis of VAP and the marked disparities between VAP rates based on clinical diagnosis versus surveillance data. Also discussed is how this debate has impacted public policy, leading to the new paradigm of ventilator-associated events. The limited ability of artificial airways to prevent microaspiration and biofilm build-up, as well as non-modifiable conditions increasing the risk of VAP, is described in detail. In addition, the origins of the mistaken but widely embraced notion that zero VAP is a realistic achievement are examined.

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Section: Weaning and Sedation Strategiesmentioning

confidence: 90%

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Kallet

2015

Respir Care

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“…Os protocolos são desenvolvidos com base em evidências, as quais tendem a ser inseridas em um fluxograma, e são elaborados por especialistas de acordo com as características de cada UTI. Diversos estudos têm demonstrado a superioridade do desmame seguindo protocolos (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14). Nota-se essa falta de metodologia quando observamos as técnicas utilizadas no GC, no qual se observaram técnicas pouco recomendadas, como o SIMV, além de outros métodos, como a utilização do modo assistido controlado na modalidade ciclada a volume.…”

Section: Discussionunclassified

“…Essa estratégia pode repercutir em desfechos ruins, evidenciando a necessidade de implementar técnicas para identificar os pacientes elegíveis para o desmame e a sua transição para a ventilação espontânea deve seguir estratégias eficazes e comprovadas, favorecendo a utilização dos protocolos (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14).…”

Section: Introductionunclassified

Efeitos da fisioterapia no desmame da ventilação mecânica

José

Pasquero²,

Timbó³

et al. 2013

Fisioter. mov.

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ResumoIntrodução: A Fisioterapia vem atuando com o objetivo de reduzir falhas no desmame da ventilação mecâ-nica (VM) que podem repercutir em desfechos desfavoráveis para o paciente. Objetivo: Avaliar os efeitos da fisioterapia no desmame da VM. Materiais e métodos: Estudo transversal e controlado com pacientes adultos. A formação dos grupos estudados foi resultado de dois períodos ocorridos em uma UTI; em determinado período, a unidade contou com a presença de um profissional de Fisioterapia, em outro, não teve a presença desse profissional por razões administrativas. Registraram-se os resultados do desmame por meio de coleta diária de informações. Foram estudados 50 pacientes, 31 fizeram fisioterapia (grupo fisioterapia, GF)Fisioter Mov. 2013 abr/jun;26(2):271-9 José A, Pasquero RC, Timbó SR, Carvalhaes SRF, Bien US, Dal Corso S. 272 e 19 não fizeram (grupo controle, GC). O GF realizou dois atendimentos diários (quarenta minutos cada), composto das técnicas: compressão do tórax, hiperinsuflação manual, aspiração traqueal e de vias aéreas, movimentação e condução do desmame. O GC recebeu tratamento médico usual. Resultados: Observou-se no GF e GC, respectivamente: sucesso no desmame -71% (22) e 21% (4) (p = 0,001); tempo de VM -152 ± 142 e 414 ± 344 horas (p = 0,04); tempo de desmame: 13 ± 48 e 140 ± 122 horas (p < 0,0001); tempo de internação na UTI -338 ± 192 e 781 ± 621 horas (p = 0,007); tempo de internação hospitalar -710 ± 628 e 1108 ± 720 horas (p = 0,058); mortalidade: 35% (11) e 47% (9) (p = 0,41). Conclusão: A fisioterapia esteve associada ao aumento do sucesso no desmame, à redução do tempo de desmame, tempo de VM e de internação na UTI. Não houve diferença no tempo de internação hospitalar e na mortalidade.[P]Palavras-chave: Desmame do respirador. Ventilação mecânica. Fisioterapia.[

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“…Other studies of RT-protocol-based liberation from mechanical ventilation have shown mixed results, with one observational study supporting benefit 20 and another pseudorandomized study not showing benefit. 21 As the authors noted in the latter study, the level of physician staffing of the ICU was "generous" enough (ie, 2 attending physicians and 10 physicians-in-training staffed a closed 14-bed ICU) to obscure any possible incremental impact of protocols.…”

Section: Are Respiratory Protocols Effectivementioning

confidence: 99%

The Scientific Basis for Protocol-Directed Respiratory Care

Modrykamien

Stoller

2013

Respir Care

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SummaryAs defined by the American Association for Respiratory Care, respiratory care protocols are "guidelines, usually written in algorithmic form, for providing respiratory therapy services." The need for protocols has been framed by the frequent occurrence of misallocation of respiratory care, consisting both of over-ordering (ie, prescribing respiratory care that is unlikely to confer benefit) and under-ordering services (ie, failing to prescribe services that would be expected to offer benefit). In this context, the current paper reviews available studies regarding the effectiveness of respiratory care protocols. Such studies can be organized into those assessing respiratory care treatments in the ICU, and those addressing non-ICU respiratory care. In the ICU, studies have addressed sampling both ABGs and liberating patients from mechanical ventilation; in the latter activity, multiple concordant randomized controlled trials have shown that weaning protocols implemented by respiratory therapists and/or nurses can accelerate patients' liberation from mechanical ventilation, with shorter stay and lower cost. Outside of the ICU, studies have addressed the effectiveness of respiratory care protocols in guiding the use of supplemental oxygen, bronchopulmonary hygiene, bronchodilator use, and of assessing patient for step-down unit placement. All such studies have shown that respiratory care protocols are effective. Furthermore, 2 concordant randomized controlled trials have shown that comprehensive respiratory care protocol programs can enhance the allocation of respiratory care services, with concomitant savings and no excess adverse outcomes. Overall, while the overwhelming weight of available evidence supports the effectiveness of respiratory care protocols, gaps in current understanding remain, especially regarding settings outside the acute care hospital (eg, geriatric care, palliative care, and extended care facilities). In the same spirit that engendered the Sugarloaf Conference to assess the effectiveness of respiratory care, further assessment of the effectiveness of respiratory care protocols is encouraged and expected.

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Protocol-Driven Ventilator Weaning Reduces Use of Mechanical Ventilation, Rate of Early Reintubation, and Ventilator-Associated Pneumonia

Abstract: Protocol-driven weaning reduces use of mechanical ventilation and VAP. Injured and general surgical patients show reduction in complications, but shorter ICU LOS depends on resources elsewhere in the health care system.

Cited by 116 publications

References 38 publications

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Efeitos da fisioterapia no desmame da ventilação mecânica

The Scientific Basis for Protocol-Directed Respiratory Care

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