The Ventilator Discontinuation Process: An Expanding Evidence BaseDiscussion

Abstract

The ventilator discontinuation process is an essential component of overall ventilator management. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. On the other hand, premature withdrawal can lead to muscle fatigue, dangerous gas exchange impairment, loss of airway protection, and also a higher mortality. Continued ventilator dependence can be a result of persistent illness or can be a result of poor management. It is obviously important for the clinician to be able to assess both of these issues. An evidence-based task force has recommended regular assessments focusing on the causes of ventilator dependence, regular assessments for evidence of disease stability/reversal, use of regular spontaneous breathing trials (SBTs) as the primary assessment tool for ventilator discontinuation potential, use of separate assessments to evaluate the need for an artificial airway in patients tolerating the SBT, and the use of comfortable, interactive ventilator modes (that do not need to be "weaned") in between regular SBTs. More recent developments have focused on the importance of linking sedation reduction protocols to ventilator discontinuation protocols. Patients with repeated SBT failures are often considered to require prolonged mechanical ventilation (PMV). These patients often receive tracheostomies and are probably better managed with more gradual reductions in support and gradually lengthened spontaneous breathing periods. PMV patients have a high 1-year mortality, and many may ultimately require lifelong support. This evidence base is growing, but the earlier guidelines are standing the test of time. Indeed, practice patterns are evolving in accordance with them. Nevertheless, there is still room for improvement, and further clinical studies, especially in the patient requiring PMV, are needed.

Understanding nurses' decision‐making when managing weaning from mechanical ventilation: a study of novice and experienced critical care nurses in Scotland and Greece

“…Yet, nurses grouped together these criteria to provide a patient‐centred assessment of the patient and make the diagnosis of a ‘weanable’ patient. The objective physiological criteria that nurses referred to in their thinking are part of the international guidelines for weaning mechanical ventilation (MacIntyre ), which suggests that they are the basis of local practice and are embodied in critical care nurses’ thinking processes. Given the lack of existence of specific plans for weaning, nurses used a trial and error approach to change ventilatory support, which was depicted in both Focus Gambling and Conservative Focusing decision‐making strategies used.…”

Concept for a study design in patients with severe community-acquired pneumonia: A randomised controlled trial with a novel IGM-enriched immunoglobulin preparation – The CIGMA study

“…Minimal haemodynamic deterioration can be achieved by avoiding excessive ventilation and PEEP, and by using the minimal necessary level of analgesia-sedation. Patients are to be evaluated daily for clinical stability, normal consciousness, and improvement of respiratory failure to decide whether to withdraw mechanical ventilation and to start a spontaneous breathing trial [42] (SBT). The duration of the SBT is to be between 30 and 120 min; the presence and persistence of criteria for SBT failure is to be assessed during the trial.…”

Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 1

“…However, strong evidence does exist supporting the employment of a short-term (30 min) breathing trail and low-level pressure support (8 cmH 2 O) [22]. If the SBT is accompanied by patient discomfort (i.e., anxiety or fatigue) and/or cardio-respiratory distress (i.e., RR ≥ 35 bpm, SpO 2 < 90%, HR variability > 20%, hemodynamic instability) [23], then it is considered to have failed. In the absence of such responses, the SBT is deemed successful and the patient can be considered for airway removal (Ready, extubing!).…”