Ventilator Weaning and Discontinuation Practices for Critically Ill Patients

Abstract

for the Canadian Critical Care Trials Group IMPORTANCE Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice.OBJECTIVE To describe practice variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs). DESIGN, SETTING, AND PARTICIPANTS Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US). EXPOSURES Receiving IMV. MAIN OUTCOMES AND MEASURES Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes. RESULTS Among 1868 patients (median [interquartile range] age, 61.8 [48.9-73.1] years; 1173 [62.8%] men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT ( 761[81.8%] successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 [4.7%] vs 96 [10.3%]; absolute difference, 5.6% [95% CI, 2.6%-8.6%]), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days [95% CI, 0.7-1.6]), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days [95% CI, 0.8-2.4]). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 [17.2%] vs 67 [8.8%]; absolute difference, 8.4% [95% CI, 2.0%-14.7%]), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days [95% CI, 1.6-3.6]), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days [95% CI, 1.1-5.2]). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days [95% CI, 3.7-4.5]), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days [95% CI, 4.0-6.3]), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days [95% CI, 6.0-11.0]). CONCLUSIONS AND RELEVANCEIn this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016...

Biosignal-Based Digital Biomarkers for Prediction of Ventilator Weaning Success

“…Although many predictive indices and clinical tools are already in use [1,[13][14][15][16][17][18][19][20][21][22], >20% of the patients who have fulfilled the classic weaning criteria require reintubation [14,[23][24][25]. The predictive performance decreases in patients with multi-organ dysfunction, older age, prolonged MV, and severe illness [26][27][28][29][30][31].…”

The Application of Electrical Impedance Tomography During the Ventilator Weaning Process

“…1,2 The exact causes of failed ventilator weaning are still debatable, but recent studies have shown that 60% of such cases could be avoided. [3][4][5][6] This suggests that the current evaluation system needs to be improved by introducing new indicators, especially those that reflect patients' pulmonary ventilation dynamics before and after ventilator weaning.…”

Fokus Beatmung, Sauerstofftherapie und Weaning

“…Bei der NIV wird der Patient entweder über eine Gesichtsmaske oder einen Helm an das Beatmungsgerät angeschlossen. Grieco et al [9] verglichen in einer multizentrischen, randomisierten klinischen Studie die frühe 48 18 Tage [IQR: 0-22] für HFNO, p = 0,26). Einige klinisch wichtige sekundäre Ergebnisse unterschieden sich zwischen den Gruppen: eine signifikant niedrigere Inzidenz von Intubationen in der Helm-NIV-Gruppe (30 vs. 51 % für HFNO, p = 0,03), und die mediane Anzahl der Tage ohne invasive mechanische Beatmung innerhalb von 28 Tagen war in der Helm-NIV-Gruppe signifikant höher als in der HFNO-Gruppe (28 Tage [IQR: [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] vs. 25 Tage [IQR: 4-28], p = 0,04).…”

“…Grieco et al [9] verglichen in einer multizentrischen, randomisierten klinischen Studie die frühe 48 18 Tage [IQR: 0-22] für HFNO, p = 0,26). Einige klinisch wichtige sekundäre Ergebnisse unterschieden sich zwischen den Gruppen: eine signifikant niedrigere Inzidenz von Intubationen in der Helm-NIV-Gruppe (30 vs. 51 % für HFNO, p = 0,03), und die mediane Anzahl der Tage ohne invasive mechanische Beatmung innerhalb von 28 Tagen war in der Helm-NIV-Gruppe signifikant höher als in der HFNO-Gruppe (28 Tage [IQR: [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] vs. 25 Tage [IQR: 4-28], p = 0,04). Diese wichtige Studie ist die erste, die Helm-NIV vs. HFNO bei Patienten mit einer relativ homogenen Ursache für akutes hypoxämisches respiratorisches Versagen ("acute hypoxemic respiratory failure", AHRF) direkt verglichen hat.…”

“…Diese Informationen können für die klinische Prognose herangezogen werden (Burns et al bestätigen z. B., dass etwa eine von 10 Extubationen fehlschlägt [18]). Darüber hinaus könnten solche epidemiologischen Basisdaten hilfreich sein, um den klinischen Fortschritt zu messen und Interventionsstudien, die auf eine Änderung der Praxis abzielen, genauer auszuwerten.…”