Chest
Volume 120, Issue 6, Supplement, December 2001, Pages 454S-463S
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Mechanical Ventilator Weaning Protocols Driven by Nonphysician Health-Care Professionals: Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.120.6_suppl.454SGet rights and content

Health-care professionals (HCPs) can provide protocol-based care that has a measurable impact on critically ill patients beyond their liberation from mechanical ventilation (MV). Randomized controlled trials have demonstrated that protocols for liberating patients from MV driven by nonphysician HCPs can reduce the duration of MV. The structure and features of protocols should be adapted from published protocols to incorporate patient-specific needs, clinician preferences, and institutional resources. As a general approach, shortly after patients demonstrate that their condition has been stabilized on the ventilator, a spontaneous breathing trial (SBT) is safe to perform and is indicated. Ventilator management strategies for patients who fail a trial of spontaneous breathing include the following: (1) consideration of all remediable factors (such as electrolyte derangements, bronchospasm, malnutrition, patient positioning, and excess secretions) to enhance the prospects of successful liberation from MV; (2) use of a comfortable, safe, and well-monitored mode of MV (such as pressure support ventilation); and (3) repeating a trial of spontaneous breathing on the following day. For patients who pass the SBT, the decision to extubate must be guided by clinical judgment and objective data to minimize the risk of unnecessary reintubations and self-extubations. Protocols should not represent rigid rules but, rather, guides to patient care. Moreover, the protocols may evolve over time as clinical and institutional experience with them increases. Useful protocols aim to safely and efficiently liberate patients from MV, reducing unnecessary or harmful variations in approach.

Section snippets

Materials and Methods

We have described the methods of our reviews in the introduction to this supplement and in the article concerning alternative discontinuation assessment methods and weaning modes. Herein, we summarize these methods briefly, focusing on aspects specific to this topic.

Results

We identified four randomized controlled trials (RCTs) that compared protocol-based weaning to conventional weaning (Table 1).9101112 One very small trial10 (15 patients) compared computer-directed weaning to physician-directed weaning and found trends in favor of the computer-directed weaning in both nonextubation and reintubation rates (Table 2).

Three RCTs91112 compared weaning protocols that were largely implemented by RCPs and nurses to conventional physician-directed weaning. These trials

Discussion

To provide clinicians with the most useful information set for the design and implementation of weaning protocols, we have structured this section into seven key recommendations (Table 5). The results of the foregoing evidence-based review were incorporated into the first three recommendations. The last four recommendations were derived from emerging data about weaning from MV and extubation, the optimal delivery of sedation and analgesia in the ICU, and the need for an objective and graded

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      A body of literature has identified factors that are associated with successful extubation: young age [7], low severity on ICU admission, short duration of MV prior to extubation [8], normocapnia [9], negative fluid balance immediately prior to extubation [10]. However, in a given patient, these factors do not allow prediction of whether weaning will be successful or not [11,12]. For this reason, a consensus conference held in 2006 has proposed a systematic approach based on step-by-step management of the weaning process [13].

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    This article is based on work performed by the McMaster University Evidence-based Practice Center, under contract to the Agency for Healthcare Research and Quality (Contract No. 290-97-0017), Rockville, MD.

    This research was supported by National Institutes of Health grant No. AG01023-01A1 (EWE) and a Beeson Scholarship from the American Federation for Aging Research (EWE).

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