Evidence-based ventilator weaning and discontinuation.

Ventilator management of a patient who is recovering from acute respiratory failure must balance competing objectives. Discontinuing mechanical ventilation and removing the artificial airway as soon as possible reduces the risk of ventilator-induced lung injury, nosocomial pneumonia, airway trauma from the endotracheal tube, and unnecessary sedation, but premature ventilator-discontinuation or extubation can cause ventilatory muscle fatigue, gas exchange failure, and loss of airway protection. In 1999 the McMaster University Outcomes Research Unit conducted a comprehensive evidence-based review of the literature on ventilator-discontinuation. Using that literature review, the American College of Chest Physicians, the Society of Critical Care Medicine, and the American Association for Respiratory Care created evidence-based guidelines, which include the following principles: 1. Frequent assessment is required to determine whether ventilatory support and the artificial airway are still needed. 2. Patients who continue to require support should be continually re-evaluated to assure that all factors contributing to ventilator dependence are addressed. 3. With patients who continue to require support, the support strategy should maximize patient comfort and provide muscle unloading. 4. Patients who require prolonged ventilatory support beyond the intensive care unit should go to specialized facilities that can provide more gradual support reduction strategies. 5. Ventilator-discontinuation and weaning protocols can be effectively carried out by nonphysician clinicians.

[1]  L. Blanch,et al.  Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. , 1999, American journal of respiratory and critical care medicine.

[2]  D. Gracey,et al.  The chronic ventilator-dependent unit: a lower-cost alternative to intensive care. , 2000, Mayo Clinic proceedings.

[3]  C. Roussos,et al.  The tension-time index and the frequency/tidal volume ratio are the major pathophysiologic determinants of weaning failure and success. , 1998, American journal of respiratory and critical care medicine.

[4]  M J Tobin,et al.  Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group. , 1994, Chest.

[5]  J. Roustan,et al.  Occlusion pressure and its ratio to maximum inspiratory pressure are useful predictors for successful extubation following T-piece weaning trial. , 1995, Chest.

[6]  Linton Dm.  Adaptive lung ventilation. , 2001 .

[7]  E. Ely,et al.  Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. , 1999, American journal of respiratory and critical care medicine.

[8]  M J Tobin,et al.  Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. , 1997, American journal of respiratory and critical care medicine.

[9]  P. Macklem,et al.  Clinical manifestations of inspiratory muscle fatigue. , 1982, The American journal of medicine.

[10]  E F Haponik,et al.  Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. , 1996, The New England journal of medicine.

[11]  J. Kesecioglu,et al.  Comparison of pressure support ventilation (PSV) and intermittent mandatory ventilation (IMV) during weaning in patients with acute respiratory failure. , 1992, Advances in experimental medicine and biology.

[12]  S Sauer,et al.  A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. , 1997, Critical care medicine.

[13]  M Dojat,et al.  Evaluation of a knowledge-based system providing ventilatory management and decision for extubation. , 1996, American journal of respiratory and critical care medicine.

[14]  V. Jounieaux,et al.  Synchronized intermittent mandatory ventilation with and without pressure support ventilation in weaning patients with COPD from mechanical ventilation. , 1994, Chest.

[15]  J. Bach,et al.  Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. A different approach to weaning. , 1996, Chest.

[16]  F. Gordo,et al.  Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. , 1997, American journal of respiratory and critical care medicine.

[17]  C. Sassoon,et al.  Mechanical ventilator design and function: the trigger variable. , 1992, Respiratory care.

[18]  N. MacIntyre,et al.  Dual-control of mechanical ventilation. Discussion , 1996 .

[19]  I. L. Cohen,et al.  Cost containment and mechanical ventilation in the United States. , 1994, New horizons.

[20]  M. Tobin,et al.  Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. , 1995, American journal of respiratory and critical care medicine.

[21]  M. Tobin,et al.  Pattern of recovery from diaphragmatic fatigue over 24 hours. , 1995, Journal of applied physiology.

[22]  L. Labree,et al.  Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center. , 1997, Chest.

[23]  N. Calaf,et al.  Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. , 1998, American journal of respiratory and critical care medicine.

[24]  G. Evans,et al.  The prognostic significance of passing a daily screen of weaning parameters , 1999, Intensive Care Medicine.

[25]  A. Esteban,et al.  A COMPARISON OF FOUR METHODS OF WEANING PATIENTS FROM MECHANICAL VENTILATION , 1995 .

[26]  A. Esteban,et al.  A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. , 1995, The New England journal of medicine.

[27]  R. Hubmayr,et al.  Tidal volume maintenance during weaning with pressure support. , 1995, American journal of respiratory and critical care medicine.

[28]  L. Brochard,et al.  Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. , 1994, American journal of respiratory and critical care medicine.

[29]  S. Epstein,et al.  Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. , 1998, American journal of respiratory and critical care medicine.

[30]  R. Hyland,et al.  Positive end-expiratory pressure vs T-piece. Extubation after mechanical ventilation. , 1991, Chest.

[31]  J. Milic-Emili,et al.  Continuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. , 1990, The American review of respiratory disease.

[32]  J. Osborn,et al.  An analysis of potential physiological predictors of respiratory adequacy following cardiac surgery. , 1976, The Journal of thoracic and cardiovascular surgery.

[33]  M. Tobin,et al.  A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. , 1992, The New England journal of medicine.