WEANING READINESS & SPONTANEOUS BREATHING TRIAL MONITORING

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1 CLINICAL EVIDENCE GUIDE WEANING READINESS & SPONTANEOUS BREATHING TRIAL MONITORING Weaning readiness and spontaneous breathing trial monitoring protocols can help you make the right weaning decisions at the right time. For mechanically ventilated patients, the length of time on the ventilator is directly correlated with the incidence of potentially serious complications, such as ventilator-associated pneumonia and airway trauma. 1 Unfortunately, accurately identifying patients who are ready to be weaned off mechanical ventilation can be challenging. In addition, the duration of the weaning process can account for approximately 25% of the total time on the ventilator, highlighting the potential for efficient weaning processes to enhance patient outcomes. 2,3 A number of studies have demonstrated the benefits of clinical decision support tools specifically designed to improve ICU protocol implementation and use. In ventilated patients, using effective protocols to better identify patients who are ready for weaning and to manage the weaning process itself can significantly reduce the duration of ventilation, cost of care, and number of complications. 2-7

2 The use of a protocolized weaning process including planned criteria for identifying patients ready for a spontaneous breathing trial, extubation and reintubation resulted in a low mechanical ventilation time and acceptable mortality and reintubation rates. Silva CS, Timenetsky KT, Taniguchi C, et al. Low mechanical ventilation times and reintubation rates associated with a specific weaning protocol in an intensive care unit setting: a retrospective study. Clinics (Sao Paolo). 2012;67(9): Retrospective, single center study. Single Arm: Patients on mechanical ventilation (MV) for more than 24 hours were assessed daily for readiness for spontaneous breathing. Each patient s clinical condition was assessed utilizing a set of clinical criteria and upon meeting the criteria, a spontaneous breathing trial (SBT) was conducted. Patients were extubated upon meeting clinical criteria for tolerance to the SBT. Patients diagnosed with specific clinical conditions were placed on non-invasive ventilation (NIV) postextubation. The protocolized weaning process also included daily interruption of sedation. To describe the application of a specific weaning protocol and its affect on the duration of MV and reintubation rates. DURATION The study was conducted over a 15-month period (January 2009 to April 2010). The study included 252 surgical (23%) and medical (77%) patients who required more than 24 hours of MV, treated at a 38-bed ICU of a private hospital in São Paulo, Brazil. Patients in the study remained on MV for an average of 3.7 days (range of 1 to 23 days). 27.7% (58) of the 252 patients studied failed to wean, defined as reintubation up to 48 hours after extubation, which included 32 patients administered non-invasive ventilation (NIV) postextubation and 26 patients who didn t meet the clinical criteria for NIV. 73% of extubated patients in the study met the clinical criteria for at least 24 hours of NIV support postextubation. The mortality rate of the 252 patients studied was 8.73% (22), with no significant difference in the demographics, duration of MV, or maximum inspiratory pressure between the survivors and nonsurvivors. The use of a protocolized weaning process including planned criteria for identifying patients ready for a spontaneous breathing trial, extubation and reintubation resulted in a low MV time and acceptable mortality and reintubation rates. Protocolized weaning, combined with robust care team training and monitoring of patient outcomes represent a useful tool in the management of patients requiring MV. 2

3 The implementation of a protocol-directed weaning practice reduced the median duration of mechanical ventilation by 40%, reduced the incidence of reintubations by 46%, and reduced the incidence of ventilator-associated pneumonia by 67%. Dries DJ, McGonigal MD, Malian MS, Bor BJ, Sullivan C. Protocol-driven ventilator weaning reduces use of mechanical ventilation, rate of early reintubation, and ventilator-associated pneumonia. J Trauma. 2004;56(5): ; discussion Single-center, prospective study. Control: Physician-directed weaning from mechanical ventilation. Intervention: Protocol-directed weaning implemented by nurses and respiratory therapists. To compare a practice of protocol-directed weaning from mechanical ventilation implemented by nurses and respiratory therapists with traditional physician-directed weaning. DURATION The study was conducted over a 6-month period (April to September) in 2000 (control period) and 2002 (intervention period). The study included 314 (control group) and 336 (intervention group) surgical ICU patients requiring mechanical ventilation for more than 24 hours. The median duration of mechanical ventilation was 3 days (±4.7 days) for the protocol-directed group compared with 5 days (±4.3 days) for the physician-directed group (p < 0.001). The incidence of reintubations was 25 of 336 patients (7%) for the protocol-directed group compared with 43 of 314 patients (14%) for the physician-directed group (p = 0.013). The incidence of ventilator-associated pneumonia was 5% for the protocol-directed group compared with 15% for the physician-directed group (p = 0.02). Protocol-guided weaning of mechanical ventilation, as performed by nurses and respiratory therapists, is safe and led to extubation more rapidly than physician-directed weaning. 3

4 The use of a ventilator management protocol reduced the median duration of mechanical ventilation by 45%. Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilatorassociated pneumonia. Chest. 2000;118(2): Single center, prospective, randomized, controlled cohort study. Control: Physician-directed weaning. Intervention: Ventilator management protocol (VMP)-based weaning, implemented by respiratory therapists. (1) To determine the effect of implementation of a protocolized weaning process in medical and surgical ICUs on the duration of mechanical ventilation. (2) To determine the effect of a VMP on the incidence of ventilator-associated pneumonia (VAP). DURATION The study was conducted over a 12-month period (June 1997 to May 1998). The study included 335 university medical center patients ( 18 years of age) receiving mechanical ventilation in a medical ICU or trauma service. The VMP-directed (intervention) and physician-directed (control) groups were comparable with respect to demographics, APACHE II or injury severity scores, and duration of respiratory failure at the time of study entry. The duration of mechanical ventilation for patients was decreased from a median of 124 hours for the control group to 68 hours in the intervention group (p = ), with the reduction attributed to VMP management through multivariate analysis (risk ratio: 124 hrs, p = ). 31 patients developed VAP during the course of the study, 20 from the control group and 11 in the intervention group. The impact of the VMP-based weaning on VAP frequency was less for medical ICU patients than for surgical patients. Mortality and weaning failure rates were similar between control and intervention groups. Standardization of the management of the weaning process through implementation of a VMP designed for multidisciplinary use was effective in reducing the duration of mechanical ventilation and the incidence of VAP rates in surgical patients, without increasing weaning failure rates. The VMP was also associated with a decrease in incidence of VAP in trauma patients. 4

5 Daily screening of patients followed by trials of spontaneous breathing reduced the duration of mechanical ventilation by 25%, reduced the incidence of complications by 51%, and reduced the cost of intensive care by $5,150 per patient. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335(25): Randomized, controlled study. Control: Daily screening of respiratory function by physicians, respiratory therapists, and nurses, but no other interventions. Intervention: Daily screening to identify those possibly capable of breathing spontaneously; successful tests were followed by 2-hour trials of spontaneous breathing in those who met the criteria. To determine if screening patients daily to identify those who could breathe spontaneously and notifying physicians promptly when patients completed a trial of spontaneous breathing successfully could alter physicians behavior and promote the earlier discontinuation of mechanical ventilation. DURATION The study was conducted over a 9-month period (June 1995 to February 1996). The study included 300 medical and coronary adult ICU patients ( 18 years of age) who were admitted to an 806-bed university medical center. Although the 149 patients randomly assigned to the intervention group had more severe disease, they received mechanical ventilation for a median of 4.5 days, as compared with 6 days for the 151 patients in the control group (p = 0.003). The median interval between the time a patient met the screening criteria and the discontinuation of mechanical ventilation was 1 day in the intervention group and 3 days in the control group (p = 0.001). Complications removal of the breathing tube by the patient, reintubation, tracheostomy, and mechanical ventilation for more than 21 days occurred in 20% of the intervention group and 41% of the control group (p = 0.001). The number of days of intensive care and hospital care was similar in the two groups. Total costs for the ICU were lower in the intervention group (median, $15,740 versus $20,890 in the controls; p = 0.03); hospital costs were lower, though not significantly (median, $26,229 and $29,048, respectively; p = 0.3). The total cost of care in the ICU over the entire study period was $3,855,001 in the intervention group and $4,297,024 in the control group. Protocolized weaning including daily screening of patients followed by trials of spontaneous breathing and timely communication of trial results significantly reduced the duration of mechanical ventilation, incidence of complications and the cost of intensive care. 5

6 1. McLean SE, Jensen LA, Schroeder DG, Gibney NR, Skjodt NM. Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. Am J Crit Care. 2006;15(3): Blackwood B, Burns KE, Cardwell CR, O Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014(11):CD Silva CS, Timenetsky KT, Taniguchi C, et al. Low mechanical ventilation times and reintubation rates associated with a specific weaning protocol in an intensive care unit setting: a retrospective study. Clinics (Sao Paolo). 2012;67(9): Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000;118(2): Dries DJ, McGonigal MD, Malian MS, Bor BJ, Sullivan C. Protocol-driven ventilator weaning reduces use of mechanical ventilation, rate of early reintubation, and ventilator-associated pneumonia. J Trauma. 2004;56(5): ; discussion Burns KE, Lellouche F, Lessard MR. Automating the weaning process with advanced closed-loop systems. Intensive Care Med. 2008;34(10): Burns KE, Meade MO, Lessard MR, et al. Wean earlier and automatically with new technology (the WEAN study). A multicenter, pilot randomized controlled trial. Am J Respir Crit Care Med. 2013;187(11): Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335(25): Medtronic. All rights reserved. Medtronic, Medtronic logo and Further, Together are trademarks of Medtronic. All other brands are trademarks of a Medtronic company. 03/ RM-0029-[WF# ] 6135 Gunbarrel Avenue Boulder, CO medtronic.com/covidien