Liberation from Mechanical Ventilation in Critically Ill Adults 2017 ACCP/ATS Clinical Practice Guidelines Timothy D. Girard, MD, MSCI Clinical Research, Investigation, and Systems Modeling of Acute Illness Center Department of Critical Care Medicine University of Pittsburgh School of Medicine
Disclosures No commercial relationships
Learning Objectives Review evidence-based practices that promote liberation from mechanical ventilation in acute hospitalized ICU patients. Identify patients most likely to benefit from these evidence-based practices. Describe the limitations of the data supporting these evidence-based practices.
Liberation from Mechanical Ventilation Guideline Question 1
PICO Question 1 In acutely hospitalized patients ventilated more than 24 hours, should the spontaneous breathing trial (SBT) be conducted with or without inspiratory pressure augmentation? Population: Acute respiratory failure ventilated >24 hrs Intervention: Inspiratory pressure augmentation during SBT Comparator: No inspiratory pressure augmentation during SBT Outcomes: Duration of ventilation, ventilator-free days, extubation success, ICU LOS, short- and longterm mortality
PICO 1 Background Clinicians underestimate the capacity of patients to breathe successfully without ventilator assistance. Conventional weaning predictors are poor predictors of readiness for liberation from the ventilator. Once patients meet weaning criteria, a spontaneous breathing trial (SBT) is recommended to identify readiness for liberation from the ventilator.
PICO 1 Background Lack of consensus regarding SBT implementation leads to differing approaches. With or without pressure augmentation With: Pressure support (5-8 cm H 2 O) or automatic tube compensation Without: T-piece or CPAP
PICO 1 Background With pressure augmentation Unloads the inspiratory muscles relative to postextubation Could lead to false positives in borderline patients Could lead extubation failure, causing harm Without pressure augmentation Most closely mimics work of breathing postextubation Could lead to false negatives in borderline patients Could delay extubation, causing harm
PICO 1 Evidence Highlight Esteban A, et.al: AJRCCM 1997;156:459-465
Pressure Augmentation and SBT Success Ouellette DR, et.al: Chest 2017;151:166-180
PICO 1 Discussion Moderate quality evidence Unblinded trials Trials examined how to conduct initial SBT only Trials primarily included patients with ARDS or COPD
PICO 1 Recommendation We suggest that the initial SBT be conducted with inspiratory pressure augmentation (5-8 cm H 2 O) rather than without (T-piece or CPAP). (Conditional Recommendation, Moderate Quality Evidence) Schmidt GA, et.al: Chest 2017;151:160-165
Liberation from Mechanical Ventilation Guideline Question 2
PICO Question 2 In acutely hospitalized patients ventilated for more than 24h, do protocols attempting to minimize sedation compared with approaches that do not attempt to minimize sedation impact duration of ventilation, duration of ICU stay, and short-term mortality (60 days)? Population: Acute respiratory failure ventilated >24 hrs Intervention: Protocols minimizing sedation Comparator: No protocol Outcomes: Duration of ventilation, ventilator-free days, extubation success, ICU LOS, short- and longterm mortality
PICO 2 Background Sedatives and analgesics during mechanical ventilation Beneficial when used to treat agitation and pain Harmful when leading to oversedation Options when dosing sedating medication Fixed dose MD/RN-directed titration Protocol-directed titration
PICO 2 Background Potential benefits of MD/RN-directed sedation Flexible and adaptive to individual patient needs Promotes highly skilled practitioners May require fewer resources Avoids institution-wide acceptance of a treatment strategy before best evidence is available
PICO 2 Background Potential benefits of protocol-directed sedation Less biased by human decision-making Evidence-based, less influenced by personal opinion Can make up for limitations in local resources or staff Frees physicians to perform other duties in the ICU Facilitate quality monitoring and improvement Enhances transparency and communication
PICO 2 Evidence Highlight Girard TD, et.al: Lancet 2008;371:126-134
Sedation Protocols and ICU Length of Stay Ouellette DR, et.al: Chest 2017;151:166-180
PICO 2 Discussion Low quality evidence Unblinded trials Inconsistent results Insufficient evidence to recommend one protocol over another Daily interruption of sedatives Light sedation protocol
PICO 2 Recommendation We suggest protocols attempting to minimize sedation. (Conditional Recommendation, Low Quality Evidence) Schmidt GA, et.al: Chest 2017;151:160-165
Liberation from Mechanical Ventilation Guideline Question 3
PICO Question 3 In high-risk patients receiving mechanical ventilation for more than 24 h who have passed an SBT, does extubation to preventive (noninvasive ventilation) NIV compared with no NIV have a favorable effect on duration of ventilation, ventilator-free days, extubation success (liberation > 48 h), duration of ICU stay, shortterm mortality (60 days), or long-term mortality? Population: Acute respiratory failure ventilated >24 hrs, passed an SBT but high risk for reintubation Intervention: Extubation to immediate NIV Comparator: No NIV Outcomes: Duration of ventilation, ventilator-free days, extubation success, ICU LOS, short- and longterm mortality
PICO 3 Background Some mechanically ventilated patients who have passed an SBT are high-risk for recurrent respiratory failure. Reintubation is associated with adverse outcomes. Delaying extubation can also increase risk for adverse outcomes. Management options for high-risk patients: Delay extubation Extubate supplemental oxygen Extubate to NIV
PICO 3 Background During acute exacerbations of COPD or CHF, NIV reduces intubations, complications, hospital length of stay, and mortality. NIV during extubation failure is not beneficial and may be harmful. Extubation immediately to NIV after passing an SBT may prevent extubation failure in high-risk patients.
PICO 3 Evidence Highlight Ferrer M et al. Lancet 2009;374:1082 1088
Extubation to NIV and Mortality Ouellette DR, et.al: Chest 2017;151:166-180
PICO 3 Discussion Moderate quality evidence Unblinded trials High risk for extubation failure Hypercapnia COPD CHF Use NIV immediately after extubation rather than when postextubation respiratory failure occurs
PICO 3 Recommendation For patients at high risk for extubation failure who have passed an SBT, we recommend extubation to preventative NIV. (Strong Recommendation, Moderate Quality Evidence) Schmidt GA, et.al: Chest 2017;151:160-165
Liberation from Mechanical Ventilation Guideline Question 4
PICO Question 4 Should acutely hospitalized adults who have been mechanically ventilated for >24 h be subjected to protocolized rehabilitation directed toward early mobilization or no protocolized attempts at early mobilization? Population: Acute respiratory failure ventilated >24 hrs Intervention: Early mobility protocols Comparator: No protocol Outcomes: Duration of ventilation, ventilator-free days, extubation success, ICU LOS, short- and longterm mortality
PICO 4 Background Adverse effects of bedrest and immobility Weakness Cardiopulmonary compromise Pressure ulcers Venous thromboembolism ICU-acquired weakness Can persist long after hospital discharge Is associated with functional disability Is associated with reduced survival
PICO 4 Background Early mobility during mechanical ventilation Feasible Safe May prevent adverse outcomes of immobility May improve functional outcomes
PICO 4 Evidence Highlight Schweickert WD, et al. Lancet 2009;373:1874-82
Early Mobility and Functional Independence Girard TD, et.al: AJRCCM 2017;195:120-133
PICO 4 Discussion Low quality evidence Unblinded trials Inconsistent results Insufficient evidence to recommend one protocol over another Cycling Sitting in a chair Progression through a mobility protocol
PICO 4 Recommendation We suggest protocolized rehabilitation directed toward early mobilization. (Conditional Recommendation, Low Quality Evidence) Schmidt GA, et.al: Chest 2017;151:160-165
Liberation from Mechanical Ventilation Guideline Question 5
PICO Question 5 Should acutely hospitalized adults who have been mechanically ventilated for > 24 h be managed with a ventilator liberation protocol or no protocol? Population: Acute respiratory failure ventilated >24 hrs Intervention: Ventilator liberation protocols Comparator: No protocol Outcomes: Duration of ventilation, ventilator-free days, extubation success, ICU LOS, short- and longterm mortality
PICO 5 Background Compared with approaches that gradually wean support, daily SBTs to identify readiness for liberation from mechanical ventilation Reduces time to extubation Safe Options when implementing SBTs MD/RT-directed Protocol-directed
PICO 5 Background Potential benefits of MD/RT-directed ventilator liberation Flexible and adaptive to individual patient needs Promotes highly skilled practitioners May require fewer resources Avoids institution-wide acceptance of a treatment strategy before best evidence is available
PICO 5 Background Potential benefits of protocol-directed ventilator liberation Less biased by human decision-making Evidence-based, less influenced by personal opinion Can make up for limitations in local resources or staff Frees physicians to perform other duties in the ICU Facilitate quality monitoring and improvement Enhances transparency and communication
PICO 5 Highlight Ely EW, et.al: NEJM 1996;335:1864-9
Liberation Protocols and Duration of MV
PICO 5 Discussion Low quality evidence Unblinded trials Inconsistent results Insufficient evidence to recommend one protocol over another RT-driven Computerized
PICO 5 Recommendation We suggest managing mechanically ventilated adults with a ventilator liberation protocol. (Conditional Recommendation, Low Quality Evidence) Schmidt GA, et.al: Chest 2017;151:160-165
Liberation from Mechanical Ventilation Guideline Question 6
PICO Question 6a/6b Should a cuff leak test (CLT) be performed prior to extubation of mechanically ventilated adults? Should systemic steroids be administered to adults who fail a CLT prior to extubation? Population: Acute respiratory failure ventilated >24 hrs Comparator: (a) No CLT, (b) No steroids Intervention: (a) CLT, (b) Systemic steroids after failed CLT Outcomes: Duration of ventilation, ventilator-free days, extubation success, ICU LOS, short- and longterm mortality
PICO 6 Background Laryngeal edema More likely after 36 hrs of endotracheal intubation May cause post-extubation stridor (6%-37%) Possible increased risk of reintubation A CLT to identify laryngeal edema prior to extubation may Allow for treatment of edema to reduced reintubation Delay extubation, prolonging mechanical ventilation
Cuff Leak Tests and Reintubation Ouellette DR, et.al: Chest 2017;151:166-180
PICO 6a Simulated Trial Cuff Leak Test: Results of Two-Arm Simulated Trial* *Percentages above were drawn from the observational studies Girard TD, et.al: AJRCCM 2017;195:120-133
PICO 6a Simulated Trial Cuff Leak Test: Two-Arm Simulated Trial Sensitivity Analysis Girard TD, et.al: AJRCCM 2017;195:120-133
PICO 6a Simulated Trial Cuff Leak Test: Two-Arm Simulated Trial Summary Reintubation rate decreased 2.4% v 4.2%; RR 0.58, 95% CI 0.40-0.83 Post-extubation stridor reduced 4.0% v 6.7%; RR 0.60, 95% CI 0.47-0.77 Delayed extubations increased 9.2% absolute increase Girard TD, et.al: AJRCCM 2017;195:120-133
Corticosteroids and Reintubation Girard TD, et.al: AJRCCM 2017;195:120-133
PICO 6 Discussion Very low quality evidence re: CLT Most studies were observational Simulated trial required assumptions Risk factors for post-extubation stridor Traumatic intubation Intubation >6 days Large endotracheal tube Female sex Reintubation after unplanned extubation A repeat CLT is not required after administration of systemic steroids
PICO 6a/6b Recommendation We suggest performing a CLT in mechanically ventilated adults deemed high risk for postextubation stridor. (Conditional Recommendation, Very Low Quality Evidence) For adults who have failed a CLT, we suggest administering systemic steroids at least 4 hr before extubation; a repeated CLT is not required. (Conditional Recommendation, Moderate Quality Evidence) Schmidt GA, et.al: Chest 2017;151:160-165