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April - 2021

   

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Ventilator Weaning and Discontinuation Practices for Critically Ill Patients

K Burns, L Rizvi, D Cook et al for the CCCTG JAMA, 2021, 325(12):1173-1184

Comment

What is routine and  how do we differ internationally, in the practice of discounting  invasive mechanical ventilation in critically ill patients?

This study did the following;

  • Aim to describe discontinuation practice in adults who received IMV for at least 24 hours duration
  • Looked at written directives, daily screening, ventilator support, SBT, sedation and mobilisation, and association between initial strategy and clinical outcomes
  • Prospective observational study of 1868 patients from 142 ICUs in Canada, Europe, the US, India, the UK, and Australia/New Zealand, from November 2013 - December 2016
  • Median age 62, 63% male, 59% acute reps failure 
  • Strategy
    • Written directives 4.5% to 83%
    • Screen for SBT not used in patients 18.5% Canada, 55% UK, 12% Europe, 62% Aust/NZ
    • SBT used PEEP/PS  (49%), T-piece (25%), no PEEP/PSV (10%). 
    • Ventilator support prior to extubation was most commonly PEEP/PSV outside US, and ACPRV/SIMV/ACV in US 
    • Few patients were mobilised (12%), personnel involved in ventilator adjustment cared, and sedation practice varied across regions. 
  • Association between initial discontinuation strategy and clinical outcomes 
    • 22.7% of patients underwent direct extubation
    • 49.8% underwent initial SBT, of which 81.8% had successful extubation)
    • 8.0% had a direct tracheostomy
    • 19.5% died before a weaning attempt
    • There was notable variation in several aspects of mechanical ventilation weaning practices.
    • ICU mortality varied with initial strategy
      • Direct extubation 4.7%
      • Tracheostomy 10.3%
      • SBT 10.3%
    • Need for MV at day 28 varied with initial strategy
      • Direct extubation 6%
      • Tracheostomy 36%
      • SBT 9%
    • ICU and hospital LOS varied with initial strategy (days)
      • Direct extubation 6.7 and 17
      • Tracheostomy 19.6 and 35
      • SBT 8.1 and 18
    • Patients who has SBT vs direct extubation were more likely to be older, solid organ malignant, and have hypertension. 

Mechanical ventilation weaning practices vary internationally, regard to the use of protocols, screening for and conducting SBTs, adjustment of ventilator support, and the responsibility of clinicians involved in weaning. Overall nearly 50% of patients underwent initial SBT, with more than 80% successful. Initial SBT (vs direct extubation) was associated with higher ICU mortality and longer duration of ventilation and ICU stay. Failing initial SBT  and undergoing later initial SBT was associated with range of negative outcomes. 

 

Abstract

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 Relevance  In 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, weaning practices varied internationally.

April


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