Abstract
BackgroundVentilator weaning protocols have been shown to reduce the duration of mechanical ventilation (MV), intensive care unit length of stay, and resource use. However, weaning protocols have not significantly affected mortality or reintubation rates. The extubation process is a critical component of respiratory care in patients who receive MV. Post-extubation respiratory failure (PERF) is a common event associated with significant morbidity and mortality. We hypothesized that a comprehensive protocol for ventilator weaning and extubation would be effective for preventing PERF and reintubation and reducing mortality in critically ill patients.MethodsA ventilator weaning and extubation protocol was developed. The protocol consisted of checklists across four evaluations: spontaneous breathing trial, extubation, prophylactic non-invasive positive pressure ventilation (NPPV), and evaluation after extubation. Observational data were collected after implementing the protocol in patients admitted to the Advanced Emergency and Critical Care Center of Shinshu University Hospital. Not only outcomes of patients but also influences of each component of the protocol on the clinical decision-making process were investigated. Further, a comparison between PERF and non-PERF patients was performed.ResultsA total of 464 consecutive patients received MV for more than 48 h, and 248 (77 women; mean age, 65 ± 17 years) were deemed eligible. The overall PERF and reintubation rates were 9.7% and 5.2%, respectively. Overall, 54.1% of patients with PERF received reintubation. Hospital stay and mortality were not significantly different between PERF and non-PERF patients (p = 0.16 and 0.057, respectively). As a result, the 28-day and hospital mortality were 1.2% and 6.9%, respectively.ConclusionsWe found that the rates of PERF, reintubation, and hospital mortality were lower than those in previous reports even with nearly the same degree of severity at extubation. The comprehensive protocol for ventilator weaning and extubation may prevent PERF and reintubation and reduce mortality in critically ill patients.
Highlights
Ventilator weaning protocols have been shown to reduce the duration of mechanical ventilation (MV), intensive care unit length of stay, and resource use
Patients were excluded from the study if they were below 18 years of age, died under MV, received tracheostomy, had self-extubation before or after fulfilling the conditions for spontaneous breathing trial (SBT), were transferred to our center under MV, or were under a do-not-resuscitate status
Comprehensive protocol for ventilator weaning and extubation We developed a protocol for ventilator weaning and extubation [1, 10, 11]
Summary
Patient selection All patients who required MV under tracheal intubation for 48 h or more between April 2007 and March 2013 at the study center were eligible During this period, for all consecutive adults, we prospectively implemented a comprehensive protocol for ventilator weaning and extubation. Comprehensive protocol for ventilator weaning and extubation We developed a protocol for ventilator weaning and extubation [1, 10, 11] This protocol consists of four risk assessment checklists: (1) tolerance of SBT, (2) eligibility for extubation, (3) evaluation for the use of prophylactic NPPV, and (4) evaluation after extubation Patients were extubated if they met all seven criteria of the eligibility for extubation (second risk assessment checklist); if not, MV was continued, and items in this checklist were rechecked the day. EZR is a modified version of the R commander (version 1.6–3) that includes statistical functions that are frequently used in biostatistics
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