Mechanical Ventilation Weaning Protocol Research Articles

The intervention of artificial intelligence to improve the weaning outcomes of patients with mechanical ventilation: Practical applications in the medical intensive care unit and the COVID-19 intensive care unit: A retrospective study.

Patients admitted to intensive care units (ICU) and receiving mechanical ventilation (MV) may experience ventilator-associated adverse events and have prolonged ICU length of stay (LOS). We conducted a survey on adult patients in the medical ICU requiring MV. Utilizing big data and artificial intelligence (AI)/machine learning, we developed a predictive model to determine the optimal timing for weaning success, defined as no reintubation within 48 hours. An interdisciplinary team integrated AI into our MV weaning protocol. The study was divided into 2 parts. The first part compared outcomes before AI (May 1 to Nov 30, 2019) and after AI (May 1 to Nov 30, 2020) implementation in the medical ICU. The second part took place during the COVID-19 pandemic, where patients were divided into control (without AI assistance) and intervention (with AI assistance) groups from Aug 1, 2022, to Apr 30, 2023, and we compared their short-term outcomes. In the first part of the study, the intervention group (with AI, n = 1107) showed a shorter mean MV time (144.3 hours vs 158.7 hours, P = .077), ICU LOS (8.3 days vs 8.8 days, P = .194), and hospital LOS (22.2 days vs 25.7 days, P = .001) compared to the pre-intervention group (without AI, n = 1298). In the second part of the study, the intervention group (with AI, n = 88) exhibited a shorter mean MV time (244.2 hours vs 426.0 hours, P = .011), ICU LOS (11.0 days vs 18.7 days, P = .001), and hospital LOS (23.5 days vs 40.4 days, P < .001) compared to the control group (without AI, n = 43). The integration of AI into the weaning protocol led to improvements in the quality and outcomes of MV patients.

Use of noninvasive mechanical ventilation weaning protocol in neonatal intensive care units in Brazil: a descriptive study.

This study aimed to investigate whether neonatal intensive care units (NICUs) in Brazilian hospitals use a protocol for weaning from noninvasive ventilation (NIV), how this ventilatory support is withdrawn, and whether there is consensus among the methods used by the institutions. A cross-sectional survey was conducted from December 2020 to February 2021, based on responses to an electronic questionnaire, filled out by physical therapists working in NICU in Brazilian hospitals about the routine of physical therapy and the use of NIV and its weaning. A total of 93 answers to the electronic questionnaire met the study criteria: 52.7% were from public health institutions, with an average of 15 NICU beds (15.2±15.9), 85% of the physical therapists worked exclusively in the NICU, 34.4% of the NICU had 24-h physical therapy care, 66.7% of the units use the continuous positive airway pressure (CPAP) as ventilatory mode, and 72% the nasal prong as NIV interface; 90% of the NICU physical therapists answered that their NICU had no NIV weaning protocol, with various methods of weaning reported, the most cited being pressure weaning. Most Brazilian NICUs have no NIV weaning protocol. The most used method among institutions, with or without a protocol, is pressure weaning. Although most of the participating physical therapists work exclusively in NICU, many hospitals do not have the recommended workload, which can be one of the negative factors in the organization of protocols and in the progress of ventilatory weaning.

Factors influencing the implementation of a ventilation weaning protocol in an adult intensive care unit: a qualitative multidisciplinary evaluation.

Development of protocolized care in the intensive care unit (ICU) improves patient outcomes, but presents multiple challenges. A mechanical ventilation weaning protocol (WP) was adopted in our institution but was underused. This study aimed to determine the factors that influenced the implementation of this protocol locally. We performed a qualitative descriptive study using semidirected interviews in small profession-specific focus groups. The interviews were based on a standardized guide covering the major domains found in the Consolidated Framework for Implementation Research. A total of 32 participants across four key professions were recruited. The interviews were transcribed and codified sequentially, followed by categorization and analysis. Three broad factors emerged that negatively impacted the implementation of the WP. First, the goals of the WP differed between professional groups. This difference led to significant frustration and breaches in collaboration. Second, there was a lack of a continuous quality improvement process. Third, the WP was incompatible with the routine and procedures already in place at the time of implementation. Time-of-day of WP application and patient safety concerns were specifically identified issues. Implementation of a continuous improvement process with regular and specific follow-up may help identify potential challenges and thus help ensure a more consistent use of the WP.

Use of a Multidisciplinary Mechanical Ventilation Weaning Protocol to Improve Patient Outcomes and Empower Staff in a Medical Intensive Care Unit.

Prolonged duration of mechanical ventilation is associated with higher mortality and increased patient complications; conventional physician-directed weaning methods are highly variable and permit significant time that weaning is inefficient and ineffective. The primary objective of this quality improvement project was to implement a registered nurse (RN)- and respiratory therapist (RT)-driven mechanical ventilation weaning protocol in a medical intensive care unit (ICU) at a tertiary care academic medical center. This quality improvement project used a quasi-experimental design with a retrospective usual care group who underwent physician-directed (conventional) weaning (n = 51) and a prospective intervention group who underwent protocol-directed weaning (n = 54). Outcomes included duration of mechanical ventilation, ICU length of stay, reintubation rates, and RN and RT satisfaction with the weaning protocol. Patients in the RN- and RT-driven mechanical ventilation weaning protocol group had significantly lower duration of mechanical ventilation (74 vs 152 hours; P = .002) and ICU length of stay (6.7 vs 10.2 days; P = .031). There was no significant difference in reintubation rates between groups. Staff surveys indicate that both RN and RTs were satisfied with the process change. Implementation of a multidisciplinary mechanical ventilation weaning protocol is a safe and effective way to improve patient outcomes and empower ICU staff.

What factors affect the use of mechanical ventilation weaning protocols for critically ill people?

What factors affect the use of mechanical ventilation weaning protocols for critically ill people?

Role of physical therapists in the weaning and extubation procedures of pediatric and neonatal intensive care units: a survey

BackgroundWeaning a patient from mechanical ventilation is a complex procedure that involves clinical and contextual aspects. Mechanical ventilation also depends on the characteristics of health professionals who work in intensive care. ObjectiveThis study described the organizational aspects associated with the physical therapist's performance in the weaning procedure from mechanical ventilation and extubation in neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil. MethodsIn order to identify the existing intensive care units in Brazil, data from the National Health Facilities Census was used to enable the researchers to obtain information about registered units. A cross-sectional survey was carried out by sending an electronic questionnaire to 298 neonatal, pediatric and mixed intensive care units in Brazil. ResultsThis study assessed questionnaires from 146 intensive care units (49.3% neonatal, 35.6% pediatric and 15.1% mixed). A total of 57.5% of these units applied mechanical ventilation weaning protocols, and a physical therapist frequently conducted this procedure (66.7%). However, the clinician responsible for conducting the weaning and deciding when to do extubation varied regardless of ICU patient age profile. Regardless of the type of hospital or the type of units, most of these had a dedicated physical therapist. However, physical therapy care 24h/7 days per week was predominantly in pediatric intensive care units (56.0%), and in public hospitals (45.9%). Moreover, when the physical therapist was available 24h/7 days per week, (s)he was responsible for the mechanical ventilation extubation decision and patients were successfully extubated on the first attempt. ConclusionIn this survey, intensive care units using physical therapy assistance 24h/7 days per week were associated with the use of a mechanical ventilation weaning protocol, an extubation decision and success commonly on the first attempt of extubation.

Mechanical ventilation weaning protocol improves medical adherence and results

IntroductionImplementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol. MethodsWe investigated all consecutive MV-dependent subjects admitted to a medical-surgical intensive care unit (ICU) for >24h over 7years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases. ResultsWe enrolled 2469 subjects over 7years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p<0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p<0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p<0.001). When the weaning protocol was evaluated step-by-step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p<0.001). ConclusionsA multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis

Helping to Clarify Mechanical Ventilation Protocols

Protocols in the ICU have become quite commonplace, thanks to studies like the one we have in this issue of Respiratory Care. It has been recommended by a collective task force that we utilize a mechanical ventilation weaning protocol.[1][1] Many papers have focused on this topic since it was proved

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Introduction: Prolonged mechanical ventilation after cardiac surgery is associated with prolonged length of stay and increased morbidity and mortality. Shorter postoperative ventilation times are accepted as a marker of quality. We implemented quality improvement efforts and methodology to reduce postoperative MV times for cardiac surgery patients in our cardiovascular intensive care unit. Methods: Baseline time-to-extubation data was obtained from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD). An institutional unit-based data collection form was instituted to allow real-time assessment of extubation times. To inform quality improvement efforts, data was collected on demographics, surgery type, medical history, and mechanical ventilation times on all critically ill adult postoperative cardiac surgery patients for 2.5 months. Individual patient-specific times to extubation were placed in run charts. Improvement actions implemented included informal education of members of the healthcare team about prolonged extubation times, renewed focus on non-physician driven extubation protocol for weaning mechanical ventilation, and implementation time-oriented goals for extubation. Extubation-time data was analyzed in run charts to determine whether system changes had produced a change in median mechanical ventilation times. Standard run chart rules were used to determine whether a statistically significant shift in median mechanical ventilation times had occurred. Results: Baseline unit STS ACSD median postoperative mechanical ventilation time from January 2013 through March 2013 was 9.48 hours. After initiation of quality improvement efforts, run charts demonstrated a shift in median ventilation time to 4.7 hours. Conclusions: Median postoperative mechanical ventilation times for cardiac surgery patients were reduced after quality improvement efforts which included real-time data collection, informal education about mechanical ventilation times, emphasis of a non-physician driven mechanical ventilation weaning protocol, and time-oriented goals for extubation. System changes produced median extubation times lower than the STS ACSD 2012 national median postoperative ventilation time of 6.8 hours. Run chart methodology proved useful in monitoring system change during quality improvement efforts in this cardiovascular intensive care unit.

The Effect of a Mechanical Ventilation Discontinuation Protocol in Patients with Simple and Difficult Weaning: Impact on Clinical Outcomes

We sought to determine whether the utilization of a respiratory therapist (RT) driven mechanical ventilation weaning protocol is associated with improvement in clinical outcomes in subjects with simple versus difficult weaning. This was a retrospective analysis of prospectively collected data obtained during a quality improvement project. We collected data on 803 consecutive mechanically ventilated patients admitted to the ICU of an academic tertiary care hospital. We compared an RT-driven weaning protocol to a physician-driven weaning strategy. Of the 803 patients, 651 with simple weaning and 131 with difficult weaning were included in the analysis. In the subjects with simple weaning, 514 (79%) were weaned with the RT-driven protocol. Among the difficult weaning subjects, 101(77.1%) were liberated with the RT-driven protocol. A multivariate analysis, which included Acute Physiology and Chronic Health Evaluation II, body mass index, and type of primary ICU team under which the subjects were admitted, revealed a significant difference in ventilator-free days at 28-days, which supports the RT-driven protocol over the physician-driven strategy. Specifically, the RT-driven protocol increased ventilator-free days by 20.92% and 68.2% among subjects with simple and difficult weaning, respectively. A multivariate analysis of ICU mortality and extubation failure found no significant difference between the RT-driven protocol and the physician-driven strategy. The RT-driven weaning protocol increased ventilator-free days among subjects with simple and difficult weaning, with no significant differences in ICU mortality or extubation failure.

Rapid shallow breathing index – a key predictor for noninvasive ventilation

The rapid shallow breathing index (RSBI) is the ratio determined by the frequency (f) divided by the tidal volume (VT). An RSBI <105 has been widely accepted by healthcare professionals as a criteria for weaning to extubation and has been integrated into most mechanical ventilation weaning protocols. We hypothesized that the converse of using the RSBI for weaning might be useful in predicting the need for noninvasive ventilation. Advancements in technology have made it easier to accurately attain bedside RSBI measurements. The purpose of this study was to ascertain a threshold value of RSBI that could predict the need for noninvasive ventilation (NIV) in patients presenting with acute respiratory distress to the critical care area (Cat 1) in the emergency department.

Weaning from mechanical ventilation in post- operatory: a clinical essay

The cardiac surgery post-operatory nurses from Hospital Universitario Pedro Ernesto use syncronized Intermittent mandatory ventilation (SIMV) as a weaning method. Extubation occurs, in average, eight hours after surgery, what is considered a long period. The study compares the period of mechanical ventilation between two weaning modalities: T-tube and SIMV. The study refers to a randomized, clinical trial and control group. A mechanical ventilation weaning protocol has been developed utilizing T-tube as a way of comparing the current protocol, which utilizes SIMV. A Student t- test has been perfomed for the comparison of both groups, with the help of 3.0 Instat GraphPad. The values were considered significant at p<0,05. It was approved by The Research Ethics Committee of the Institution. In the previous analysis, on comparing the time between the two techniques, the use of T-tube was the modality when the patients were weaned in a shorter period of time (45 minutes). However, the values have not been considered significant due to the small size of the sample (n=30). It has been noted that the higher the level of sedation in the post-operatory phase, the faster the weaning. This finding has been related with the absence of pain felt at this stage; once the patient without pain cooperates in the weaning process. The pain limits the movement. As a result, coughing, deep breathing and change in position will be restrained. Therefore, the patient will be agitated at awakening, being necessary the restraint of his movements in bed, prolonging sedation and extubation.

Application of a mechanical ventilation weaning protocol in a coronary unit

Weaning is the transitional period when a patient under mechanical ventilation (MV) transfers to unassisted spontaneous breathing. Failure in the discontinuation of ventilatory support is associated with an increase in the number of complications. The use of standardized guidelines to carry out weaning is already well established in general ICUs. The conditions most commonly seen in the coronary unit of care (CUC), such as acute myocardial ischemia, left ventricular dysfunction and after coronary artery bypass grafting surgery, however, cause completely different hemodynamic and circulatory alterations to those observed in other types of severely ill patients. The effects of mechanical ventilation and of weaning should therefore be tested specifically for these patients.

Improving Adherence to a Mechanical Ventilation Weaning Protocol for Critically Ill Adults: Outcomes After an Implementation Program

Despite multiple reminders, education sessions, and multidisciplinary team involvement, adherence to an evidence-based mechanical ventilation weaning protocol had been less than 1% in a general systems intensive care unit since implementation. To assess the effectiveness of using an implementation program, the Model for Accelerating Improvement, to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit. A prospective comparative design, before and after implementation of the Model for Accelerating Improvement, was used with a consecutive sample of 129 patients and 112 multidisciplinary team members. Clinical outcomes were rate of unsuccessful extubations, rate of ventilator-associated pneumonia, and duration of mechanical ventilation; practice outcomes were staff's understanding of the mechanical ventilation weaning protocol, perceptions of the practice safety climate, and adherence to the weaning protocol. After the intervention, the rate of unsuccessful extubations decreased, and staff's understanding of and adherence to the weaning protocol increased significantly. The rate of ventilator-associated pneumonia, duration of mechanical ventilation, and staff's perceptions of the practice safety climate did not change significantly. Implementing the Model for Accelerating Improvement improved understanding of and adherence to protocol-directed weaning and reduced the rate of unsuccessful extubations.

Insanity legislation.

The McNaughton Rules, which are used when someone pleads insanity at the time of a homicide, are out of date and unsatisfactory. Suggestions have been made about how the insanity defence can be reformulated. The preference of a defence of diminished responsibility means abandoning an ancient and humane principle of not convicting those who are so mentally disordered as not to be responsible for their actions. There is a need for Parliament to consider changes to the law both to prevent the mentally disordered being sent to prison inappropriately, and because the Mental Health Act 1983 has not taken account of rare cases where an offender such as an epileptic might be found legally insane but not mentally disordered.