Use Of Weaning Protocols Research Articles

Challenges and Responsibilities of Critical Care Nurses in the Weaning Process from Mechanical Ventilation for Patients Post-Cardiothoracic Surgery: A Qualitative Study

Background: The responsibilities of critical care nurses for mechanical ventilation (MV) management may differ among countries, particularly in the weaning process. Aim: To identify nurses' perceptions, roles, and challenges regarding the weaning process for patients in intensive care units (ICUs) in Denmark, Egypt, and the Kingdom of Saudi Arabia (KSA). Methods: This study was a qualitative study using a phenomenological-hermeneutic design. Results: Nurses in Egypt and the KSA were more likely to independently adjust ventilator settings. They used body language, facial expressions, and eye contact to communicate with patients. They prepared patients for the weaning process following physicians' orders. They provided routine nursing care with no specific nursing guidelines or protocols for the weaning process. In contrast, the nurses in Denmark checked the ventilator settings frequently, assessed the consistency of secretions, and frequently performed endotracheal suctioning. They used body language, facial expressions, and eye contact, and they used low technology devices (e.g. word or picture charts, alphabet boards and rewritable magnetic boards) and advanced technological devices (e.g. electronic voice output communication aids through a computer) to communicate with their patients. Moreover, the criteria for weaning and the protocol were used to wean patients from MV. Unfortunately, no protocol was applied for patients with long-term MV. Therefore, the weaning of these patients was conducted by consultation between the nurses and physicians. Conclusion: The use of weaning protocols in Danish settings is an excellent example of collaborative teamwork to apply the best practices in MV weaning processes. It is recommended that nurses in Arab countries apply this experience.

Management of tracheostomies in the intensive care unit: a scoping review

ObjectivesWhile there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU)...

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.

Risk factors, pathogen profile and outcome of ventilator associated pneumonia in a Neonatal intensive care unit

Background: Objective of current study was to know the risk factors, pathological profile and outcome of ventilator associated pneumonia in the neonatal intensive care unit. Methods: Design: Prospective observational study. Settings: A teaching, referral, neonatal intensive care unit at Srinagar, Kashmir. Participants: All ventilated neonates who required mechanical ventilation for more than 48 hours between August 2011 to July 2012. Procedure : The diagnosis of VAP was made on the basis of criteria given by National Nosocomial Infection Surveillance System (1996), paediatric modification of the original guidelines given by Centre of Disease Control & prevention (CDC). Risk factors for VAP were assessed by bivariate and multivariate analysis. Semi-quantitative culture was done using blood agar, chocolate agar and McConkey’s agar as plating media. Results: VAP developed in 32 of 96 ventilated neonates (33.34% VAP rate). Prematurity, very low birth weight, use of nasogastric tube, mean duration of mechanical ventilation, NICU stay in days and number of endotracheal tube changes were statistically significant risk factors associated with VAP. Multiple logistic regression analysis revealed that duration of mechanical ventilation (P = 0.006) and VLBW (<15000 grams) (P = 0.032) were only two single independent and statistically significant risk factors. Most common bacteria isolated from ETA was Klebsiella (37.5%). There were 9 (28.1%) mortalities in VAP group and 14 (21.8%) in non-VAP group, which was statistically insignificant. Conclusions: A number of measures is required to decrease the incidence of VAP based on the prevalent modifiable risk factors and etiological organisms in NICU. Daily assessments of readiness to wean and use of weaning protocols must be adhered to in NICUs.

Respiratorentwöhnung – Welche Verfahren sind geeignet?

During acute respiratory failure, intubation and invasive mechanical ventilation may be life saving procedures. However, with increasing time on the ventilator, the rate of complications increases and prolonged mechanical ventilation is associated with increased morbidity, mortality and high ICU cost. Since the weaning period accounts for 40% of the overall ventilation period, optimizing weaning is mandatory to shorten mechanical ventilation. Various concepts to facilitate weaning have been proposed and there is an ongoing debate about the most effective methods. These include an early screening of weaning readiness based on established criteria, the choice of the concept of ventilation and ventilator modes, the use of weaning protocols, "closed loop" automated ventilation and weaning. This article describes the relevance of the different ventilator strategies that are applied during weaning from mechanical ventilation.

Weaning newborn infants from mechanical ventilation

Invasive mechanical ventilation is a life-saving procedure which is largely used in neonatal intensive care units, particularly in very premature newborn infants. However, this essential treatment may increase mortality and cause substantial morbidity, including lung or airway injuries, unplanned extubations, adverse hemodynamic effects, analgosedative dependency and severe infectious complications, such as ventilator-associated pneumonia. Therefore, limiting the duration of airway intubation and mechanical ventilator support is crucial for the neonatologist, who should aim to a shorter process of discontinuing mechanical ventilation as well as an earlier appreciation of readiness for spontaneous breathing trials. Unfortunately, there is scarce information about the best ways to perform an effective weaning process in infants undergoing mechanical ventilation, thus in most cases the weaning course is still based upon the individual judgment of the attending clinician. Nonetheless, some evidence indicate that volume targeted ventilation modes are more effective in reducing the duration of mechanical ventilation than traditional pressure limited ventilation modes, particularly in very preterm babies. Weaning and extubation directly from high frequency ventilation could be another option, even though its effectiveness, when compared to switching and subsequent weaning and extubating from conventional ventilation, is yet to be adequately investigated. Some data suggest the use of weaning protocols could reduce the weaning time and duration of mechanical ventilation, but better designed prospective studies are still needed to confirm these preliminary observations. Finally, the implementation of short spontaneous breathing tests in preterm infants has been shown to be beneficial in some centres, favoring an earlier extubation at higher ventilatory settings compared with historical controls, without worsening the extubation failure rate. Further research is still required to identify the best practices capable to shorten the duration of mechanical ventilation in term and preterm infants, at the same time keeping to a minimum the risk of extubation failure. Proceedings of the 9th International Workshop on Neonatology · Cagliari (Italy) · October 23rd-26th, 2013 · Learned lessons, changing practice and cutting-edge research

Weaning from the ventilator and extubation in ICU

The decision to extubate is a crucial moment for intubated patients. In most cases, the transition to spontaneous breathing is uneventful, but in some patients, it implies a more challenging decision. Both extubation delay and especially the need for reintubation are associated with poor outcomes. We aim to review the recent literature on weaning and to clarify the role of certain interventions intending to help in this process. Cardiac dysfunction is probably one of the most common causes of weaning failure. Several studies have evaluated the ability of B-natriuretic peptides and echocardiographic tools to predict weaning outcome due to cardiac origin, attempting to prevent its failure. Noninvasive ventilation may have a potential benefit in preventing respiratory failure after extubation of hypercapnic patients, although more studies are needed to define a target population. Current research is focusing on preventing extubation failure, especially in the most challenging cases. The use of weaning protocols - written or computerized - attempts to early identify patients who are able to breathe spontaneously and to hasten extubation, resulting in better outcomes. Nevertheless, individualized care is needed in the most vulnerable patients, trying to prompt weaning without exposing patients to unnecessary risks.

Nurses and ventilators

In the previous issue of Critical Care, Rose and colleagues report the results of a survey on the frequency with which ICU nurses are involved in decision-making in ventilator management. About 63 to 88% of the decisions were made by nurses in collaboration with physicians, and as much as 68% of ventilator adjustments were performed by nurses independent of physicians. Nurse involvement in decision-making was twice as likely in ICUs that use weaning protocols. The ICU nurse performs many roles, the most important being the continuous observation of a patient. The diversion of a nurse's attention from constant vigilance by performing tasks of no benefit, such as the use of weaning protocols, would be a most unfortunate turn of events.

The Impact of Intra‐Aortic Balloon Pump Weaning Protocols on In‐Hospital Clinical Outcomes

Current literature recommends weaning intra-aortic balloon pump (IABP) support prior to discontinuation. To date, no studies have compared various weaning strategies for safety or efficacy. This study was designed to evaluate the impact of weaning on in-hospital clinical outcomes. From 5/1/07 through 5/1/09 429 patients receiving IABP therapy were retrospectively identified using CPT1 billing codes. The study population and clinical outcomes analysis were stratified by use of weaning protocols versus immediate discontinuation of the IABP. In a subset analysis the patients receiving weaning protocols prior to IABP discontinuation were stratified for further analysis of clinical outcomes by whether they had received 1:3 ratio counterpulsation during their wean or whether they only received 1:2 counterpulsation prior to IABP discontinuation. These groups were analyzed for differences in primary and secondary end-points. Of the 429 patients identified, 344 (80.2%) were weaned prior to IABP discontinuation and 85 (19.8%) of the patients had their IABP abruptly discontinued. Patients not weaned had a lower heart rate after IABP discontinuation than those weaned, but no difference in systolic and mean blood pressure or urine output. There was no significant difference in mortality. Weaning was associated with a nonsignificant trend toward increased length of stay. This study suggests that weaning protocols offer no hemodynamic benefits or improvement in in-hospital mortality rates. Weaning is associated with trend toward increased length of stay. We conclude that weaning offers no advantage over direct device removal and would advocate that balloon pumps be directly withdrawn when counterpulsation is terminated.

Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis

Objective To investigate the effects of weaning protocols on the total duration of mechanical ventilation, mortality, adverse events, quality of life, weaning duration, and length of stay in the intensive...

The difficult-to-wean patient

Up to 20% of patients requiring mechanical ventilation will suffer from difficult weaning (the need of more than 7 days of weaning after the first spontaneous breathing trial), which may depend on several reversible causes: respiratory and/or cardiac load, neuromuscular and neuropsychological factors, and metabolic and endocrine disorders. Clinical consequences (and/or often causes) of prolonged mechanical ventilation comprise features such as myopathy, neuropathy, and body composition alterations and depression, which increase the costs, morbidity and mortality of this. These difficult-to-wean patients may be managed in two type of units: respiratory intermediate-care units and specialized regional weaning centers. Two weaning protocols are normally used: progressive reduction of ventilator support (which we usually use), or progressively longer periods of spontaneous breathing trials. Physiotherapy is an important component of weaning protocols. Weaning success depends strongly on patients’ complexity and comorbidities, hospital organization and personnel expertise, availability of early physiotherapy, use of weaning protocols, patients’ autonomy and families’ preparation for home discharge with mechanical ventilation.

Protocolized vs. non‐protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients: Cochrane review protocol

This paper is a report of the protocol for a review to identify, critically appraise and synthesize the best current evidence supporting the use of weaning protocols compared to non-protocolized practice in liberating patients from mechanical ventilation. Patients experiencing difficulty in weaning require a longer hospital stay and have higher morbidity and mortality. Consequently, efforts to reduce weaning time are desirable to reduce the duration of ventilation and related complications. Standardized weaning protocols are safe and effective in reducing the time spent on mechanical ventilation.Notwithstanding, the evidence supporting their use in practice is inconsistent. The discordant results of studies may reflect the fact that protocols vary in composition and are implemented in different environments by various healthcare providers. The objectives of this review are to compare the total duration of mechanical ventilation between patients weaned using protocols vs. non-protocolized practice; to ascertain differences between protocolized and non-protocolized weaning with regards to mortality, adverse events, quality of life, weaning duration, ICU and hospital stay; and to explore variation in outcomes by the type of ICU, the type of protocol and approach to delivering the protocol. We will search the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, ISI Web of Science and LILACS. In addition, we will endeavour to identify unpublished data and contact first authors of studies included in the review to obtain information on unpublished studies or work in progress. This review will provide much needed direction for healthcare professionals in intensive care in terms of both research and practice.

Issues in weaning from mechanical ventilation: literature review

The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation. Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process. In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations. Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level. Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.