Top

Canadian Journal of Anesthesia/Journal canadien d'anesthésie

Published in:

01-08-2009 | Reports of Original Investigations

Weaning critically ill adults from invasive mechanical ventilation: a national survey

Authors: Karen E. A. Burns, MD, Francois Lellouche, MD, France Loisel, MD, Arthur S. Slutsky, MD, Aleksander Meret, B. Kin, Orla Smith, MN, Refik Saskin, MSc, Maureen Meade, MD

Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Issue 8/2009

Abstract

Purpose

To determine the stated practices of clinicians in weaning critically ill adults from invasive ventilation.

Methods

We conducted a cross-sectional, self-administered postal survey of Critical Care physicians and respiratory therapists (RTs) in leadership roles at Canadian teaching hospitals. We identified respondents using electronic mail and telephone correspondence. We used rigorous survey methodology to develop, test, and administer the questionnaire.

Results

One hundred ten of 162 (67.9%) clinicians returned the survey with 99 respondents (55 physicians and 44 RTs) completing it either in-part or in-full. Approximately 95% of respondents acknowledged ever performing spontaneous breathing trials (SBTs) in clinical practice. Of these, 95.6% and 32% of respondents reported conducting daily and twice-daily screening to identify SBT candidates, at least sometimes. The three most common techniques to conduct SBTs included; pressure support (PS) with positive end-expiratory pressure (70.8%), continuous positive airway pressure (35.7%), and use of a T-piece (25.0%). PS ventilation was the weaning strategy used most frequently before SBTs. Most respondents (57.1%) considered continuous infusion of sedative-hypnotics to be a relative contraindication to tracheal extubation. However, concurrent administration of low dose vasopressors, inotropes, and analgesic boluses, or continuous analgesic infusions were considered acceptable amongst 60.8%, 73.2%, 78.4% and 58.8% of respondents, respectively. We did not observe regional variation in whether clinicians ever perform SBTs, the ventilatory modes used prior to an SBT nor in the use of PS and SBTs during the weaning process.

Conclusions

Pressure support and SBTs are common features of weaning in Canadian teaching hospitals. Compared to the published literature, our survey suggests that weaning practices have evolved over time and that practice variation may be greater on an international level compared to a national level.

Angus DC, Kelley MA, Schmitz RJ, et al. Carding for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population. JAMA 2000; 284: 2762–70.PubMedCrossRef

Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 2005; 33: 1266–71.PubMedCrossRef

Esteban A, Alia I, Ibanez J, Benito S, Tobin MJ. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group. Chest 1994; 106: 1188–93.PubMedCrossRef

Ely EW, Baker AM, Dunagan DP, et al. Effect of the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996; 335: 1864–9.PubMedCrossRef

Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 1997; 25: 567–74.PubMedCrossRef

Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest 2000; 118: 459–67.PubMedCrossRef

Esteban A, Alia I, Gordo F, et al. Extubation outcome after spontaneous breathing trials with t-tube or pressure support ventilation. Am J Respir Crit Care Med 1997; 156: 459–65.PubMed

Esteban A, Alia I, Tobin MJ, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1999; 159: 512–8.PubMed

Perren A, Domenighetti G, Mauri S, Genini F, Vizzardi N. Protocol-directed weaning from mechanical ventilation: clinical outcome in patients randomized for a 30-min and 120-min trial with pressure support ventilation. Intensive Care Med 2002; 28: 1058–63.PubMedCrossRef

10.

Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994; 150: 896–903.PubMed

11.

Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. The Spanish Lung Failure Collaborative Group. N Engl J Med 1995; 332: 345–50.PubMedCrossRef

12.

Esen F, Denkel T, Telci L, et al. Comparison of pressure support ventilation (PSV) and intermittent mandatory ventilation (IMV) during weaning in patients with acute respiratory failure. Adv Exp Med Biol 1992; 317: 371–6.PubMed

13.

Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 1999; 159: 439–46.PubMed

14.

Vitacca M, Clini E, Porta R, Ambrosino N. Preliminary results on nursing workload in a dedicated weaning center. Intensive Care Med 2000; 26: 796–9.PubMedCrossRef

15.

Burns KE, Duffett M, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ 2008; 179: 245–52.PubMed

16.

Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27: 1325–9.PubMedCrossRef

17.

Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974; 2: 656–9.PubMedCrossRef

18.

Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166: 1338–44.PubMedCrossRef

19.

Venus B, Smith RA, Mathru M. National survey of methods and criteria used for weaning from mechanical ventilation. Crit Care Med 1987; 15: 530–3.PubMedCrossRef

20.

Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002; 287: 345–55.PubMedCrossRef

21.

Leung P, Jubran A, Tobin MJ. Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. Am J Respir Crit Care Med 1997; 155: 1940–8.PubMed

22.

Le Bourdelles G, Mier L, Fiquet B, et al. Comparison of the effects of heat and moisture exchangers and heated humidifiers on ventilation and gas exchange during weaning trials from mechanical ventilation. Chest 1996; 110: 1294–8.PubMedCrossRef

23.

Pelosi P, Solca M, Ravagnan I, Tubiolo D, Ferrario L, Gattinoni L. Effects of heat and moisture exchangers on minute ventilation, ventilatory drive, and work of breathing during pressure-support ventilation in acute respiratory failure. Crit Care Med 1996; 24: 1184–8.PubMedCrossRef

24.

Iotti GA, Olivei MC, Palo A, et al. Unfavorable mechanical effects of heat and moisture exchangers in ventilated patients. Intensive Care Med 1997; 23: 339–405.CrossRef

25.

Campbell RS, Davis K Jr, Johanniqman JA, Branson RD. The effects of passive humidifier dead space on respiratory variables in paralyzed and spontaneously breathing patients. Respir Care 2000; 45: 306–12.PubMed

26.

Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA 2002; 287: 3238–44.PubMedCrossRef

27.

Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350: 2452–60.PubMedCrossRef

28.

Squadrone V, Coha M, Cerutti E, et al. Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA 2005; 293: 589–95.PubMedCrossRef

29.

Kingden-Milles D, Muller E, Buhl R, et al. Nasal-continuous positive airway pressure reduces pulmonary morbidity and length of hospital stay following thoracoabdominal aortic surgery. Chest 2005; 128: 821–8.CrossRef

30.

Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med 2006; 173: 164–70.PubMedCrossRef

31.

Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005; 33: 2465–70.PubMedCrossRef

32.

Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002; 324: 1183.PubMedCrossRef

33.

Rubenfeld G. Surveys: an introduction. Respir Care 2004; 49: 1181–5.PubMed

Title: Weaning critically ill adults from invasive mechanical ventilation: a national survey
Authors: Karen E. A. Burns, MD
Francois Lellouche, MD
France Loisel, MD
Arthur S. Slutsky, MD
Aleksander Meret, B. Kin
Orla Smith, MN
Refik Saskin, MSc
Maureen Meade, MD
Publication date: 01-08-2009
Publisher: Springer-Verlag
Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Issue 8/2009
Print ISSN: 0832-610X
Electronic ISSN: 1496-8975
DOI: https://doi.org/10.1007/s12630-009-9124-8

2024 ASCO Annual Meeting

Springer Medicine

Weaning critically ill adults from invasive mechanical ventilation: a national survey

Abstract

Purpose

Methods

Results

Conclusions

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 8/2009

Coronary left ventricular outflow tract fistula after resection of a subaortic valve membrane

Cephalad migration of intrathecal clonidine in an infant undergoing bilateral herniorrhaphy

Transversalis fascia plane block, a novel ultrasound-guided abdominal wall nerve block

Weaning from mechanical ventilatory support in the 21st century: Procrustes’ bed, rocket science, or art?

Repeated large-volume epidural blood patches for the treatment of spontaneous intracranial hypotension

Bilateral infraorbital nerve blocks decrease postoperative pain but do not reduce time to discharge following outpatient nasal surgery