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Cover of Criteria for Weaning from Mechanical Ventilation

Criteria for Weaning from Mechanical Ventilation

Evidence Reports/Technology Assessments, No. 23

Investigators: , MD, Principal Investigator, , MD, , MD, , MSc, and , BA.

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 01-E010ISBN-10: 1-58763-011-7

Structured Abstract

Objectives:

Because mechanical ventilation incurs significant morbidity, mortality, and costs and because premature extubation as well as delayed extubation can cause harm, weaning that is both expeditious and safe is highly desirable. We sought to determine whether the current literature elucidates when and how weaning should begin, proceed, and end.

Search Strategy:

We used five computerized bibliographic databases, hand searching, bibliographic references, expert consultation, and a duplicate independent review process to identify relevant articles.

Selection Criteria:

Our eligibility criteria were broad. We selected studies evaluating any weaning modes, algorithms, or other interventions to facilitate weaning; studies of weaning predictors; and studies evaluating patient and nursing experiences during weaning.

Data Collection and Analysis:

We developed generic forms to abstract data from all studies, in addition to forms specific to randomized trials, nonrandomized controlled studies, and studies of weaning predictors. We developed an instruction manual and trained eight individuals to abstract data related to study characteristics and results using duplicate, independent review. Quantitative data were abstracted using several metrics. We pooled results across randomized trials and across studies of weaning predictors only when our assessment of the patients, interventions, and outcomes indicated that pooling was legitimate.

Main Results:

We reviewed 154 articles. For stepwise reductions in mechanical support, pressure support mode or multiple daily T-piece trials may be superior to synchronized intermittent mandatory ventilation. For trials of unassisted breathing, low levels of pressure support may be beneficial. There may be substantial benefits to early extubation and institution of noninvasive positive pressure ventilation before patients are ready to breathe without mechanical assistance. The value of differing modes as reflected in these studies depends on the thresholds for initiating, progressing through, and terminating weans in the specific study protocols. Unfortunately, these thresholds involve more than objective data and appear to be related to physician judgment.

The implementation of nurse-driven or respiratory therapist-driven weaning protocols, regardless of what modes are employed, significantly expedites weaning and is probably safe. Following cardiac surgery, early extubation is unequivocably achieved with a variety of anesthetic interventions and intensive care unit protocols; however, the corresponding reduction in intensive care unit stay is generally small and the impact on complications, though rare, remains unclear. The role of computerized protocols has not been established.

We did not uncover any consistently powerful weaning predictors. The most frequently studied and one of the most helpful tests is the rapid shallow breathing index; however, the pooled likelihood ratio for a positive test ranged from 1.3 to 2.8. Two other predictors, occlusion pressure/maximum inspiratory pressure and the compliance, rate, oxygenation, and pressure index, are more powerful, though less intensively studied. In general, the probable reason for the poor performance of weaning predictors is that physicians have already considered the results of these predictors when they select patients for study.

Conclusions:

Future research initiatives should include: determining the optimal tradeoff between prolonged time on a ventilator and reintubation in specific patient groups, further evaluation of weaning protocols (What types of patients are most likely to benefit? Which protocols are most effective? How large are the associated cost reductions? Is there a role for computers?), and clarification of the risk-benefit of early extubation with noninvasive positive pressure ventilation.

Contents

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-97-0017. Prepared by: Department of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada.

Suggested citation:

Cook D, Meade M, Guyatt G, et al. Criteria for Weaning From Mechanical Ventilation. Evidence Report/Technology Assessment No. 23 (Prepared by McMaster University under Contract No. 290-97-0017). AHRQ Publication No. 01-E010. Rockville MD: Agency for Healthcare Research and Quality. November 2000.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost, quality, and outcomes of health care, and expands its role to improve patient safety and address medical errors.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, test, treatment, or other clinical service.

1

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Bookshelf ID: NBK33323
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