Risks and Challenges with Ventilator Weaning Management

Clinical studies show that clinical evaluation has a low sensitivity for correctly identifying patients who are ready for successful weaning compared to protocolized weaning.([FOOTNOTE=Kollef, M. H., Shapiro, S. D., Silver, P., et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25(4):567-574.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Navalesi, P., Frigerio, P., Moretti, M. P., et al. Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation. Crit Care Med. 2008;36(11):2986-2992.],[ANCHOR=],[LINK=])

One survey of intensivists using clinical judgment to assess the potential for discontinuation found a sensitivity of only 35% (6 of 17 patients who were successfully discontinued were identified) and a specificity of 79% (11 of 14 patients who failed discontinuation were identified).([FOOTNOTE=Stroetz, R. W., & Hubmayr, R. D. Tidal volume maintenance during weaning with pressure support. Am J Respir Crit Care Med. 1995;152(3):1034-1040.],[ANCHOR=],[LINK=])

Ventilator-associated pneumonia (VAP) is a relatively common complication in patients who receive prolonged mechanical ventilation.([FOOTNOTE=Cook, D. J., Walter, S. D., Cook, R. J., et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med. 1998;129(6):433-440.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Fagon, J. Y., Chastre, J., Domart, Y., et al. Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis. 1989;139(4):877-884.],[ANCHOR=],[LINK=])

In a prospective study of 567 patients, Fagon et al. found that the actuarial risk of VAP was 6.5% at 10 days, 19% at 20 days, and 28% at 30 days of ventilation.⁹

Mechanical ventilation is expensive and ventilator-associated complications can further increase the costs dramatically.([FOOTNOTE=Wunsch, H., Linde-Zwirble, W. T., Angus, D. C., Hartman, M. E., Milbrandt, E. B., & Kahn, J. M. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010;38(10):1947-1953.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Zimlichman, E., Henderson, D., Tamir, O., et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.],[ANCHOR=],[LINK=])

Most studies suggest that the rate of reintubation ranges between 15% and 30% at most ICUs.

Patients who have to be reintubated are much more likely to die in the hospital.([FOOTNOTE=Epstein, S. K., Ciubotaru, R. L., & Wong, J. B. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997;112(1):186-192.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Esteban, A., Alia, I., Gordo, F., et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156(2 Pt 1):459-465.],[ANCHOR=],[LINK=])^,([FOOTNOTE= Frutos-Vivar, F., Esteban, A., Apezteguia, C., et al. Outcome of reintubated patients after scheduled extubation. J Crit Care. 2011;26(5):502-509.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Rady, M. Y., & Ryan, T. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med. 1999;27(2):340-347.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Vallverdu, I., Calaf, N., Subirana, M., Net, A., Benito, S., & Mancebo, J. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med. 1998;158(6):1855-1862.],[ANCHOR=],[LINK=])

Patients who have to be reintubated are more likely to develop VAP.¹⁷

Patients who have to be reintubated have significantly increased length of ICU stay and overall hospital stay.^14,15,16,17