Ventilation Management Clinical Studies, Reduce Ventilator Time

Protocol-driven weaning has been shown to reduce the time spent on mechanical ventilation by 26% on average compared to clinician driven, non-protocolized weaning.¹

Weaning protocols usually consist of three parts:

Objective criteria to judge readiness to wean;
Guidelines to decrease support gradually;
Criteria to assess readiness for extubation.²

Select each of these parts below to learn more.

EVALUATE WEANING READINESS

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Evaluate Weaning Readiness

Prior to participation in a spontaneous breathing trial, patients must be evaluated for eligibility. Patients may be assessed for readiness for a spontaneous breathing trial by confirming the following:³

Reversal of the indication for ventilator support (underlying disease needs to be controlled, no fever, electrolytes balanced, etc.)
Adequate gas exchange
Ability to initiate a breath (sedatives stopped for 4 hours, analgesics kept for active pain)
Hemodynamic stability

SPONTANEOUS BREATHING TRIAL METHODS

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Spontaneous Breathing Trial Methods

A spontaneous breathing trial (SBT) is a focused assessment of a patient’s ability to breathe independently while receiving minimal or no respiratory support, and is typically considered the best way to see if a patient is ready to be extubated.⁴ Guidelines also suggest that a patient’s initial SBT should last at least 30 minutes but not more than 120 minutes. There are a number of different SBT methods that can be used.⁴ A recent Cochrane Report found generally limited differences in weaning success across PSV and T-tube SBT methods, though in patients where first-attempt SBT is successful, Pressure Support Ventilation appeared to be slightly more effective.⁵

Learn more about the spontaneous breathing trial tools available on the PB980 Ventilator

SBT Methods	Definition
T-Tube	The patient is disconnected from the ventilator and allowed to breathe spontaneously through a T-piece with supplemental oxygen.⁵
Pressure Support Ventilation	The patient remains connected to the ventilator and the PS value is adjusted to decrease the work of breathing (typically 5-10 cmH₂O).⁵
Other methods	Use of synchronized intermittent mandatory ventilation (SIMV), continuous positive airway pressure (CPAP), and automatic tube compensation (ATC).^3,⁶

ARDSNET VENTILATION PROTOCOL

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Ardsnet Ventilation Protocol

The ARDS network, funded by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (NIH), was established to develop evidence for the management of ventilated patients with Acute Respiratory Distress Syndrome (ARDSnet.org). As such, ARDSnet trials have provided some of the most influential ventilation-related evidence of the past 20 years. The SBT eligibility criteria and spontaneous breathing trial method below are included in the ARDSnet ventilation protocol.

ARDSnet SBT Eligibility Criteria⁷

(A) Conduct a SPONTANEOUS BREATHING TRIAL daily when:

FiO₂ ≤ 0.40 and PEEP ≤ 8 OR FiO₂ ≤ 0.50 and PEEP ≤ 5
PEEP and FiO₂ ≤ values of previous day
Patient has acceptable spontaneous breathing efforts
SBP ≥ 90 mmHg
No neuromuscular blocking agents of blockade

(B) SPONTANEOUS BREATHING TRIAL (SBT):

If all above criteria are met, initiate a trial of UP TO 120 minutes of spontaneous breathing with FiO₂ ≤ 0.5 and PEEP ≤ 5:

Place on T-piece, trach collar, or CPAP ≤ 5 cm H₂O with PS < 5
Assess for tolerance as below for up to two hours.
1. SpO₂ ≥ 90: and/or PaO₂ ≥ 60 mmHg
2. Spontaneous VT ≥ 4 ml/kg PBW
3. RR ≤ 35/min
4. pH ≥ 7.3
5. No respiratory distress (distress = 2 or more)
  - HR > 120% of baseline
  - Marked accessory muscle use
  - Abdominal paradox
  - Diaphoresis
  - Marked dyspnea
If tolerated for at least 30 minutes, consider extubation.
If not tolerated resume pre-weaning settings.

Modified from ARDSnet.⁷

In ventilated patients, using effective protocols to better identify patients who are ready for weaning and to better manage the weaning process itself can significantly reduce the duration of ventilation and number of complications.^1,⁸^,⁹

Discover below what the positive impact on each outcome can be in case weaning protocols are followed.

SUCCESSFUL EXTUBATION

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In a study by McLean et al., the authors instituted a 4-step process improvement model with the goal of improving protocol adherence and clinical outcomes. After implementing the model, the authors reported that protocol adherence improved to 21.2% coinciding with a significant reduction in the rate of unsuccessful extubation (3.0% vs. 12.7%; P=0.05).¹¹

Dries et al., in a survey of 2 years' activity in a multidisciplinary surgical ICU, found that protocolized weaning resulted in a reduction in the number of patients failing extubation from 13.7% to 7.4% (P=0.013).¹⁰

WEANING TIME

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In a recent Cochrane report, Blackwood et al. found that protocolized weaning reduced weaning duration by 70% (P=0.009).¹

TIME OF MECHANICAL VENTILATION

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In a Cochrane Review of 17 clinical studies encompassing 2,434 patients, Blackwood et al. found that protocolized weaning resulted a 26% reduction (P=0.0002) in the mean duration of mechanical ventilation.¹

LENGTH OF STAY

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In a recent Cochrane Review, Blackwood et al. found that protocolized weaning reduced the length of ICU stay 11% (P= 0.01).¹

VENTILATOR-ASSOCIATED PNEUMONIA (VAP)

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Marelich et al. studied the effect of a single ventilator management protocol (VMP) on the incidence of VAP. In this study, the VMP group tended to have less VAP (6%) as compared to the control group (15%; P= 0.061).¹³

In a 2002 study of 352 ICU patients, Iregui et al. found that after implementation of a computerized weaning guide, fewer patients developed VAP as compared to a control period (25 cases vs. 42 cases; P= 0.021).¹⁴

Dries et al. studied the effect of protocol-driven ventilator weaning on VAP; after protocol implementation, the number of VAP cases fell from 17 to 5 (P= 0.165).¹⁰

In a study by McLean et al., increased adherence to weaning protocols corresponded with a reduction in VAP incidence (19.7% vs. 34.9%), though the difference was not statistically significant (P= 0.14).¹¹

COST OF CARE

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In a randomized, controlled study in 300 mechanically ventilated ICU patients, Ely et al. found that protocolized weaning resulted in total ICU costs that were approximately $5,000 less in the intervention group compared to the control group ($15,740 vs. $20,890; P=0.03) and a tendency towards reduced overall costs ($26,229 vs. $29,048; P=0.3).¹⁵

One study by Burns et al. calculated that implementation of standardized ventilation management programs, including protocol-driven sedation and weaning, resulted in more than $3 million in cost savings the first year of implementation, with an average savings of over $3,000 per case.¹²

MORTALITY

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Burns et al. demonstrated that the implementation of a multidisciplinary outcomes management (OM) process for mechanically ventilated patients, including standardized protocols for weaning and sedation use, resulted in a reduced mortality rate (31% vs. 38%; P=0.02).¹²

Multiple clinical studies have demonstrated that even in the highly structured environment of clinical trials adherence to weaning protocols is low, ranging from 21-66%.^11,15These low rates may be a product of healthcare professionals perceiving protocols as removing clinical judgment from clinical decision making.¹¹ In order to overcome this obstacle, McLean et al. demonstrated that a process improvement intervention program designed to improve weaning protocol adherence resulted in a 13-fold increase in adherence rates accompanied by a 4-fold decrease in reintubation.¹¹

Weaning guidelines typically include strategies to reduce the duration of mechanical ventilation once intubated, earlier appreciation of readiness for an SBT, and a shorter process of discontinuation of mechanical ventilation after passing an SBT.

Discover below which monitoring products & solutions from Medtronic can help evaluating weaning readiness.

Recommendations supporting the utilization of protocolized weaning to improve clinical outcomes in mechanically ventilated patients

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16. Akoumianaki, E., Prinianakis, G., Kondili, E., Malliotakis, P., & Georgopoulos, D. Physiologic comparison of neurally adjusted ventilator assist, proportional assist and pressure support ventilation in critically ill patients. Respir Physiol Neurobiol. 2014;203:82-89.
17. Grasso, S., Puntillo, F., Mascia, L., et al. Compensation for increase in respiratory workload during mechanical ventilation. Pressure-support versus proportional-assist ventilation. Am J Respir Crit Care Med. 2000;161(3 Pt 1):819-826.
18. Kondili, E., Prinianakis, G., Alexopoulou, C., Vakouti, E., Klimathianaki, M., & Georgopoulos, D. Respiratory load compensation during mechanical ventilation--proportional assist ventilation with load-adjustable gain factors versus pressure support. Intensive Care Med. 2006;32(5):692-699.
1. Blackwood, B., Burns, K. E., Cardwell, C. R., & O'Halloran, P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014(11):CD006904.
2. McConville, J. F., & Kress, J. P. Weaning patients from the ventilator. N Engl J Med. 2012;367(23):2233-2239.
3. MacIntyre, N. R., Cook, D. J., Ely, E. W., Jr., et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(6 Suppl):375S-395S.
4. Boles, J. M., Bion, J., Connors, A., et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033-1056.
5. Ladeira, M. T., Vital, F. M., Andriolo, R. B., Andriolo, B. N., Atallah, A. N., & Peccin, M. S. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014(5):CD006056.
6. Figueroa-Casas, J. B., Montoya, R., Arzabala, A., & Connery, S. M. Comparison between automatic tube compensation and continuous positive airway pressure during spontaneous breathing trials. Respir Care. 2010;55(5):549-554.
7. NHLBI ARDS Network. NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary. View Abstract
8. Burns, K. E., Meade, M. O., Lessard, M. R., et al. Wean earlier and automatically with new technology (the WEAN study). A multicenter, pilot randomized controlled trial. Am J Respir Crit Care Med. 2013;187(11):1203-1211.
9. 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.
10. Dries, D. J., McGonigal, M. D., Malian, M. S., Bor, B. J., & Sullivan, C. Protocol-driven ventilator weaning reduces use of mechanical ventilation, rate of early reintubation, and ventilator-associated pneumonia. J Trauma. 2004;56(5):943-951; discussion 951-942.
11. McLean, S. E., Jensen, L. A., Schroeder, D. G., Gibney, N. R., & Skjodt, N. M. Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. Am J Crit Care. 2006;15(3):299-309.
12. Burns, S. M., Earven, S., Fisher, C., et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31(12):2752-2763.
13. Marelich, G. P., 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(2):459-467.
14. Iregui, M., Ward, S., Clinikscale, D., Clayton, D., & Kollef, M. H. Use of a handheld computer by respiratory care practitioners to improve the efficiency of weaning patients from mechanical ventilation. Crit Care Med. 2002;30(9):2038-2043.
15. Ely, E. W., Bennett, P. A., Bowton, D. L., Murphy, S. M., Florance, A. M., & Haponik, E. F. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med. 1999;159(2):439-446.

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Reducing Mechanical Venitaltion via Weaning Management

Protocolized Weaning

EVALUATE WEANING READINESS

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Evaluate Weaning Readiness

SPONTANEOUS BREATHING TRIAL METHODS

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Spontaneous Breathing Trial Methods

SBT Methods

ARDSNET VENTILATION PROTOCOL

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Ardsnet Ventilation Protocol

ARDSnet SBT Eligibility Criteria7

(A) Conduct a SPONTANEOUS BREATHING TRIAL daily when:

(B) SPONTANEOUS BREATHING TRIAL (SBT):

Improved Outcomes Associated with Protocolized Weaning

Discover below what the positive impact on each outcome can be in case weaning protocols are followed.

SUCCESSFUL EXTUBATION

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Successful Extubation

Protocolized weaning can increase the rate of successful extubations.10,11

WEANING TIME

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Weaning Time

Protocolized weaning can reduce weaning time.1

TIME OF MECHANICAL VENTILATION

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Time of Mechanical Ventilation

Protocolized weaning can reduce the overall time spent on mechanical ventilation.1,12,13

LENGTH OF STAY

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Length of Stay

Protocolized weaning can reduce the overall time in ICU.1

VENTILATOR-ASSOCIATED PNEUMONIA (VAP)

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Ventilator-Associated Pneumonia (VAP)

Protocolized weaning can reduce the incidence of VAP.10,11,13,14

COST OF CARE

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Cost of Care

Protocolized weaning can reduce the cost of hospitalization in mechanically ventilated patients.

MORTALITY

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Mortality

Protocolized weaning can reduce patient mortality in mechanically ventilated patients.

Weaning Adherence

While weaning protocols have been shown to improve outcomes, adherence to these protocols remains relatively poor and highly variable across ICUs.

Guidelines Supporting Protocolized Weaning

Numerous critical and respiratory care societies have developed guidelines to support the weaning process.

Discover below which monitoring products & solutions from Medtronic can help evaluating weaning readiness.

E-Learning

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Vital Sync™ Weaning Readiness & Spontaneous Breathing Trial (SBT) Monitoring Application

Puritan Bennett™ Ventilation Systems

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ARDSnet SBT Eligibility Criteria⁷

Protocolized weaning can increase the rate of successful extubations.¹⁰^,¹¹

Protocolized weaning can reduce weaning time.¹

Protocolized weaning can reduce the overall time spent on mechanical ventilation.^1,¹²^,¹³

Protocolized weaning can reduce the overall time in ICU.¹

Protocolized weaning can reduce the incidence of VAP.^10,11,13,¹⁴