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LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.
The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.
At the annual meeting of the American College of Chest Physicians, one of the six project cochairs, Daniel R. Ouellette, MD, said that the guidelines were intended to address “new territory” from the evidence-based guidelines for weaning and discontinuing ventilator support that were published in 2001. That effort, chaired by Neil R. MacIntyre, MD, “was a landmark article that helped us learn about the steps that we needed to take to liberate patients from mechanical ventilation,” said Dr. Ouellette of the Henry Ford Hospital Department of Pulmonary and Critical Care Medicine, Detroit. “We hope that this guideline lives up to the importance of that one. We wanted to look over new information and give new recommendations about things that haven’t been addressed in the past.”
Six recommendations from the guideline panel include:
We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.
We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”
We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.
We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.
We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.
In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”
Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.
Daniel R. Ouellette, MD, FCCP, comments: Liberation from mechanical ventilation is one of the most important goals in taking care of critically ill patients receiving mechanical ventilation in the ICU. Patients who have a prolonged ventilator course are at risk for many complications and so physicians who work in the intensive care unit must work carefully to liberate patients from the ventilator at the earliest possible moment. That has to be done in a safe fashion so criteria to ensure that this can be done safely are important as well.
Patients often have medical illness that requires sedation, and it is often necessary to sedate patients so that they can tolerate being on mechanical ventilation; however, we know that oversedation can lead to failure to liberate patients from mechanical ventilation expeditiously. Therefore, one of our recommendations’ suggestions is to design protocols for sedation that focus on minimizing sedation so that patients can be extubated expeditiously.
All of the recommendations ultimately focused on a team approach to liberation from mechanical ventilation, because involvement of team members is always important. However, there are a couple of our recommendations that are particularly important in terms of their implications for the team approach and those include recommendations about using protocols to liberate patients from ventilators, in general, and also to use sedation protocols to minimize sedations.
We began to look at developing this topic, because we had initially published guidelines on [liberation from mechanical ventilation] in 2001. We knew that there was much new information that had emerged since the 2001 guidelines. For that reason we began to think about an update. With the initial inception of this project, we reached out to the American Thoracic Society so as to develop a collaborative effort since this was a topic that interested both societies. This collaboration was at all levels at CHEST and it involved not only the guidelines organization, but also the leadership of both societies and, of course, the panel that was ultimately constructed to address these issues was made up of members from both societies. The entire process [of developing the new guideline] took nearly 3 years.
When one develops a guideline, one makes an effort to make a guideline as comprehensive and globally applicable as possible. I think the practices in Europe are very similar to practices in North America in terms of mechanical ventilation. Several of our panelists are European and some of the important work that we reviewed came from centers in Europe. It’s my opinion that our guideline will be broadly applicable in both North America and Europe, but there may be regional or local differences. Nevertheless, we recognize in different regions in the world, there are different resource allocations for medical treatment, there are different cultural precepts, and there are other factors that implicate medical problems.
Certainly the European Respiratory Society and other European organizations developed guidelines on related topics ... one of the important caveats when CHEST decides to develop a guideline is that we are not reproducing the work that has been done elsewhere and so this guideline represents a project that fills a gap that previously had not been filled.
All guidelines that CHEST develops are living guidelines … it’s hard to envision exactly how often a guideline will be updated. We know that there will be certain areas of our guideline that will stand the test of time, but there will be other areas that will need to be updated, some sooner than others.
The original CHEST guideline on liberation from mechanical ventilation was a very important document that appeared in 2001 and changed the practice of medicine and the practice of managing patients on mechanical ventilation. Nevertheless, the guideline was somewhat limited in scope, because there was only so much information available. … Our goal in developing this guideline was to address some of practitioners’ questions that had emerged in the last decade by looking at newly available data.
[In formulating these guidelines], we purposely chose six new questions that were not directly related to any of the questions [that has been answered] in the previous guideline.
Daniel R. Ouellette, MD, FCCP, comments: Liberation from mechanical ventilation is one of the most important goals in taking care of critically ill patients receiving mechanical ventilation in the ICU. Patients who have a prolonged ventilator course are at risk for many complications and so physicians who work in the intensive care unit must work carefully to liberate patients from the ventilator at the earliest possible moment. That has to be done in a safe fashion so criteria to ensure that this can be done safely are important as well.
Patients often have medical illness that requires sedation, and it is often necessary to sedate patients so that they can tolerate being on mechanical ventilation; however, we know that oversedation can lead to failure to liberate patients from mechanical ventilation expeditiously. Therefore, one of our recommendations’ suggestions is to design protocols for sedation that focus on minimizing sedation so that patients can be extubated expeditiously.
All of the recommendations ultimately focused on a team approach to liberation from mechanical ventilation, because involvement of team members is always important. However, there are a couple of our recommendations that are particularly important in terms of their implications for the team approach and those include recommendations about using protocols to liberate patients from ventilators, in general, and also to use sedation protocols to minimize sedations.
We began to look at developing this topic, because we had initially published guidelines on [liberation from mechanical ventilation] in 2001. We knew that there was much new information that had emerged since the 2001 guidelines. For that reason we began to think about an update. With the initial inception of this project, we reached out to the American Thoracic Society so as to develop a collaborative effort since this was a topic that interested both societies. This collaboration was at all levels at CHEST and it involved not only the guidelines organization, but also the leadership of both societies and, of course, the panel that was ultimately constructed to address these issues was made up of members from both societies. The entire process [of developing the new guideline] took nearly 3 years.
When one develops a guideline, one makes an effort to make a guideline as comprehensive and globally applicable as possible. I think the practices in Europe are very similar to practices in North America in terms of mechanical ventilation. Several of our panelists are European and some of the important work that we reviewed came from centers in Europe. It’s my opinion that our guideline will be broadly applicable in both North America and Europe, but there may be regional or local differences. Nevertheless, we recognize in different regions in the world, there are different resource allocations for medical treatment, there are different cultural precepts, and there are other factors that implicate medical problems.
Certainly the European Respiratory Society and other European organizations developed guidelines on related topics ... one of the important caveats when CHEST decides to develop a guideline is that we are not reproducing the work that has been done elsewhere and so this guideline represents a project that fills a gap that previously had not been filled.
All guidelines that CHEST develops are living guidelines … it’s hard to envision exactly how often a guideline will be updated. We know that there will be certain areas of our guideline that will stand the test of time, but there will be other areas that will need to be updated, some sooner than others.
The original CHEST guideline on liberation from mechanical ventilation was a very important document that appeared in 2001 and changed the practice of medicine and the practice of managing patients on mechanical ventilation. Nevertheless, the guideline was somewhat limited in scope, because there was only so much information available. … Our goal in developing this guideline was to address some of practitioners’ questions that had emerged in the last decade by looking at newly available data.
[In formulating these guidelines], we purposely chose six new questions that were not directly related to any of the questions [that has been answered] in the previous guideline.
Daniel R. Ouellette, MD, FCCP, comments: Liberation from mechanical ventilation is one of the most important goals in taking care of critically ill patients receiving mechanical ventilation in the ICU. Patients who have a prolonged ventilator course are at risk for many complications and so physicians who work in the intensive care unit must work carefully to liberate patients from the ventilator at the earliest possible moment. That has to be done in a safe fashion so criteria to ensure that this can be done safely are important as well.
Patients often have medical illness that requires sedation, and it is often necessary to sedate patients so that they can tolerate being on mechanical ventilation; however, we know that oversedation can lead to failure to liberate patients from mechanical ventilation expeditiously. Therefore, one of our recommendations’ suggestions is to design protocols for sedation that focus on minimizing sedation so that patients can be extubated expeditiously.
All of the recommendations ultimately focused on a team approach to liberation from mechanical ventilation, because involvement of team members is always important. However, there are a couple of our recommendations that are particularly important in terms of their implications for the team approach and those include recommendations about using protocols to liberate patients from ventilators, in general, and also to use sedation protocols to minimize sedations.
We began to look at developing this topic, because we had initially published guidelines on [liberation from mechanical ventilation] in 2001. We knew that there was much new information that had emerged since the 2001 guidelines. For that reason we began to think about an update. With the initial inception of this project, we reached out to the American Thoracic Society so as to develop a collaborative effort since this was a topic that interested both societies. This collaboration was at all levels at CHEST and it involved not only the guidelines organization, but also the leadership of both societies and, of course, the panel that was ultimately constructed to address these issues was made up of members from both societies. The entire process [of developing the new guideline] took nearly 3 years.
When one develops a guideline, one makes an effort to make a guideline as comprehensive and globally applicable as possible. I think the practices in Europe are very similar to practices in North America in terms of mechanical ventilation. Several of our panelists are European and some of the important work that we reviewed came from centers in Europe. It’s my opinion that our guideline will be broadly applicable in both North America and Europe, but there may be regional or local differences. Nevertheless, we recognize in different regions in the world, there are different resource allocations for medical treatment, there are different cultural precepts, and there are other factors that implicate medical problems.
Certainly the European Respiratory Society and other European organizations developed guidelines on related topics ... one of the important caveats when CHEST decides to develop a guideline is that we are not reproducing the work that has been done elsewhere and so this guideline represents a project that fills a gap that previously had not been filled.
All guidelines that CHEST develops are living guidelines … it’s hard to envision exactly how often a guideline will be updated. We know that there will be certain areas of our guideline that will stand the test of time, but there will be other areas that will need to be updated, some sooner than others.
The original CHEST guideline on liberation from mechanical ventilation was a very important document that appeared in 2001 and changed the practice of medicine and the practice of managing patients on mechanical ventilation. Nevertheless, the guideline was somewhat limited in scope, because there was only so much information available. … Our goal in developing this guideline was to address some of practitioners’ questions that had emerged in the last decade by looking at newly available data.
[In formulating these guidelines], we purposely chose six new questions that were not directly related to any of the questions [that has been answered] in the previous guideline.
LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.
The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.
At the annual meeting of the American College of Chest Physicians, one of the six project cochairs, Daniel R. Ouellette, MD, said that the guidelines were intended to address “new territory” from the evidence-based guidelines for weaning and discontinuing ventilator support that were published in 2001. That effort, chaired by Neil R. MacIntyre, MD, “was a landmark article that helped us learn about the steps that we needed to take to liberate patients from mechanical ventilation,” said Dr. Ouellette of the Henry Ford Hospital Department of Pulmonary and Critical Care Medicine, Detroit. “We hope that this guideline lives up to the importance of that one. We wanted to look over new information and give new recommendations about things that haven’t been addressed in the past.”
Six recommendations from the guideline panel include:
We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.
We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”
We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.
We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.
We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.
In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”
Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.
LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.
The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.
At the annual meeting of the American College of Chest Physicians, one of the six project cochairs, Daniel R. Ouellette, MD, said that the guidelines were intended to address “new territory” from the evidence-based guidelines for weaning and discontinuing ventilator support that were published in 2001. That effort, chaired by Neil R. MacIntyre, MD, “was a landmark article that helped us learn about the steps that we needed to take to liberate patients from mechanical ventilation,” said Dr. Ouellette of the Henry Ford Hospital Department of Pulmonary and Critical Care Medicine, Detroit. “We hope that this guideline lives up to the importance of that one. We wanted to look over new information and give new recommendations about things that haven’t been addressed in the past.”
Six recommendations from the guideline panel include:
We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.
We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”
We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.
We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.
We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.
In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”
Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.
AT CHEST 2016