Professional Documents
Culture Documents
Weaning Patients From The Ventilator Nejm2012
Weaning Patients From The Ventilator Nejm2012
Review article
Current Concepts
I
n the United States, almost 800,000 patients who are hospitalized From the Department of Medicine, Sec-
each year require mechanical ventilation.1 This estimate excludes neonates, and tion of Pulmonary and Critical Care, Uni-
versity of Chicago, Chicago. Address re-
there is little doubt that mechanical ventilation will be increasingly used as the print requests to Dr. Kress at the
number of patients 65 years of age or older continues to increase.2,3 The majority of University of Chicago, Department of
patients who receive mechanical ventilation have acute respiratory failure in the Medicine, Section of Pulmonary and Crit-
ical Care, 5841 S. Maryland Ave., MC
postoperative period, pneumonia, congestive heart failure, sepsis, trauma, or the 6026, Chicago, IL 60637, or at jkress@
acute respiratory distress syndrome (ARDS).4 medicine.bsd.uchicago.edu.
Our discussion below assumes that physicians have addressed metabolic, inflam- N Engl J Med 2012;367:2233-9.
matory, and infectious conditions that may be present and have corrected them to the DOI: 10.1056/NEJMra1203367
extent possible. As soon as the condition that caused respiratory failure has started Copyright © 2012 Massachusetts Medical Society.
Table 1. Strategies to Prevent the Need for Mechanical Ventilation and to Reduce Its Duration.
Strategy Source
Evidence-based approaches to reduce the need for mechanical ventilation
Early goal-directed therapy in the initial treatment of sepsis Rivers et al.10
Use of noninvasive ventilation in selected patients with an acute exacerbation Brochard et al.,11 Ram et al.,12 Masip et al.,13 Gray et al.14
of chronic obstructive pulmonary disease or acute cardiogenic pulmonary
edema
Ventilator management and associated care to reduce the duration of mechanical
ventilation
Use of small tidal volumes (6 ml/kg of ideal body weight) in patients with the The Acute Respiratory Distress Syndrome Network15
acute respiratory distress syndrome
Daily interruption of sedative infusion Kress et al.16
Interruption of sedative infusion before spontaneous-breathing trial Girard et al.5
Early physical and occupational therapy Schweickert et al.17
No use of sedatives in patients receiving mechanical ventilation Strøm et al.18
Conservative strategy of fluid management in patients with acute lung injury ARDS Clinical Trials Network19
Strategies to reduce ventilator-associated pneumonia Dezfulian et al.20
patients these trials are most likely to be success- to definitively state which aspect or aspects of
ful. Yang and Tobin23 found that a ratio of the these protocols are responsible for a reduction in
respiratory rate (expressed in breaths per min- the duration of mechanical ventilation. Never-
ute) to tidal volume (expressed in liters) (f:Vt) of theless, the reproducible benefit shown in stud-
105 breaths per minute per liter or less during a ies of various protocols in multiple ICUs sug-
1-minute trial with the use of a T-piece was quite gests that it is the standardized approach to
accurate in identifying patients in whom a sub- management rather than any specific method of
sequent spontaneous-breathing trial would be suc- ventilator support, prespecified readiness, or
cessful (positive predictive value, 78%; negative criteria for discontinuation of mechanical venti-
predictive value, 95%). However, most experts lation that reduces the duration of mechanical
agree that the best method of determining wheth- ventilation and improves outcomes. Thus, most
er patients are ready to breathe on their own is guidelines recommend that patients who are
to perform a trial of spontaneous breathing once receiving mechanical ventilation be assessed
they have met readiness criteria.24 daily for their readiness to breathe spontane-
Many ICUs use protocols to guide the transition ously and afforded the opportunity to do so if
from assisted ventilation to spontaneous breathing they meet prespecified criteria.24
and subsequent discontinuation of mechanical
ventilation. Most protocols include three compo- A pproache s t o Sp on ta neous-
nents: objective criteria to determine whether a Br e athing T r i a l s
patient is ready to breathe with reduced ventila-
tory support, structured guidelines for reducing Trials of spontaneous breathing do not succeed
ventilatory support, and a list of criteria to deter- for a variety of reasons. Often, respiratory me-
mine whether a patient is ready for extubation. chanics worsen during a spontaneous-breathing
There is also growing consensus that the use of trial, causing increased work in breathing that
systematic protocols for discontinuation of me- cannot be maintained in critically ill patients.30
chanical ventilation, as compared with usual care, Deterioration of respiratory mechanics can result
may reduce the duration of mechanical ventila- from the following: increased respiratory resis-
tion.25 However, not all studies that use protocols tance such as that which occurs in status asth-
for these strategies have shown improvement maticus and other obstructive pulmonary condi-
over usual care.26-29 Because there are differ- tions; decreased lung compliance in diseases
ences between readiness criteria for spontane- such as pulmonary fibrosis, pulmonary edema,
ous-breathing trials and algorithms for discon- acute lung injury, or ARDS; and air trapping that
tinuation of mechanical ventilation, it is difficult can occur in chronic obstructive pulmonary dis-
There are no data from randomized trials to spiratory distress in the period after discontinu-
indicate which approach is superior, but we be- ation of ventilation.49,52 Although this aggressive
lieve a universally applied aggressive approach to approach may lead to higher rates of reintubation,
discontinuation of mechanical ventilation that we believe that the benefits of earlier discontinu-
emphasizes early spontaneous breathing and seeks ation of ventilation outweigh the risks associated
to minimize the duration of mechanical ventila- with waiting another 12 to 24 hours for contin-
tion results in fewer ICU-related complications. We ued clinical improvement before assessing a pa-
recommend extubation and the use of preemptive tient’s ability to breathe spontaneously.
noninvasive positive-pressure ventilation in pa-
tients who have had a successful spontaneous- F u t ur e R e se a rch
breathing trial but are at risk for unsuccessful
discontinuation of mechanical ventilation. In these Ongoing research is likely to alter our approach to
situations, we reassess the patient within 30 min- the discontinuation of mechanical ventilation in
utes after initiating noninvasive positive-pressure the near future. Currently, computerized systems
ventilation. If respiratory effort is normal and the automatically adjust ventilatory support on the
patient is comfortable, then we will continue non- basis of frequent monitoring of a patient’s respi-
invasive positive-pressure ventilation as long as ratory rate, tidal volume, and gas exchange. Early
necessary. However, if the respiratory rate is el- studies of these automated weaning systems have
evated or the patient is in mild distress, then we had conflicting results. Nevertheless, a system that
advocate immediate reintubation. We believe that can automatically assess a patient’s ability to re-
extubation and the prespecified use of noninvasive ceive reduced levels of ventilatory support without
positive-pressure ventilation in patients with a adverse effects has the potential to more quickly
borderline performance during a spontaneous- identify patients who are ready for spontaneous
breathing trial lead to earlier discontinuation of breathing. Additional studies are also likely to iden-
ventilation in many patients. This approach is tify treatment algorithms that shorten the dura-
coupled with an early decision regarding the need tion of mechanical ventilation or that reduce risk
for reintubation. Because delayed time to reintu- factors for unsuccessful discontinuation of ventila-
bation has been associated with increased mortal- tion after a successful spontaneous-breathing trial.
ity among patients in whom discontinuation of Dr. Kress reports receiving lecture fees from Hospira and the
ventilation has been unsuccessful, it is essential to France Foundation. No other potential conflict of interest rele-
vant to this article was reported.
determine quickly whether noninvasive positive- Disclosure forms provided by the authors are available with
pressure ventilation is adequately addressing re- the full text of this article at NEJM.org.
References
1. Wunsch H, Linde-Zwirble WT, Angus and ventilator weaning protocol for me- Early goal-directed therapy in the treat-
DC, Hartman ME, Milbrandt EB, Kahn chanically ventilated patients in intensive ment of severe sepsis and septic shock.
JM. The epidemiology of mechanical ven- care (Awakening and Breathing Controlled N Engl J Med 2001;345:1368-77.
tilation use in the United States. Crit Care trial): a randomised controlled trial. Lan- 11. Brochard L, Mancebo J, Wysocki M, et
Med 2010;38:1947-53. cet 2008;371:126-34. al. Noninvasive ventilation for acute exac-
2. Carson SS, Cox CE, Holmes GM, 6. Esteban A, Alìa I, Ibañez J, Benito S, erbations of chronic obstructive pulmo-
Howard A, Carey TS. The changing epide- Tobin MJ. Modes of mechanical ventilation nary disease. N Engl J Med 1995;333:
miology of mechanical ventilation: a pop- and weaning: a national survey of Spanish 817-22.
ulation-based study. J Intensive Care Med hospitals. Chest 1994;106:1188-93. 12. Ram FSF, Picot J, Lightowler J, Wedzi-
2006;21:173-82. 7. Esteban A, Ferguson ND, Meade MO, cha JA. Non-invasive positive pressure
3. Needham DM, Bronskill SE, Calina et al. Evolution of mechanical ventilation ventilation for treatment of respiratory
wan JR, Sibbald WJ, Pronovost PJ, Laupacis in response to clinical research. Am J failure due to exacerbations of chronic
A. Projected incidence of mechanical ven- Respir Crit Care Med 2008;177:170-7. obstructive pulmonary disease. Cochrane
tilation in Ontario to 2026: preparing for 8. Bendixin HH, Egbert LD, Hedley- Database Syst Rev 2004;3:CD004104.
the aging baby boomers. Crit Care Med Whyte J, Laver MB, Pontopippidan H. Re- 13. Masip J, Roque M, Sánchez B, Fernán-
2005;33:574-9. spiratory care. St. Louis: Mosby, 1965: dez R, Subirana M, Expósito JA. Noninva-
4. Esteban A, Anzueto A, Frutos F, et al. 149-50. sive ventilation in acute cardiogenic pul-
Characteristics and outcomes in adult pa- 9. Coplin WM, Pierson J, Cooley KD, monary edema: systematic review and
tients receiving mechanical ventilation: a Newell DW, Rubenfeld GD. Implications of meta-analysis. JAMA 2005;294:3124-30.
28-day international study. JAMA 2002; extubation delay in brain-injured patients 14. Gray A, Goodacre S, Newby DE, Mas-
287:345-55. meeting standard weaning criteria. Am J son M, Sampson F, Nicholl J. Noninvasive
5. Girard TD, Kress JP, Fuchs BD, et al. Respir Crit Care Med 2000;161:1530-6. ventilation in acute cardiogenic pulmonary
Efficacy and safety of a paired sedation 10. Rivers E, Nguyen B, Havstad S, et al. edema. N Engl J Med 2008;359:142-51.
15. The Acute Respiratory Distress Syn- Predictors of successful extubation in ventilated patients after cardiac surgery: a
drome Network. Ventilation with lower neurosurgical patients. Am J Respir Crit randomized trial. Ann Intern Med 2011;
tidal volumes as compared with tradition- Care Med 2001;163:658-64. 154:373-83.
al tidal volumes for acute lung injury and 28. Randolph AG, Wypij D, Venkataraman 40. Patel SB, Kress JP. Early tracheotomy
the acute respiratory distress syndrome. ST, et al. Effect of mechanical ventilator after cardiac surgery: not ready for prime
N Engl J Med 2000;342:1301-8. weaning protocols on respiratory outcomes time. Ann Intern Med 2011;154:434-5.
16. Kress JP, Pohlman AS, O’Connor MF, in infants and children: a randomized 41. Gomes Silva BN, Andriolo RB, Sacon-
Hall JB. Daily interruption of sedative in- controlled trial. JAMA 2002;288:2561-8. ato H, Atallah ÁN, Valente O. Early versus
fusions in critically ill patients undergo- 29. Rose L, Presneill JJ, Johnston L, Cade late tracheostomy for critically ill pa-
ing mechanical ventilation. N Engl J Med JF. A randomised, controlled trial of con- tients. Cochrane Database Syst Rev 2012;
2000;342:1471-7. ventional versus automated weaning from 3:CD007271.
17. Schweickert WD, Pohlman MC, Pohl- mechanical ventilation using SmartCare/ 42. Epstein SK, Ciubotaru RL, Wong JB.
man AS, et al. Early physical and occupa- PS. Intensive Care Med 2008;34:1788-95. Effect of failed extubation on the outcome
tional therapy in mechanically ventilated, 30. Jubran A, Tobin JM. Pathophysiologic of mechanical ventilation. Chest 1997;112:
critically ill patients: a randomised con- basis of acute respiratory distress in pa- 186-92.
trolled trial. Lancet 2009;373:1874-82. tients who fail a trial of weaning from 43. Esteban A, Alía I, Tobin MJ, et al. Ef-
18. Strøm T, Martinussen T, Toft P. A pro- mechanical ventilation. Am J Respir Crit fect of spontaneous breathing trial dura-
tocol of no sedation for critically ill pa- Care Med 1997;155:906-15. tion on outcome of attempts to discon-
tients receiving mechanical ventilation: a 31. Lemaire F, Teboul JL, Cinotti L, et al. tinue mechanical ventilation. Am J Respir
randomised trial. Lancet 2010;375:475-80. Acute left ventricular dysfunction during Crit Care Med 1999;159:512-8.
19. The National Heart, Lung, and Blood unsuccessful weaning from mechanical 44. Esteban A, Alía I, Gordo F, et al. Extu-
Institute Acute Respiratory Distress Syn- ventilation. Anesthesiology 1988;69:171-9. bation outcome after spontaneous breath-
drome (ARDS) Clinical Trials Network. 32. Boles J-M, Bion J, Connors A, et al. ing trials with T-tube or pressure support
Comparison of two fluid-management Weaning from mechanical ventilation. ventilation. Am J Respir Crit Care Med
strategies in acute lung injury. N Engl J Eur Respir J 2007;29:1033-56. 1997;156:459-65. [Erratum, Am J Respir
Med 2006;354:2564-75. 33. Funk G-C, Anders S, Breyer M-K, et al. Crit Care Med 1997;156:2028.]
20. Dezfulian C, Shojania K, Collard H, Incidence and outcome of weaning from 45. Epstein SK. Noninvasive ventilation to
Kim HM, Matthay MA, Saint S. Subglottic mechanical ventilation according to new shorten the duration of mechanical venti-
secretion drainage for preventing ventila- categories. Eur Respir J 2010;35:88-94. lation. Respir Care 2009;54:198-208.
tor-associated pneumonia: a meta-analy- 34. Seneff MG, Zimmerman JE, Knaus 46. Salam A, Tilluckdharry L, Amoateng-
sis. Am J Med 2005;118:11-8. WA, Wagner DP, Draper EA. Predicting Adjepong Y, Manthous CA. Neurologic
21. Brochard L, Rauss A, Benito S, et al. the duration of mechanical ventilation: status, cough, secretions and extubation
Comparison of three methods of gradual the importance of disease and patient outcomes. Intensive Care Med 2004;30:
withdrawal from ventilator support during characteristics. Chest 1996;110:469-79. 1334-9.
weaning from mechanical ventilation. Am 35. Kurek CJ, Cohen IL, Lambrinos J, Mi- 47. Frutos-Vivar F, Ferguson ND, Esteban
J Respir Crit Care Med 1994;150:896-903. natoya K, Booth FV, Chalfin DB. Clinical A, et al. Risk factors for extubation failure
22. Esteban A, Frutos F, Tobin MJ, et al. A and economic outcome of patients under- in patients following a successful sponta-
comparison of four methods of weaning going tracheostomy for prolonged me- neous breathing trial. Chest 2006;130:
patients from mechanical ventilation. chanical ventilation in New York State 1664-71.
N Engl J Med 1995;332:345-50. during 1993: analysis of 6,353 cases under 48. Keenan SP, Powers C, McCormack
23. Yang KL, Tobin MJ. A prospective diagnosis-related group 483. Crit Care DG, Block G. Noninvasive positive-pres-
study of indexes predicting the outcome Med 1997;25:983-8. sure ventilation for postextubation respi-
of trials of weaning from mechanical ven- 36. Cox CE, Carson SS, Holmes GM, ratory distress: a randomized controlled
tilation. N Engl J Med 1991;324:1445-50. Howard ABS, Carey TS. Increase in tra- trial. JAMA 2002;287:3238-44.
24. MacIntyre NR, Cook DJ, Ely EW Jr, et cheostomy for prolonged mechanical ven- 49. Esteban A, Frutos-Vivar F, Ferguson
al. Evidence-based guidelines for weaning tilation in North Carolina, 1993-2002. ND, et al. Noninvasive positive-pressure
and discontinuing ventilatory support: a Crit Care Med 2004;32:2219-26. ventilation for respiratory failure after ex-
collective task force facilitated by the 37. Arabi Y, Haddad S, Shirawi N, Al tubation. N Engl J Med 2004;350:
American College of Chest Physicians, the Shimemeri A. Early tracheostomy in in- 2452-60.
American Association for Respiratory Care, tensive care trauma patients improves re- 50. Nava S, Gregoretti C, Fanfulla F, et al.
and the American College of Critical Care source utilization: a cohort study and lit- Noninvasive ventilation to prevent respi-
Medicine. Chest 2001;120:Suppl:375S-395S. erature review. Crit Care 2004;8:R347- ratory failure after extubation in high-risk
25. Blackwood B, Alderdice F, Burns KEA, R352. patients. Crit Care Med 2005;33:2465-70.
Cardwell CR, Lavery G, O’Halloran P. Pro- 38. Rumbak MJ, Newton M, Truncale T, 51. Ferrer M, Valencia M, Nicolas JM, Ber-
tocolized versus non-protocolized wean- Schwartz SW, Adams JW, Hazard PB. A nadich O, Badia JR, Torres A. Early non-
ing for reducing the duration of mechani- prospective, randomized, study compar- invasive ventilation averts extubation
cal ventilation in critically ill adult ing early percutaneous dilational trache- failure in patients at risk: a randomized
patients. Cochrane Database Syst Rev otomy to prolonged translaryngeal intu- trial. Am J Respir Crit Care Med 2006;173:
2010;5:CD006904. bation (delayed tracheotomy) in critically 164-70.
26. Krishnan JA, Moore D, Robeson C, ill medical patients. Crit Care Med 2004; 52. Epstein SK, Ciubotaru RL. Indepen-
Rand CS, Fessler HE. A prospective, con- 32:1689-94. [Erratum, Crit Care Med 2004; dent effects of etiology of failure and time
trolled trial of a protocol-based strategy to 32:2566.] to reintubation on outcome for patients
discontinue mechanical ventilation. Am J 39. Trouillet JL, Luyt CE, Guiguet M, et al. failing extubation. Am J Respir Crit Care
Respir Crit Care Med 2004;169:673-8. Early percutaneous tracheotomy versus Med 1998;158:489-93.
27. Namen AM, Ely EW, Tatter SB, et al. prolonged intubation of mechanically Copyright © 2012 Massachusetts Medical Society.