Weaning from mechanical ventilatory support

Prolonged Ventilator Dependence

The purpose of this qualitative inquiry was to examine the meaning of prolonged mechanical ventilation from the perspective of the patient with a diagnosis of chronic obstructive pulmonary disease (COPD). Interviews were conducted with four individuals with a diagnosis of COPD who had experienced long-term ventilator dependence. Participants were asked to reflect on their experiences while they were ventilator dependent, and their narratives were utilized as text for hermeneutical analysis. The study's findings describe three distinct phases experienced by the participants, beginning with intubation and lasting until well after discharge from the hospital. The support of nurses was an important aspect of maintaining hope for the participants. The study revealed that prolonged mechanical ventilation had a profound impact on COPD patients and their sense of self. Postdischarge psychological support and follow-up with survivors of this experience is warranted.

Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients

BACKGROUND

Mechanical ventilation is a critical component of paediatric intensive care therapy. It is indicated when the patient's spontaneous ventilation is inadequate to sustain life. Weaning is the gradual reduction of ventilatory support and the transfer of respiratory control back to the patient. Weaning may represent a large proportion of the ventilatory period. Prolonged ventilation is associated with significant morbidity, hospital cost, psychosocial and physical risks to the child and even death. Timely and effective weaning may reduce the duration of mechanical ventilation and may reduce the morbidity and mortality associated with prolonged ventilation. However, no consensus has been reached on criteria that can be used to identify when patients are ready to wean or the best way to achieve it.

OBJECTIVES

To assess the effects of weaning by protocol on invasively ventilated critically ill children. To compare the total duration of invasive mechanical ventilation of critically ill children who are weaned using protocols versus those weaned through usual (non-protocolized) practice. To ascertain any differences between protocolized weaning and usual care in terms of mortality, adverse events, intensive care unit length of stay and quality of life.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 10, 2012), MEDLINE (1966 to October 2012), EMBASE (1988 to October 2012), CINAHL (1982 to October 2012), ISI Web of Science and LILACS. We identified unpublished data in the Web of Science (1990 to October 2012), ISI Conference Proceedings (1990 to October 2012) and Cambridge Scientific Abstracts (earliest to October 2012). We contacted first authors of studies included in the review to obtain further information on unpublished studies or work in progress. We searched reference lists of all identified studies and review papers for further relevant studies. We applied no language or publication restrictions.

SELECTION CRITERIA

We included randomized controlled trials comparing protocolized weaning (professional-led or computer-driven) versus non-protocolized weaning practice conducted in children older than 28 days and younger than 18 years.

DATA COLLECTION AND ANALYSIS

Two review authors independently scanned titles and abstracts identified by electronic searching. Three review authors retrieved and evaluated full-text versions of potentially relevant studies, independently extracted data and assessed risk of bias.

MAIN RESULTS

We included three trials at low risk of bias with 321 children in the analysis. Protocolized weaning significantly reduced total ventilation time in the largest trial (260 children) by a mean of 32 hours (95% confidence interval (CI) 8 to 56; P = 0.01). Two other trials (30 and 31 children, respectively) reported non-significant reductions with a mean difference of -88 hours (95% CI -228 to 52; P = 0.2) and -24 hours (95% CI -10 to 58; P = 0.06). Protocolized weaning significantly reduced weaning time in these two smaller trials for a mean reduction of 106 hours (95% CI 28 to 184; P = 0.007) and 21 hours (95% CI 9 to 32; P < 0.001). These studies reported no significant effects for duration of mechanical ventilation before weaning, paediatric intensive care unit (PICU) and hospital length of stay, PICU mortality or adverse events.

AUTHORS' CONCLUSIONS

Limited evidence suggests that weaning protocols reduce the duration of mechanical ventilation, but evidence is inadequate to show whether the achievement of shorter ventilation by protocolized weaning causes children benefit or harm.

Ventilatory weaning: a case study of protracted weaning

BACKGROUND

Dysfunctional ventilatory weaning response (DVWR) is characterized by interrupted and prolonged weaning. This reflective analysis presents how using nursing diagnoses in critical care can raise awareness of, and provide strategies for, managing problems related to ventilatory weaning.

AIM

To examine and reflect upon why one patient took so long to wean from the ventilator using the structured approach of instrumental case study and nursing diagnosis to explain aspects of the weaning process.

ANALYSIS

This case study examines one patient's experiences around ventilatory weaning using selected nursing diagnoses, exploring the implications that physiological, social, emotional and psychological factors have on both weaning and healing processes in critical care. By using dialogue, an explicit texture is presented of how one patient felt, with particular resonance to the relationships she had and the impact they made. Various nursing diagnoses proved useful in determining why this patient had an extended weaning trajectory and included DVWR, ineffective breathing pattern, impaired spontaneous ventilation, anxiety and impaired verbal communication. There were specific points of interest, in particular her anxiety, which proved a major factor, and her significantly improved functional status after the critical care episode. A DVWR may be minimized by nursing presence, reassurance and respect for patient autonomy. Complex anatomy and physiology contributes to protracted weaning and a DVWR and is compounded by anxiety. Furthermore, there is a significant element of nursing care, timely reassurance and presence, which can have a positive impact on patient well-being.

CONCLUSIONS

This reflective analysis highlights the benefits and importance of the nurse-patient relationship during what was a very protracted ventilatory wean. This shared trajectory enabled significant patient empowerment, and this case study gives the patient the voice she temporarily lost.

A randomised controlled trial of weaning from mechanical ventilation in paediatric intensive care (PIC). Methodological and practical issues

INTRODUCTION

Most children admitted to the Paediatric Intensive Care Unit (PICU) require assistance with breathing via a mechanical ventilator. Weaning from mechanical ventilation is the transition from ventilatory support to spontaneous breathing. Traditionally weaning has been with the authority of the medical staff. However, current opinion suggests that weaning could be performed by nurses using a standardised protocol [Schultz TR, Lin RJ, Watzman HM, Durning SM, Hales R, Woodson A, et al. Weaning children from mechanical ventilation: A prospective randomised trial of protocol-directed versus physician-directed weaning. Respir Care 2001;46(8):772-82]. The potential advantages of nurse-led (protocol-directed) weaning include: A reduction in weaning time and PICU stay with cost savings. Reduced complications. Improved quality of care. Appropriate use of resources.

METHODS

A Randomised Controlled Trial was performed to test the null hypothesis: there is no difference between the clinical effectiveness of nurse-led versus medical-led weaning of infants from mechanical ventilation. Data was collected for 7 infants and analysed.

RESULTS

Results indicated no significant differences between the two study groups. Unfortunately due to recruitment problems few inferences can be drawn from the data.

CONCLUSION

The trial was unsuccessful due to Recruitment issues. Physical constraints. Impractical entry criteria. Limited randomisation service. Ethical constraints. Barriers to parental participation. The methods, the difficulties encountered and the implications for future research are addressed.

Weaning from long-term mechanical ventilation: a nonpulmonary weaning index

OBJECTIVE

Despite the extensive investigations in the area of weaning, clinicians are still struggling with the question of when to begin the process of weaning. Clinical weaning indices designed to predict the weaning potential are most frequently based on pulmonary factors. However, many physiological, respiratory, and mechanical factors also have impact on weaning, but are often overlooked. We suggest a new "nonpulmonary weaning index" (NPWI), which assesses the influence of factors such as blood albumin and total blood protein on the weaning success.

METHODS

We assess the information value of 17 clinical and paraclinical indices in a retrospective study covering 151 patients on a long-term (at least 7 days) mechanical ventilation. The most informative of those 17 indices are used in the formulation of NPWI. Its threshold differentiates the successful from the unsuccessful weaning trials.

RESULTS

From all 17 indices the most significant are: total blood protein, blood albumin, PaO2, hematocrit, lactate, the ratio PaO2/FiO2, hemoglobine, and RUE. The proposed index uses only two of them: blood albumin and total blood protein. It is easily calculated and can easily be tracked in time. It has high sensitivity and specificity.

CONCLUSIONS

The results of this study suggest that in the decision whether to attempt weaning from long-term mechanical ventilation, more attention should be paid to the nonpulmonary factors.

A study exploring factors which influence the decision to commence nurse-led weaning

Nurse-led weaning can improve patient outcome. Exploration of the factors that influence the commencement of weaning. Themes of decision-making, pathophysiological and multidisciplinary team factors emerged. Experience was a key factor in the decision to wean. The use of protocol-led weaning may not be useful in the decision to wean.

Subjective Perceptions and Physiological Variables During Weaning From Mechanical Ventilation

• Background As costs related to mechanical ventilation increase, clear indicators of patients’ readiness to be weaned are needed. Research has not yet yielded a consensus on physiological variables that are consistent correlates of weaning outcomes. Subjective perceptions rarely have been examined for their contribution to successful weaning.

• Objective To explore the subjective perceptions of dyspnea, fatigue, and self-efficacy and selected physiological variables in patients being weaned from mechanical ventilation.

• Methods Data were collected prospectively on 68 patients being weaned from mechanical ventilation. Subjective perceptions were measured by using 3 visual analog scales; physiological variables were measured by using the Burns Weaning Assessment Program and a patient profile. Weaning outcomes were recorded 24 hours after data collection.

• Results Participants were primarily white women and required mechanical ventilation for a mean of less than 4 days. Participants reported mild dyspnea, moderate fatigue, and high weaning self-efficacy. High Pao2, low Paco2, stable hemodynamic status, adequate cough and swallow reflexes, no metabolic changes, and no abdominal problems were associated with complete weaning (P = .05). Subjective perceptions were associated with physiological variables but not with weaning outcomes.

• Conclusions Multidimensional assessment of both primary and secondary indicators of readiness to be weaned is necessary for timely, efficient weaning from mechanical ventilation. Primary assessments include physiological variables related to gas exchange, hemodynamic status, diaphragmatic expansion, and airway clearance. Secondary assessments include perceptions related to key physiological variables. Additional research is needed to determine the predictive value of physiological variables and perceptions of dyspnea, fatigue, and self-efficacy.

Nurse led weaning from ventilatory and respiratory support

Weaning from mechanical ventilation is challenging and requires expert knowledge and skill. Weaning can be defined as the process of assisting patients to breathe spontaneously without mechanical ventilatory support [Am. J. Crit. Care 7 (1998) 1491. Weaning from mechanical ventilation is not about the method used but more about how that method is employed [Crit. Care Med. 27 (1999) 2331]. A review of the literature revealed that there was no one method of weaning that was superior, furthermore evidence suggests that the use of a protocol was more effective in reducing the duration of weaning [Dimensions Crit. Care Nurs. 2 (1991) 398; Respir. Care Clin. North Am. 2 (1996) 105; AACN Clin. Issues Crit. Care 7 (1996) 550; Crit. Care Med. 25 (1997) 567; Arch. Surg. 133 (1998) 483; Chest 118 (2000) 459]. A retrospective audit of all patients who were ventilated for 7 or more days in one intensive care over a 1-year period, revealed 94 (of 500) patients were ventilated for an average of 16.8 days. There were no weaning guidelines or protocols in place at this time and weaning from mechanical ventilation was inconsistent and uncoordinated. A process mapping exercise revealed there was a delay in initiating the decision to wean of 96 h. Weaning protocols were put in place and nurse led weaning was initiated and supported by the nurse consultant. Monthly statistics were collated and this revealed the average ventilator time had reduced. Protocol led weaning has been effective in reducing the duration of ventilation. Problems still occur in initiating the decision to wean early. An audit of patient notes has revealed many reasons for this. These reasons include, over sedation, the use of morphine and midazolam, particularly in the elderly and those with renal impairment, is delaying weaning. Other reasons include, delay in tracheostomy placement. Staff are not initiating weaning guidelines early this may be due to lack of knowledge, lack of support or failure of the guidelines. Mechanisms are in place to support nurses at the bedside.

Multiple stab wounds: a short-term respiratory case study

Respiratory management is a role that is of paramount importance to intensive care nurses. Proactive nursing allows a nurse to have a positive effect on a patient's condition by actively improving the patient's status and setting priorities of care, avoiding deterioration wherever possible. In this account of the respiratory management of a patient who has sustained bilateral pneumothoraces following multiple stab wounds to the chest and back, the physiological assessment of the patient is described and a proactive respiratory plan of care is formed. Anatomy, physiology and pathophysiology in relation to pneumothoraces, metabolic acidosis and magnesium links with functional residual capacity are addressed. The potential risk of Adult Respiratory Distress Syndrome (ARDS) following direct and indirect lung injury is discussed. Recent research into ventilation modes and into areas of nursing practice relating to respiratory management are also considered.