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Quach S, Reise K, McGregor C, Papaconstantinou E, Nonoyama ML. A Delphi Survey of Canadian Respiratory Therapists' Practice Statements on Pediatric Mechanical Ventilation. Respir Care 2022; 67:1420-1436. [PMID: 35922069 PMCID: PMC9993971 DOI: 10.4187/respcare.09886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pediatric mechanical ventilation practice guidelines are not well established; therefore, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) developed consensus recommendations on pediatric mechanical ventilation management in 2017. However, the guideline's applicability in different health care settings is unknown. This study aimed to determine the consensus on pediatric mechanical ventilation practices from Canadian respiratory therapists' (RTs) perspectives and consensually validate aspects of the ESPNIC guideline. METHODS A 3-round modified electronic Delphi survey was conducted; contents were guided by ESPNIC. Participants were RTs with at least 5 years of experience working in standalone pediatric ICUs or units with dedicated pediatric intensive care beds across Canada. Round 1 collected open-text feedback, and subsequent rounds gathered feedback using a 6-point Likert scale. Consensus was defined as ≥ 75% agreement; if consensus was unmet, statements were revised for re-ranking in the subsequent round. RESULTS Fifty-two RTs from 14 different pediatric facilities participated in at least one of the 3 rounds. Rounds 1, 2, and 3 had a response rate of 80%, 93%, and 96%, respectively. A total of 59 practice statements achieved consensus by the end of round 3, categorized into 10 sections: (1) noninvasive ventilation and high-flow oxygen therapy, (2) tidal volume and inspiratory pressures, (3) breathing frequency and inspiratory times, (4) PEEP and FIO2 , (5) advanced modes of ventilation, (6) weaning, (7) physiological targets, (8) monitoring, (9) general, and (10) equipment adjuncts. Cumulative text feedback guided the formation of the clinical remarks to supplement these practice statements. CONCLUSIONS This was the first study to survey RTs for their perspectives on the general practice of pediatric mechanical ventilation management in Canada, generally aligning with the ESPNIC guideline. These practice statements considered information from health organizations and institutes, supplemented with clinical remarks. Future studies are necessary to verify and understand these practices' effectiveness.
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Affiliation(s)
- Shirley Quach
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada; McMaster University, School of Rehabilitation Sciences, Institute for Applied Health Sciences, Hamilton, Ontario, Canada; and Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada
| | - Katherine Reise
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada
| | - Carolyn McGregor
- Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada; and University of Technology, Sydney, New South Wales, Australia
| | | | - Mika L Nonoyama
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada; and Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada.
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Vahedian-Azimi A, Gohari-Moghadam K, Rahimi-Bashar F, Samim A, Khoshfetrat M, Mohammadi SM, de Souza LC, Mahmoodpoor A. New integrated weaning indices from mechanical ventilation: A derivation-validation observational multicenter study. Front Med (Lausanne) 2022; 9:830974. [PMID: 35935785 PMCID: PMC9354807 DOI: 10.3389/fmed.2022.830974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 07/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background To develop ten new integrated weaning indices that can predict the weaning outcome better than the traditional indices. Methods This retrospective-prospective derivation-validation observational multicenter clinical trial (Clinical Trial.Gov, NCT 01779297), was conducted on 1,175 adult patients admitted at 9 academic affiliated intensive care units (ICUs; 4 surgical and 5 medical), from Jan 2013 to Dec 2018. All patients, intubated and mechanically ventilated for at least 24 h and ready for weaning were enrolled. The study had two phases: at first, the threshold values of each index that best discriminate between a successful and an unsuccessful weaning outcome was determined among 208 patients in the derivation group. In the second phase, the predictive performance of these values was prospectively tested in 967 patients in the validation group. In the prospective-validation set we used Bayes’ theorem to assess the probability of each test in predicting weaning. Results In the prospective validation group, sensitivity, specificity, diagnostic accuracy, positive and negative predictive values, and finally area under the receiver operator characteristic curves and standard errors for each index (ten formulae) were calculated. Statistical values of ten formulae for aforesaid variables were higher than 87% (0.87–0.99). Conclusion The new indices can be used for hospitalized patients in intensive care settings for accurate prediction of the weaning outcome.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Keivan Gohari-Moghadam
- Medical ICU and Pulmonary Unit, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshid Rahimi-Bashar
- Anesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Abbas Samim
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- *Correspondence: Abbas Samim,
| | - Masoum Khoshfetrat
- Department of Anesthesiology and Critical Care, Khatamolanbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Seyyede Momeneh Mohammadi
- Department of Anatomical Sciences, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | - Ata Mahmoodpoor
- Evidence Based Medicine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Ata Mahmoodpoor,
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Blackwood B, Morris KP, Jordan J, McIlmurray L, Agus A, Boyle R, Clarke M, Easter C, Feltbower RG, Hemming K, Macrae D, McDowell C, Murray M, Parslow R, Peters MJ, Phair G, Tume LN, Walsh TS, McAuley DF. Co-ordinated multidisciplinary intervention to reduce time to successful extubation for children on mechanical ventilation: the SANDWICH cluster stepped-wedge RCT. Health Technol Assess 2022; 26:1-114. [PMID: 35289741 DOI: 10.3310/tcfx3817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population. OBJECTIVES To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective). DESIGN A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations. SETTING Paediatric intensive care units in the UK. PARTICIPANTS Invasively mechanically ventilated children (aged < 16 years). INTERVENTIONS The intervention incorporated co-ordinated multidisciplinary care, patient-relevant sedation plans linked to sedation assessment, assessment of ventilation parameters with a higher than usual trigger for undertaking an extubation readiness test and a spontaneous breathing trial on low levels of respiratory support to test extubation readiness. The comparator was usual care. Hospital sites were randomised sequentially to transition from control to intervention and were non-blinded. MAIN OUTCOME MEASURES The primary outcome measure was the duration of invasive mechanical ventilation until the first successful extubation. The secondary outcome measures were successful extubation, unplanned extubation and reintubation, post-extubation use of non-invasive ventilation, tracheostomy, post-extubation stridor, adverse events, length of intensive care and hospital stay, mortality and cost per respiratory complication avoided at 28 days. RESULTS The trial included 10,495 patient admissions from 18 paediatric intensive care units from 5 February 2018 to 14 October 2019. In children with anticipated prolonged ventilation (n = 8843 admissions: control, n = 4155; intervention, n = 4688), the intervention resulted in a significantly shorter time to successful extubation [cluster and time-adjusted median difference -6.1 hours (interquartile range -8.2 to -5.3 hours); adjusted hazard ratio 1.11, 95% confidence interval 1.02 to 1.20; p = 0.02] and a higher incidence of successful extubation (adjusted relative risk 1.01, 95% confidence interval 1.00 to 1.02; p = 0.03) and unplanned extubation (adjusted relative risk 1.62, 95% confidence interval 1.05 to 2.51; p = 0.03), but not reintubation (adjusted relative risk 1.10, 95% confidence interval 0.89 to 1.36; p = 0.38). In the intervention period, the use of post-extubation non-invasive ventilation was significantly higher (adjusted relative risk 1.22, 95% confidence interval 1.01 to 1.49; p = 0.04), with no evidence of a difference in intensive care length of stay or other harms, but hospital length of stay was longer (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.97; p = 0.01). Findings for all children were broadly similar. The control period was associated with lower, but not statistically significantly lower, total costs (cost difference, mean £929.05, 95% confidence interval -£516.54 to £2374.64) and significantly fewer respiratory complications avoided (mean difference -0.10, 95% confidence interval -0.16 to -0.03). LIMITATIONS The unblinded intervention assignment may have resulted in performance or detection bias. It was not possible to determine which components were primarily responsible for the observed effect. Treatment effect in a more homogeneous group remains to be determined. CONCLUSIONS The intervention resulted in a statistically significant small reduction in time to first successful extubation; thus, the clinical importance of the effect size is uncertain. FUTURE WORK Future work should explore intervention sustainability and effects of the intervention in other paediatric populations. TRIAL REGISTRATION This trial is registered as ISRCTN16998143. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, UK
| | - Joanne Jordan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Roisin Boyle
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Mike Clarke
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Christina Easter
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Richard G Feltbower
- School of Medicine, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Karla Hemming
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Duncan Macrae
- Paediatric Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Margaret Murray
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Roger Parslow
- School of Medicine, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Elisa P, Francesca C, Marco P, Davide V, Laura Z, Fabrizio Z, Andrea P, Marco D, Maria BC. Ventilation Weaning and Extubation Readiness in Children in Pediatric Intensive Care Unit: A Review. Front Pediatr 2022; 10:867739. [PMID: 35433554 PMCID: PMC9010786 DOI: 10.3389/fped.2022.867739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
Ventilation is one of the most common procedures in critically ill children admitted to the pediatric intensive care units (PICUs) and is associated with potential severe side effects. The longer the mechanical ventilation, the higher the risk of infections, mortality, morbidity and length of stay. Protocol-based approaches to ventilation weaning could have potential benefit in assisting the physicians in the weaning process but, in pediatrics, clear significant outcome difference related to their use has yet to be shown. Extubation failure occurs in up to 20% of patients in PICU with evidences demonstrating its occurrence related to a worse patient outcome including higher mortality. Various clinical approaches have been described to decide the best timing for extubation which can usually be achieved by performing a spontaneous breathing trial before the extubation. No clear evidence is available over which technique best predicts extubation failure. Within this review we summarize the current strategies of ventilation weaning and extubation readiness evaluation employed in the pediatric setting in order to provide an updated view on the topic to guide intensive care physicians in daily clinical practice. We performed a thorough literature search of main online scientific databases to identify principal studies evaluating different strategies of ventilation weaning and extubation readiness including pediatric patients receiving mechanical ventilation. Various strategies are available in the literature both for ventilation weaning and extubation readiness assessment with unclear clear data supporting the superiority of any approach over the others.
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Affiliation(s)
- Poletto Elisa
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Cavagnero Francesca
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Pettenazzo Marco
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Visentin Davide
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Zanatta Laura
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Zoppelletto Fabrizio
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Pettenazzo Andrea
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Daverio Marco
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Bonardi Claudia Maria
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
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Kishore R, Jhamb U. Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial. Indian J Crit Care Med 2021; 25:1059-1065. [PMID: 34963728 PMCID: PMC8664023 DOI: 10.5005/jp-journals-10071-23944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Identifying ventilated patients ready for extubation is a challenge for clinicians. Premature extubation increases risks of reintubation while delayed weaning increases complications of prolonged ventilation. We compared the duration of mechanical ventilation (MV) and extubation failure in children extubated using a weaning protocol based on pressure support spontaneous breathing trial (PS SBT) vs those extubated after nonprotocolized physician-directed weaning. Patients and methods A prospective randomized controlled trial was conducted in the pediatric intensive care unit of a tertiary care hospital in children ventilated for ≥24 hours. All eligible patients underwent daily screening and were randomized once found fit. The intervention group underwent PS SBT of 2 hours duration followed by a T-piece trial and extubation. Controls underwent conventional weaning with synchronized intermittent mandatory ventilation mode and a T-piece trial before extubation. Results Eighty patients were randomized into two groups of 40 each. About 77.5% of patients passed the PS SBT on the first attempt. No statistical difference was found either in the duration of MV between the two groups [median (interquartile range) in days: 4.77 (2.89, 9.46) in controls and 4.94 (2.23, 6.35) in cases, p = 0.62] or in the rate of extubation failure (13% and 10.5%, p = 1). Mortality was found to be significantly higher in the reintubated patients compared to those not reintubated in both groups (p = 0.002 in cases and 0.005 in controls). Conclusion Weaning using PS SBT-based protocol though did not shorten the duration of MV, it was found to be safe for assessing extubation readiness and did not increase extubation failure (CTRI no—CTRI/2018/04/013270). How to cite this article Kishore R, Jhamb U. Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial. Indian J Crit Care Med 2021;25(9):1059–1065.
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Affiliation(s)
- Rashmi Kishore
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India
| | - Urmila Jhamb
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India
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Baalaaji ARM. Weaning from Mechanical Ventilation in Children: Are We Getting It Right? Indian J Crit Care Med 2021; 25:974-975. [PMID: 34963712 PMCID: PMC8664013 DOI: 10.5005/jp-journals-10071-23974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
How to cite this article: Baalaaji ARM. Weaning from Mechanical Ventilation in Children: Are We Getting It Right? Indian J Crit Care Med 2021;25(9):974-975.
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Affiliation(s)
- AR Mullai Baalaaji
- Department of Pediatric Critical Care, Kovai Medical Centerand Hospital, Coimbatore, Tamil Nadu, India
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Blackwood B, Tume LN, Morris KP, Clarke M, McDowell C, Hemming K, Peters MJ, McIlmurray L, Jordan J, Agus A, Murray M, Parslow R, Walsh TS, Macrae D, Easter C, Feltbower RG, McAuley DF. Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units: A Randomized Clinical Trial. JAMA 2021; 326:401-410. [PMID: 34342620 PMCID: PMC8335576 DOI: 10.1001/jama.2021.10296] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is limited evidence on the optimal strategy for liberating infants and children from invasive mechanical ventilation in the pediatric intensive care unit. OBJECTIVE To determine if a sedation and ventilator liberation protocol intervention reduces the duration of invasive mechanical ventilation in infants and children anticipated to require prolonged mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS A pragmatic multicenter, stepped-wedge, cluster randomized clinical trial was conducted that included 17 hospital sites (18 pediatric intensive care units) in the UK sequentially randomized from usual care to the protocol intervention. From February 2018 to October 2019, 8843 critically ill infants and children anticipated to require prolonged mechanical ventilation were recruited. The last date of follow-up was November 11, 2019. INTERVENTIONS Pediatric intensive care units provided usual care (n = 4155 infants and children) or a sedation and ventilator liberation protocol intervention (n = 4688 infants and children) that consisted of assessment of sedation level, daily screening for readiness to undertake a spontaneous breathing trial, a spontaneous breathing trial to test ventilator liberation potential, and daily rounds to review sedation and readiness screening and set patient-relevant targets. MAIN OUTCOMES AND MEASURES The primary outcome was the duration of invasive mechanical ventilation from initiation of ventilation until the first successful extubation. The primary estimate of the treatment effect was a hazard ratio (with a 95% CI) adjusted for calendar time and cluster (hospital site) for infants and children anticipated to require prolonged mechanical ventilation. RESULTS There were a total of 8843 infants and children (median age, 8 months [interquartile range, 1 to 46 months]; 42% were female) who completed the trial. There was a significantly shorter median time to successful extubation for the protocol intervention compared with usual care (64.8 hours vs 66.2 hours, respectively; adjusted median difference, -6.1 hours [interquartile range, -8.2 to -5.3 hours]; adjusted hazard ratio, 1.11 [95% CI, 1.02 to 1.20], P = .02). The serious adverse event of hypoxia occurred in 9 (0.2%) infants and children for the protocol intervention vs 11 (0.3%) for usual care; nonvascular device dislodgement occurred in 2 (0.04%) vs 7 (0.1%), respectively. CONCLUSIONS AND RELEVANCE Among infants and children anticipated to require prolonged mechanical ventilation, a sedation and ventilator liberation protocol intervention compared with usual care resulted in a statistically significant reduction in time to first successful extubation. However, the clinical importance of the effect size is uncertain. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN16998143.
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Affiliation(s)
- Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Lyvonne N. Tume
- School of Health and Society, University of Salford, Manchester, England
- Alder Hey Children’s NHS Trust, Liverpool, England
| | - Kevin P. Morris
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Ireland
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | | | - Mark J. Peters
- Great Ormond Street Hospital, London, England
- University College London, Great Ormond Street Institute of Child Health, NIHR Biomedical Research Centre, London, England
| | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Joanne Jordan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | - Margaret Murray
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | - Roger Parslow
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Timothy S. Walsh
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland
| | | | | | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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9
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Abstract
Supplemental Digital Content is available in the text. Our objective was to obtain international consensus on a set of core outcome measures that should be recorded in all clinical trials of interventions intended to modify the duration of ventilation for invasively mechanically ventilated patients in the ICU.
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Blackwood B, Agus A, Boyle R, Clarke M, Hemming K, Jordan J, Macrae D, McAuley DF, McDowell C, McIlmurray L, Morris KP, Murray M, Parslow R, Peters MJ, Tume LN, Walsh T. Sedation AND Weaning In Children (SANDWICH): protocol for a cluster randomised stepped wedge trial. BMJ Open 2019; 9:e031630. [PMID: 31712342 PMCID: PMC6858098 DOI: 10.1136/bmjopen-2019-031630] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Weaning from ventilation is a complex process involving several stages that include recognition of patient readiness to begin the weaning process, steps to reduce ventilation while optimising sedation in order not to induce distress and removing the endotracheal tube. Delay at any stage can prolong the duration of mechanical ventilation. We developed a multicomponent intervention targeted at helping clinicians to safely expedite this process and minimise the harms associated with unnecessary mechanical ventilation. METHODS AND ANALYSIS This is a 20-month cluster randomised stepped wedge clinical and cost-effectiveness trial with an internal pilot and a process evaluation. It is being conducted in 18 paediatric intensive care units in the UK to evaluate a protocol-based intervention for reducing the duration of invasive mechanical ventilation. Following an initial 8-week baseline data collection period in all sites, one site will be randomly chosen to transition to the intervention every 4 weeks and will start an 8-week training period after which it will continue the intervention for the remaining duration of the study. We aim to recruit approximately 10 000 patients. The primary analysis will compare data from before the training (control) with that from after the training (intervention) in each site. Full details of the analyses will be in the statistical analysis plan. ETHICS AND DISSEMINATION This protocol was reviewed and approved by NRES Committee East Midlands-Nottingham 1 Research Ethics Committee (reference: 17/EM/0301). All sites started patient recruitment on 5 February 2018 before randomisation in April 2018. Results will be disseminated in 2020. The results will be presented at national and international conferences and published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER ISRCTN16998143.
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Affiliation(s)
- Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Roisin Boyle
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Mike Clarke
- Centre for Public Health, Institute of Clinical Sciences, Queen's University Belfast, Belfast, UK
| | - Karla Hemming
- Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Joanne Jordan
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Duncan Macrae
- Paediatric Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Daniel Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | | | - Roger Parslow
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK
- Institute of Child Health, University College London, London, UK
| | - Lyvonne N Tume
- Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | - Tim Walsh
- MRC Centre for Inflammation Research, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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Al Mandhari H, Finelli M, Chen S, Tomlinson C, Nonoyama ML. Effects of an extubation readiness test protocol at a tertiary care fully outborn neonatal intensive care unit. ACTA ACUST UNITED AC 2019; 55:81-88. [PMID: 31667334 PMCID: PMC6797061 DOI: 10.29390/cjrt-2019-011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background and objectives Extubation readiness testing (ERT) in the Neonatal Intensive Care Unit (NICU) is highly variable and lacking standardized criteria. To address this gap, an evidence-based, inter-professionally developed ERT protocol was implemented to assess effectiveness on extubation failure within 72 h and on duration of intubation (DOI). Methods A longitudinal retrospective chart review in a level III, fully outborn NICU, of intubated infants admitted 1-year prior (Group 1), and 1 year after implementation (Group 2). Patients were extubated if they passed a 2-stage ERT protocol (3 min continuous positive airway pressure (CPAP) followed by 7 min CPAP + pressure support). Descriptive, comparative statistics, and univariate and multiple logistic regression were completed on all patients and a ≤32 6/7 weeks subgroup (intubated at day-of-life 1); p < 0.05 is considered significant. Results All patients (n = 589 (n = 294 Group 1, n = 295 Group 2)) were included (preterm, intubated day of life one subgroup: n = 42 Group 1, n = 38 Group 2). For all patients, extubation failure decreased significantly from 9.9% to 4.1% (p = 0.006); Group 1 patients were 2.42 times more likely to experience extubation failure compared with Group 2. Extubation failure in the preterm subgroup decreased from 21.7% to 2.6% (p = 0.01); Group 1 patients were 10.71 times more likely to experience extubation failure. Median DOI was similar in both groups for all patients and in the preterm subgroup. Conclusions A unique two-stage ERT protocol was effective at reducing extubation failure rate, without increasing DOI, largely in preterm infants. The evidence-based, interprofessionally developed ERT protocol and its integration into the NICU culture largely contributed to its success.
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Affiliation(s)
- Hilal Al Mandhari
- Neonatal Unit, Child Health department, Sultan Qaboos University Hospital, Muscat, Oman.,Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael Finelli
- Neonatology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Respiratory Therapy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Shiyi Chen
- Clinical Research Services, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Mika L Nonoyama
- Department of Respiratory Therapy, The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada.,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
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12
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Sasaki M, Yamaguchi Y, Miyashita T, Matsuda Y, Ohtsuka M, Yamaguchi O, Goto T. Simulation of pressure support for spontaneous breathing trials in neonates. Intensive Care Med Exp 2019; 7:10. [PMID: 30737561 PMCID: PMC6368635 DOI: 10.1186/s40635-019-0223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 01/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endotracheal tubes used for neonates are not as resistant to breathing as originally anticipated; therefore, spontaneous breathing trials (SBTs) with continuous positive airway pressure (CPAP), without pressure support (PS), are recommended. However, PS extubation criteria have predetermined pressure values for each endotracheal tube diameter (PS 10 cmH2O with 3.0- and 3.5-mm tubes or PS 8 cmH2O with 4.0-mm tubes). This study aimed to assess the validity of these SBT criteria for neonates, using an artificial lung simulator, ASL 5000™ lung simulator, and a SERVO-i Universal™ ventilator (minute volume, 240-360 mL/kg/min; tidal volume, 30 mL; respiratory rate, 24-36/min; lung compliance, 0.5 mL/cmH2O/kg; resistance, 40 cmH2O/L/s) in an intensive care unit. We simulated a spontaneous breathing test in a 3-kg neonate after cardiac surgery with 3.0-3.5-mm endotracheal tubes. We measured the work of breathing (WOB), trigger work, and parameters of pressure support ventilation (PSV), T-piece breathing, or ASL 5000™ alone. RESULTS WOB displayed respiratory rate dependency under intubation. PS compensating tube resistance fluctuated with respiratory rate. At a respiratory rate of 24/min, the endotracheal tube did not greatly influence WOB under PSV and the regression line of WOB converged with the WOB of ASL 5000™ alone under PS 1 cmH2O; however, at 36/min, endotracheal tube was resistant to breathing under PSV because trigger work increased exponentially with PS ≤ 9 cmH2O. The regression line of WOB under PSV converged with the WOB of T-piece breathing under PS 1 cmH2O. Furthermore, PS compensating endotracheal tube resistance was 6 cmH2O. The WOB of ASL 5000™ alone approached that of respiratory distress syndrome (RDS); however, the pressure of patient effort was normal physiological range at PS 10 cmH2O. PS equalizing WOB under PSV with that after extubation depended on the respiratory rate and upper airway resistance. If WOB after extubation equaled that of T-piece breathing, the PS was 0 cmH2O regardless of the respiratory rates. If WOB after extubation approximated to that of ASL 5000™ alone, the PS depended on the respiratory rate. CONCLUSION SBT strategies should be selected per neonatal respiratory rates and upper airway resistance.
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Affiliation(s)
- Makoto Sasaki
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan.
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Tetsuya Miyashita
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Yuko Matsuda
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Masahide Ohtsuka
- Department of Critical Care Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Osamu Yamaguchi
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
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13
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Role of physical therapists in the weaning and extubation procedures of pediatric and neonatal intensive care units: a survey. Braz J Phys Ther 2018; 23:317-323. [PMID: 30249437 DOI: 10.1016/j.bjpt.2018.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/09/2018] [Accepted: 08/22/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Weaning a patient from mechanical ventilation is a complex procedure that involves clinical and contextual aspects. Mechanical ventilation also depends on the characteristics of health professionals who work in intensive care. OBJECTIVE This study described the organizational aspects associated with the physical therapist's performance in the weaning procedure from mechanical ventilation and extubation in neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil. METHODS In order to identify the existing intensive care units in Brazil, data from the National Health Facilities Census was used to enable the researchers to obtain information about registered units. A cross-sectional survey was carried out by sending an electronic questionnaire to 298 neonatal, pediatric and mixed intensive care units in Brazil. RESULTS This study assessed questionnaires from 146 intensive care units (49.3% neonatal, 35.6% pediatric and 15.1% mixed). A total of 57.5% of these units applied mechanical ventilation weaning protocols, and a physical therapist frequently conducted this procedure (66.7%). However, the clinician responsible for conducting the weaning and deciding when to do extubation varied regardless of ICU patient age profile. Regardless of the type of hospital or the type of units, most of these had a dedicated physical therapist. However, physical therapy care 24h/7 days per week was predominantly in pediatric intensive care units (56.0%), and in public hospitals (45.9%). Moreover, when the physical therapist was available 24h/7 days per week, (s)he was responsible for the mechanical ventilation extubation decision and patients were successfully extubated on the first attempt. CONCLUSION In this survey, intensive care units using physical therapy assistance 24h/7 days per week were associated with the use of a mechanical ventilation weaning protocol, an extubation decision and success commonly on the first attempt of extubation.
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14
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Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med 2017; 43:1764-1780. [PMID: 28936698 PMCID: PMC5717127 DOI: 10.1007/s00134-017-4920-z] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Purpose Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. Methods The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. Results The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement. Conclusions These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research. Electronic supplementary material The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.
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15
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Accuracy of an Extubation Readiness Test in Predicting Successful Extubation in Children With Acute Respiratory Failure From Lower Respiratory Tract Disease. Crit Care Med 2017; 45:94-102. [PMID: 27632676 DOI: 10.1097/ccm.0000000000002024] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Identifying children ready for extubation is desirable to minimize morbidity and mortality associated with prolonged mechanical ventilation and extubation failure. We determined the accuracy of an extubation readiness test (Randomized Evaluation of Sedation Titration for Respiratory Failure extubation readiness test) in predicting successful extubation in children with acute respiratory failure from lower respiratory tract disease. DESIGN Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial, a pediatric multicenter cluster randomized trial of sedation. SETTING Seventeen PICUs in the intervention arm. PATIENTS Children 2 weeks to 17 years receiving invasive mechanical ventilation for lower respiratory tract disease. INTERVENTION Extubation readiness test in which spontaneously breathing children with oxygenation index less than or equal to 6 were placed on FIO2 of 0.50, positive end-expiratory pressure of 5 cm H2O, and pressure support. MEASUREMENTS AND MAIN RESULTS Of 1,042 children, 444 (43%) passed their first extubation readiness test. Of these, 295 (66%) were extubated within 10 hours of starting the extubation readiness test, including 272 who were successfully extubated, for a positive predictive value of 92%. Among 861 children who were extubated for the first time within 10 hours of performing an extubation readiness test, 788 passed their extubation readiness test and 736 were successfully extubated for a positive predictive value of 93%. The median time of day for extubation with an extubation readiness test was 12:15 hours compared with 14:54 hours for extubation without an extubation readiness test within 10 hours (p < 0.001). CONCLUSIONS In children with acute respiratory failure from lower respiratory tract disease, an extubation readiness test, as described, should be considered at least daily if the oxygenation index is less than or equal to 6. If the child passes the extubation readiness test, there is a high likelihood of successful extubation.
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16
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Jordan J, Rose L, Dainty KN, Noyes J, Blackwood B. Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis. Cochrane Database Syst Rev 2016; 10:CD011812. [PMID: 27699783 PMCID: PMC6458040 DOI: 10.1002/14651858.cd011812.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions. OBJECTIVES 1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used. SEARCH METHODS We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.We reran the search on 3rd July 2016 and found three studies, which are awaiting classification. SELECTION CRITERIA We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation. DATA COLLECTION AND ANALYSIS At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews. MAIN RESULTS We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as 'low', 13 as 'moderate' and five as 'high' confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents. AUTHORS' CONCLUSIONS There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of 'ownership'. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.
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Affiliation(s)
- Joanne Jordan
- Ulster UniversitySchool of NursingShore RoadNewtownabbeyNorthern IrelandUKBT37 OQB
| | - Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research InstituteDepartment of Critical Care MedicineTorontoCanada
| | - Katie N Dainty
- St. Michael's HospitalLi Ka Shing Knowledge InstituteTorontoONCanada
| | - Jane Noyes
- Bangor UniversityCentre for Health‐Related Research, Fron HeulogBangorWalesUKLL57 2EF
| | - Bronagh Blackwood
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7LB
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Wielenga JM, van den Hoogen A, van Zanten HA, Helder O, Bol B, Blackwood B. Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in newborn infants. Cochrane Database Syst Rev 2016; 3:CD011106. [PMID: 26998745 PMCID: PMC8750746 DOI: 10.1002/14651858.cd011106.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mechanical ventilation is a life-saving intervention for critically ill newborn infants with respiratory failure admitted to a neonatal intensive care unit (NICU). Ventilating newborn infants can be challenging due to small tidal volumes, high breathing frequencies, and the use of uncuffed endotracheal tubes. Mechanical ventilation has several short-term, as well as long-term complications. To prevent complications, weaning from the ventilator is started as soon as possible. Weaning aims to support the transfer from full mechanical ventilation support to spontaneous breathing activity. OBJECTIVES To assess the efficacy of protocolized versus non-protocolized ventilator weaning for newborn infants in reducing the duration of invasive mechanical ventilation, the duration of weaning, and shortening the NICU and hospital length of stay. To determine efficacy in predefined subgroups including: gestational age and birth weight; type of protocol; and type of protocol delivery. To establish whether protocolized weaning is safe and clinically effective in reducing the duration of mechanical ventilation without increasing the risk of adverse events. SEARCH METHODS We searched the Cochrane Central Register of Controlled trials (CENTRAL; the Cochrane Library; 2015, Issue 7); MEDLINE In-Process and other Non-Indexed Citations and OVID MEDLINE (1950 to 31 July 2015); CINAHL (1982 to 31 July 2015); EMBASE (1988 to 31 July 2015); and Web of Science (1990 to 15 July 2015). We did not restrict language of publication. We contacted authors of studies with a subgroup of newborn infants in their study, and experts in the field regarding this subject. In addition, we searched abstracts from conference proceedings, theses, dissertations, and reference lists of all identified studies for further relevant studies. SELECTION CRITERIA Randomized, quasi-randomized or cluster-randomized controlled trials that compared protocolized with non-protocolized ventilator weaning practices in newborn infants with a gestational age of 24 weeks or more, who were enrolled in the study before the postnatal age of 28 completed days after the expected date of birth. DATA COLLECTION AND ANALYSIS Four authors, in pairs, independently reviewed titles and abstracts identified by electronic searches. We retrieved full-text versions of potentially relevant studies. MAIN RESULTS Our search yielded 1752 records. We removed duplicates (1062) and irrelevant studies (843). We did not find any randomized, quasi-randomized or cluster-randomized controlled trials conducted on weaning from mechanical ventilation in newborn infants. Two randomized controlled trials met the inclusion criteria on type of study and type of intervention, but only included a proportion of newborns. The study authors could not provide data needed for subgroup analysis; we excluded both studies. AUTHORS' CONCLUSIONS Based on the results of this review, there is no evidence to support or refute the superiority or inferiority of weaning by protocol over non-protocol weaning on duration of invasive mechanical ventilation in newborn infants.
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Affiliation(s)
- Joke M Wielenga
- Women's and Children's Clinic, Academic Medical CenterIntensive Care NeonatologyPO Box 22660AmsterdamNetherlands1100 DD
| | - Agnes van den Hoogen
- Whilhelmina Children's Hospital, University Medical CenterNeonatologyUtrechtNetherlands
| | - Henriette A van Zanten
- Leiden University Medical CenterNeonatal Intensive Care UnitAlbinusdreef 2LeidenNetherlands2333AZ
| | - Onno Helder
- Erasmus Medical Centre ‐ Sophia Children's HospitalDepartment of Pediatrics, Division of NeonatologyDr. Molewaterplein 60RotterdamNetherlands
| | - Bas Bol
- Erasmus Medical Centre ‐ Sophia Children's HospitalDepartment of Pediatrics, Division of NeonatologyDr. Molewaterplein 60RotterdamNetherlands
| | - Bronagh Blackwood
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7LB
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18
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Sward KA, Newth CJL. Computerized Decision Support Systems for Mechanical Ventilation in Children. J Pediatr Intensive Care 2015; 5:95-100. [PMID: 31110892 DOI: 10.1055/s-0035-1568161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/10/2015] [Indexed: 10/22/2022] Open
Abstract
Mechanical ventilation is an effective treatment in the ICU but can have significant adverse effects. Approaches from adult research have been adopted in pediatric critical care despite known differences in respiratory physiology and ICU processes. There continues to be considerable variation in how ventilators are managed. Computerized decision support systems implement explicit protocols, and are designed to make mechanical ventilation management safer, more consistent, and more lung protective. Variable results and low or unknown compliance with protocols and CDSS tools have been reported. To date, there has been limited research regarding CDSS for mechanical ventilation in children.
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Affiliation(s)
- Katherine A Sward
- Department of Biomedical Informatics, College of Nursing, University of Utah, Salt Lake City, Utah, United States
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, United States
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Slatore CG, Horeweg N, Jett JR, Midthun DE, Powell CA, Wiener RS, Wisnivesky JP, Gould MK. An Official American Thoracic Society Research Statement: A Research Framework for Pulmonary Nodule Evaluation and Management. Am J Respir Crit Care Med 2015; 192:500-14. [PMID: 26278796 DOI: 10.1164/rccm.201506-1082st] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pulmonary nodules are frequently detected during diagnostic chest imaging and as a result of lung cancer screening. Current guidelines for their evaluation are largely based on low-quality evidence, and patients and clinicians could benefit from more research in this area. METHODS In this research statement from the American Thoracic Society, a multidisciplinary group of clinicians, researchers, and patient advocates reviewed available evidence for pulmonary nodule evaluation, characterized six focus areas to direct future research efforts, and identified fundamental gaps in knowledge and strategies to address them. We did not use formal mechanisms to prioritize one research area over another or to achieve consensus. RESULTS There was widespread agreement that novel tests (including novel imaging tests and biopsy techniques, biomarkers, and prognostic models) may improve diagnostic accuracy for identifying cancerous nodules. Before they are used in clinical practice, however, better evidence is needed to show that they improve more distal outcomes of importance to patients. In addition, the pace of research and the quality of clinical care would be improved by the development of registries that link demographic and nodule characteristics with patient-level outcomes. Methods to share data from registries are also necessary. CONCLUSIONS This statement may help researchers to develop impactful and innovative research projects and enable funders to better judge research proposals. We hope that it will accelerate the pace and increase the efficiency of discovery to improve the quality of care for patients with pulmonary nodules.
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20
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Tume LN, Preston J, Blackwood B. Parents' and young people's involvement in designing a trial of ventilator weaning. Nurs Crit Care 2015; 21:e10-8. [PMID: 26486094 DOI: 10.1111/nicc.12221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/04/2015] [Accepted: 09/05/2015] [Indexed: 01/05/2023]
Abstract
Consulting with users is considered best practice and is highly recommended in designing new trials. As part of our feasibility work, we undertook a consultation exercise with parents, ex-patients and young people prior to designing a trial of protocol-based ventilator weaning. Our aims were to (1) ascertain views on the relevance and importance of the trial; (2) determine the important parent/patient outcome measures; and (3) ascertain views on informed consent in a cluster randomized controlled trial. We conducted audio-recorded face-to-face, telephone and focus group interviews with parents and young people. Data were content analysed to generate information to address our specific consultation objectives. The setting was the north-western region of England. A total of 16 participants were interviewed: 2 parents of paediatric intensive care unit (PICU) survivors; 1 PICU survivor; and 13 young people from the former Medicines for Children Research Network. The trial objectives were deemed important and relevant, and participants considered the most important outcome measure to be the length of time on ventilation. Parents and young people did not consider written informed consent to be a necessary requirement in the context of this trial, rather awareness of unit participation in the trial was important with the opportunity of opting out of data collection. This consultation provided useful, pragmatic insights to inform trial design. We encountered significant challenges in recruiting parents and young people for this consultation exercise, and novel recruitment methods need to be considered for future work in this field. Patient and public involvement is essential to ensure that future trials answer parent-relevant questions and have meaningful outcome measures, as well as involving parents and young people in the general development of health care services.
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Affiliation(s)
- Lyvonne N Tume
- PICU and Children's Nursing Research Unit, Alder Hey Children's NHS FT, Liverpool, UK.,School of Health, University of Central Lancashire, Preston, UK
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Blackwood B, Ringrow S, Clarke M, Marshall J, Rose L, Williamson P, McAuley D. Core Outcomes in Ventilation Trials (COVenT): protocol for a core outcome set using a Delphi survey with a nested randomised trial and observational cohort study. Trials 2015; 16:368. [PMID: 26289560 PMCID: PMC4545990 DOI: 10.1186/s13063-015-0905-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/07/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among clinical trials of interventions that aim to modify time spent on mechanical ventilation for critically ill patients there is considerable inconsistency in chosen outcomes and how they are measured. The Core Outcomes in Ventilation Trials (COVenT) study aims to develop a set of core outcomes for use in future ventilation trials in mechanically ventilated adults and children. METHODS/DESIGN We will use a mixed methods approach that incorporates a randomised trial nested within a Delphi study and a consensus meeting. Additionally, we will conduct an observational cohort study to evaluate uptake of the core outcome set in published studies at 5 and 10 years following core outcome set publication. The three-round online Delphi study will use a list of outcomes that have been reported previously in a review of ventilation trials. The Delphi panel will include a range of stakeholder groups including patient support groups. The panel will be randomised to one of three feedback methods to assess the impact of the feedback mechanism on subsequent ranking of outcomes. A final consensus meeting will be held with stakeholder representatives to review outcomes. DISCUSSION The COVenT study aims to develop a core outcome set for ventilation trials in critical care, explore the best Delphi feedback mechanism for achieving consensus and determine if participation increases use of the core outcome set in the long term.
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Affiliation(s)
- Bronagh Blackwood
- Centre for Infection and Immunity, Queen's University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7AE, Northern Ireland.
| | - Suzanne Ringrow
- Centre for Infection and Immunity, Queen's University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7AE, Northern Ireland.
| | - Mike Clarke
- Northern Ireland Network for Trials Methodology Research, Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Block B, Royal Victoria Hospital, Belfast, BT12 6BA, Northern Ireland.
| | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
| | - Louise Rose
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada. .,Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. .,Provincial Centre of Weaning Excellence, Toronto East General Hospital, Toronto, ON, Canada. .,West Park Healthcare Centre, Toronto, ON, Canada.
| | - Paula Williamson
- Department of Biostatistics, University of Liverpool, Shelley's Cottage, Brownlow Street, Liverpool, L69 3GS, UK.
| | - Danny McAuley
- Centre for Infection and Immunity, Queen's University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7AE, Northern Ireland. .,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, Northern Ireland.
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Blackwood B, Tume L. The implausibility of 'usual care' in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK). Trials 2015; 16:325. [PMID: 26228836 PMCID: PMC4520209 DOI: 10.1186/s13063-015-0846-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/02/2015] [Indexed: 01/08/2023] Open
Abstract
Background The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.
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Affiliation(s)
- Bronagh Blackwood
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, University Road, Belfast, BT7 1NN, Northern Ireland, UK.
| | - Lyvonne Tume
- School of Health, PICU, Alder Hey Hospital, Eaton Road, Liverpool, Merseyside, L12 2AP, UK. .,University of Central Lancashire, Fylde Road, Preston, Lancashire, PR1 2HE, UK.
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Jordan J, Rose L, Dainty KN, Noyes J, Blackwood B. Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011812] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Taniguchi C, Victor ES, Pieri T, Henn R, Santana C, Giovanetti E, Saghabi C, Timenetsky K, Caserta Eid R, Silva E, Matos GFJ, Schettino GPP, Barbas CSV. Smart Care™ versus respiratory physiotherapy-driven manual weaning for critically ill adult patients: a randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:246. [PMID: 26580673 PMCID: PMC4511442 DOI: 10.1186/s13054-015-0978-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/05/2015] [Indexed: 11/10/2022]
Abstract
Introduction A recent meta-analysis showed that weaning with SmartCare™ (Dräger, Lübeck, Germany) significantly decreased weaning time in critically ill patients. However, its utility compared with respiratory physiotherapist–protocolized weaning is still a matter of debate. We hypothesized that weaning with SmartCare™ would be as effective as respiratory physiotherapy–driven weaning in critically ill patients. Methods Adult critically ill patients mechanically ventilated for more than 24 hours in the adult intensive care unit of the Albert Einstein Hospital, São Paulo, Brazil, were randomly assigned to be weaned either by progressive discontinuation of pressure support ventilation (PSV) with SmartCare™. Demographic data, respiratory function parameters, level of PSV, tidal volume (VT), positive end-expiratory pressure (PEEP), inspired oxygen fraction (FiO2), peripheral oxygen saturation (SpO2), end-tidal carbon dioxide concentration (EtCO2) and airway occlusion pressure at 0.1 second (P0.1) were recorded at the beginning of the weaning process and before extubation. Mechanical ventilation time, weaning duration and rate of extubation failure were compared. Results Seventy patients were enrolled 35 in each group. There was no difference between the two groups concerning age, sex or diagnosis at study entry. There was no difference in maximal inspiratory pressure, maximal expiratory pressure, forced vital capacity or rapid shallow breathing index at the beginning of the weaning trial. PEEP, VT, FiO2, SpO2, respiratory rate, EtCO2 and P0.1 were similar between the two groups, but PSV was not (median: 8 vs. 10 cmH2O; p =0.007). When the patients were ready for extubation, PSV (8 vs. 5 cmH2O; p =0.015) and PEEP (8 vs. 5 cmH2O; p <0.001) were significantly higher in the respiratory physiotherapy–driven weaning group. Total duration of mechanical ventilation (3.5 [2.0–7.3] days vs. 4.1 [2.7-7.1] days; p =0.467) and extubation failure (2 vs. 2; p =1.00) were similar between the two groups. Weaning duration was shorter in the respiratory physiotherapy–driven weaning group (60 [50–80] minutes vs. 110 [80–130] minutes; p <0.001). Conclusion A respiratory physiotherapy–driven weaning protocol can decrease weaning time compared with an automatic system, as it takes into account individual weaning difficulties. Trial registration Clinicaltrials.gov Identifier: NCT02122016. Date of Registration: 27 August 2013.
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Affiliation(s)
- Corinne Taniguchi
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Elivane S Victor
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Talita Pieri
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Renata Henn
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Carolina Santana
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Erica Giovanetti
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Cilene Saghabi
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Karina Timenetsky
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Raquel Caserta Eid
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Eliezer Silva
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Gustavo F J Matos
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Guilherme P P Schettino
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil.
| | - Carmen S V Barbas
- Adult ICU, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, 5 andar, São Paulo, SP, CEP:05652-900, Brazil. .,Respiratory ICU, University of São Paulo Medical School, Avenida Dr Eneas de Carvalho Aguiar, 255, 6 andar, São Paulo, CEP: 05403-000, Brazil.
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Shalish W, Anna GMS. The use of mechanical ventilation protocols in Canadian neonatal intensive care units. Paediatr Child Health 2015; 20:e13-9. [PMID: 26038643 DOI: 10.1093/pch/20.4.e13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To identify the proportion of Canadian neonatal intensive care units with existing mechanical ventilation protocols and to determine the characteristics and respiratory care practices of units that have adopted such protocols. METHODS A structured survey including 36 questions about mechanical ventilation protocols and respiratory care practices was mailed to the medical directors of all tertiary care neonatal units in Canada and circulated between December 2012 and March 2013. RESULTS Twenty-four of 32 units responded to the survey (75%). Of the respondents, 91% were medical directors and 71% worked in university hospitals. Nine units (38%) had at least one type of mechanical ventilation protocol, most commonly for the acute and weaning phases. Units with pre-existing protocols were more commonly university-affiliated and had higher ratios of ventilated patients to physicians or respiratory therapists, although this did not reach statistical significance. The presence of a mechanical ventilation protocol was highly correlated with the coexistence of a protocol for noninvasive ventilation (P<0.001, OR 4.5 [95% CI 1.3 to 15.3]). There were overall wide variations in ventilation practices across units. However, units with mechanical ventilation protocols were significantly more likely to extubate neonates from the assist control mode (P=0.039, OR 8.25 [95% CI 1.2 to 59]). CONCLUSION Despite the lack of compelling evidence to support their use in neonates, a considerable number of Canadian neonatal intensive care units have adopted mechanical ventilation protocols. More research is needed to better understand their role in reducing unnecessary variations in practice and improving short- and long-term outcomes.
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Affiliation(s)
- Wissam Shalish
- Division of Neonatology, Montreal Children's Hospital, McGill University, Montreal, Quebec
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Solberg MT, Hansen TWR, Bjørk IT. The need for predictability in coordination of ventilator treatment of newborn infants--a qualitative study. Intensive Crit Care Nurs 2015; 31:205-12. [PMID: 25617081 DOI: 10.1016/j.iccn.2014.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 10/27/2014] [Accepted: 12/28/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVE New strategies for interprofessional collaboration are needed to achieve best practice in the care of ventilated newborns. This study explores what physicians and nurses believe to be important to improve collaboration during ventilator treatment. METHODS Qualitative data collected from one focus group were analysed using Gittell's theory of relational coordination. RESULTS To optimise communication about and coordination of ventilator treatment, six strategies were needed: (1) a pathway toward the goal for each newborn, (2) regular meetings, (3) accurate communication following an established pattern in the rounds conference, (4) collaboration to improve interprofessional level of knowledge, (5) courage to communicate one's own point of view, and (6) flexible responsibility in extubation situations. CONCLUSION By identifying weak areas in collaboration, nurses and physicians were inspired to suggest and discuss concrete improvements of work practices in the neonatal intensive care unit. Nurses and physicians can coordinate ventilator treatment by using a pathway and at the same time enhance nurses' involvement and responsibility in order to increase the flexibility of job boundaries, allowing the professions to cover for each other's work.
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Affiliation(s)
- Marianne Trygg Solberg
- Lovisenberg Deaconal University College, Oslo, Norway; Department of Nursing Science, Faculty of Medicine, University of Oslo, Nedre Ullevål 9, Stjerneblokka, 0850 Oslo, Norway.
| | - Thor Willy R Hansen
- Department of Neonatal Intensive Care, Women's and Children's Division, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Ida Torunn Bjørk
- Department of Nursing Science, Faculty of Medicine, University of Oslo, Nedre Ullevål 9, Stjerneblokka, 0850 Oslo, Norway.
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Abstract
PURPOSE OF REVIEW Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology. RECENT FINDINGS Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking. SUMMARY Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.
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Affiliation(s)
- Joanna Hart
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott D. Halpern
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Epidemiology and Biostatistics and Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Blackwood B, Burns KEA, Cardwell CR, 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; 2014:CD006904. [PMID: 25375085 PMCID: PMC6517015 DOI: 10.1002/14651858.cd006904.pub3] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND This is an update of a review last published in Issue 5, 2010, of The Cochrane Library. Reducing weaning time is desirable in minimizing potential complications from mechanical ventilation. Standardized weaning protocols are purported to reduce time spent on mechanical ventilation. However, evidence supporting their use in clinical practice is inconsistent. OBJECTIVES The first objective of this review was to compare the total duration of mechanical ventilation of critically ill adults who were weaned using protocols versus usual (non-protocolized) practice.The second objective was to ascertain differences between protocolized and non-protocolized weaning in outcomes measuring weaning duration, harm (adverse events) and resource use (intensive care unit (ICU) and hospital length of stay, cost).The third objective was to explore, using subgroup analyses, variations in outcomes by type of ICU, type of protocol and approach to delivering the protocol (professional-led or computer-driven). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2014), MEDLINE (1950 to January 2014), EMBASE (1988 to January 2014), CINAHL (1937 to January 2014), LILACS (1982 to January 2014), ISI Web of Science and ISI Conference Proceedings (1970 to February 2014), and reference lists of articles. We did not apply language restrictions. The original search was performed in January 2010 and updated in January 2014. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs of protocolized weaning versus non-protocolized weaning from mechanical ventilation in critically ill adults. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We performed a priori subgroup and sensitivity analyses. We contacted study authors for additional information. MAIN RESULTS We included 17 trials (with 2434 patients) in this updated review. The original review included 11 trials. The total geometric mean duration of mechanical ventilation in the protocolized weaning group was on average reduced by 26% compared with the usual care group (N = 14 trials, 95% confidence interval (CI) 13% to 37%, P = 0.0002). Reductions were most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. Weaning duration was reduced by 70% (N = 8 trials, 95% CI 27% to 88%, P = 0.009); and ICU length of stay by 11% (N = 9 trials, 95% CI 3% to 19%, P = 0.01). There was significant heterogeneity among studies for total duration of mechanical ventilation (I(2) = 67%, P < 0.0001) and weaning duration (I(2) = 97%, P < 0.00001), which could not be explained by subgroup analyses based on type of unit or type of approach. AUTHORS' CONCLUSIONS There is evidence of reduced duration of mechanical ventilation, weaning duration and ICU length of stay with use of standardized weaning protocols. Reductions are most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. However, significant heterogeneity among studies indicates caution in generalizing results. Some study authors suggest that organizational context may influence outcomes, however these factors were not considered in all included studies and could not be evaluated. Future trials should consider an evaluation of the process of intervention delivery to distinguish between intervention and implementation effects. There is an important need for further development and research in the neurosurgical population.
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Affiliation(s)
- Bronagh Blackwood
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7LB
| | - Karen EA Burns
- Keenan Research Centre/Li Ka Shing Knowledge Institute, University of TorontoInterdepartmental Division of Critical Care30 Bond Street, Rm 4‐045 Queen WingTorontoONCanadaM5B 1WB
| | - Chris R Cardwell
- Queen's University BelfastCentre for Public HealthSchool of MedicineDentistry and Biomedical SciencesBelfastNorthern IrelandUKBT12 6BJ
| | - Peter O'Halloran
- Queen's University Belfast, Medical Biology CentreSchool of Nursing & Midwifery97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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Does intraoperative ulinastatin improve postoperative clinical outcomes in patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. BIOMED RESEARCH INTERNATIONAL 2014; 2014:630835. [PMID: 24734237 PMCID: PMC3964764 DOI: 10.1155/2014/630835] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/04/2013] [Accepted: 12/02/2013] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The systematic meta-analysis of randomized controlled trials (RCTs) evaluated the effects of intraoperative ulinastatin on early-postoperative recovery in patients undergoing cardiac surgery. METHODS RCTs comparing intraoperative ulinastatin with placebo in cardiac surgery were searched through PubMed, Cochrane databases, Medline, SinoMed, and the China National Knowledge Infrastructure (1966 to May 20th, 2013). The primary endpoints included hospital mortality, postoperative complication rate, length of stay in intensive care unit, and extubation time. The physiological and biochemical parameters illustrating postoperative cardiac and pulmonary function as well as inflammation response were considered as secondary endpoints. RESULTS Fifteen RCTs (509 patients) met the inclusion criteria. Ulinastatin did not affect hospital mortality, postoperative complication rate, or ICU length of stay but reduced extubation time. Ulinastatin also increased the oxygenation index on postoperative day 1 and reduced the plasma level of cardiac troponin-I. Additionally, ulinastatin inhibited the increased level of tumor necrosis factor-alpha, polymorphonuclear neutrophil elastase, interleukin-6, and interleukin-8 associated with cardiac surgery. CONCLUSION Ulinastatin may be of value for the inhibition of postoperative increased inflammatory agents and most likely provided pulmonary protective effects in cardiac surgery. However, larger adequately powered RCTs are required to define the clinical effect of ulinastatin on postoperative outcomes in cardiac surgery.
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