Mechanical ventilation weaning protocol improves medical adherence and results

Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator

Background and purpose

Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists).

Methods

A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning.

Result

This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions).

Conclusion

This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards.

How to cite this article

Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.

Assessment of the Safety and Efficiency of a Preperitoneal Continuous Infusion Using Bupivacaine after Abdominal Laparotomy in Digestive Carcinology

The purpose of this paper is to evaluate the safety and efficacy of continuous preperitoneal wound infiltration using bupivacaine after abdominal laparotomy in relation to plasma bupivacaine concentration and visual analog scale. Our study was performed on 60 adult patients with digestive cancer, operated at laparotomy, and randomized into two groups: bupivacaine and saline groups. The wound infiltration was through a multiperforated catheter along the scar. For the bupivacaine group, 0.25% bupivacaine was used; however, for the saline group, only saline (0.9%) was infiltrated. The pain was assessed by using the visual analog scale (VAS) in both groups. Plasma bupivacaine concentration was measured by high-performance liquid chromatography. The bupivacaine group had significantly lower postoperative morphine consumption and lower postoperative pain than the saline group (P < 0.0001). The majority of patients in the bupivacaine group had significant relief with the VAS scores of less than 3/10 cm at rest and 6/10 cm on mobilization. However, for the saline group, the VAS scores were higher than 6/10 cm either at rest or with mobilization. There was no clinical sign of toxicity and no technical complications for the bupivacaine group. Only eleven patients required morphine in this group, but the majority of patients received morphine at different doses in the saline group. Plasma bupivacaine was at very low concentrations. Overall, the current study has confirmed that continuous preperitoneal wound infiltration as postoperative analgesia is a simple, effective, and safe technique. It allows decreasing of morphine consumption and subsequently canceling their side effects.

Artificial Intelligence-Based Methods for Precision Cardiovascular Medicine

Precision medicine has the potential to revolutionize the way cardiovascular diseases are diagnosed, predicted, and treated by tailoring treatment strategies to the individual characteristics of each patient. Artificial intelligence (AI) has recently emerged as a promising tool for improving the accuracy and efficiency of precision cardiovascular medicine. In this scoping review, we aimed to identify and summarize the current state of the literature on the use of AI in precision cardiovascular medicine. A comprehensive search of electronic databases, including Scopes, Google Scholar, and PubMed, was conducted to identify relevant studies. After applying inclusion and exclusion criteria, a total of 28 studies were included in the review. We found that AI is being increasingly applied in various areas of cardiovascular medicine, including the diagnosis, prognosis of cardiovascular diseases, risk prediction and stratification, and treatment planning. As a result, most of these studies focused on prediction (50%), followed by diagnosis (21%), phenotyping (14%), and risk stratification (14%). A variety of machine learning models were utilized in these studies, with logistic regression being the most used (36%), followed by random forest (32%), support vector machine (25%), and deep learning models such as neural networks (18%). Other models, such as hierarchical clustering (11%), Cox regression (11%), and natural language processing (4%), were also utilized. The data sources used in these studies included electronic health records (79%), imaging data (43%), and omics data (4%). We found that AI is being increasingly applied in various areas of cardiovascular medicine, including the diagnosis, prognosis of cardiovascular diseases, risk prediction and stratification, and treatment planning. The results of the review showed that AI has the potential to improve the performance of cardiovascular disease diagnosis and prognosis, as well as to identify individuals at high risk of developing cardiovascular diseases. However, further research is needed to fully evaluate the clinical utility and effectiveness of AI-based approaches in precision cardiovascular medicine. Overall, our review provided a comprehensive overview of the current state of knowledge in the field of AI-based methods for precision cardiovascular medicine and offered new insights for researchers interested in this research area.

Type-1 α-Fe2O3/TiO2 photocatalytic degradation of tetracycline from wastewater using CCD-based RSM optimization

Antibiotic pollution in water is a growing threat to public health and the environment, leading to the spread of antimicrobial-resistant bacteria. While photocatalysis has emerged as a promising technology for removing antibiotics from water, its limited efficiency in the visible light range remains a challenge. In this study, we present a novel method for the photocatalytic degradation of tetracycline, the second most commonly used antibiotic worldwide, using α-Fe₂O₃/TiO₂ nanocomposites synthesized via rapid sonochemical and wet impregnation methods. The nanocomposites were characterised and tested using a range of techniques, including BET, TEM, FTIR, XRD, FESEM, EDS, and UV-Vis. The RSM-CCD method was also used to optimize the degradation process by varying four key variables (initial concentration, photocatalyst quantity, irradiation time, and pH). The resulting optimized conditions achieved a remarkable degradation rate of 97.5%. We also investigated the mechanism of photodegradation and the reusability of the photocatalysts, as well as the effect of light source operating conditions. Overall, the results demonstrate the effectiveness of the proposed approach in degrading tetracycline in water and suggest that it may be a promising, eco-friendly technology for the treatment of water contaminated with antibiotics.

The knowledge map of gender equality in cross-cultural communication: A bibliometric approach

It is urgent to solve the gender issues in global cross-cultural communication. Countries worldwide should responsible for achieving gender equality (SDG5). Hence, the study aims to portray the knowledge map of the gender issue in intercultural communication to explore the research status and future potential. The study used CiteSpace to conduct a bibliometric method within 2728 English articles on cross-cultural communication and gender equality topics from the Web of Science (WoS). After cluster analysis and time series analysis, this study emphasis the continued attention and increasing trend of publications and elaborates on the critical authors, institutions, and countries of research on this issue. The results introduced Putnick as the dominant author contributed to the topic. The University of Oxford ranked the top1 in the institution cooperation relationship. Europe countries and the United States have made major contributions and influenced Asian and African countries, such as Burkina Faso, North Macedonia, and Kosovo. Gender issues in Asia and Africa are getting much attention. The keyword clusters formed by the authors' cooperation include gender equality, life satisfaction, network analysis, and alcohol use. In addition, childbirth technology, patient safety competition, life satisfaction, capital safety, and sex difference are the key word clustering results of institutional cooperation. At the level of national cooperation, internet addition, risk sexual behavior, covid-19 pandemic and suicidal idea have become the main keywords The results of keyword cluster analysis show that gender role attribute, psychological properties, dating policy, professional fulfillment, and entrepreneurial intention have become the main topics in the current research. The research frontier analysis reflects the importance of gender, women and health. The research on self-efficacy, diversity, image, life satisfaction and choice has become the trend of cross-cultural communication and gender issues. Furthermore, abundant achievement emerged in the subjects of Psychology, Education, Sociology, and Business economics. Geography, Language and Literature, Medicine, and Health industries also have been highly influential in recent years. Therefore, the conclusion suggests the studies of gender issues can be further deepened into more authors, areas, subject and other multiple cooperation sectors.

Biomarker-based approach to determine etiology and severity of pulmonary hypertension: Focus on microRNA

Pulmonary arterial hypertension (PAH) is characterized by remodeling of the pulmonary arteries, and defined by elevated pulmonary arterial pressure, measured during right heart catheterization. There are three main challenges to the diagnostic and therapeutic process of patients with PAH. First, it is difficult to differentiate particular PAH etiology. Second, invasive diagnostic is required to precisely determine the severity of PAH, and thus to qualify patients for an appropriate treatment. Third, the results of treatment of PAH are unpredictable and remain unsatisfactory. MicroRNAs (miRNAs) are small non-coding RNAs that regulate post transcriptional gene-expression. Their role as a prognostic, and diagnostic biomarkers in many different diseases have been studied in recent years. MiRNAs are promising novel biomarkers in PAH due to their activity in various molecular pathways and processes underlying PAH. Lack of biomarkers to differentiate between particular PAH etiology and evaluate the severity of PAH, as well as paucity of therapeutic targets in PAH open a new field for the possibility to use miRNAs in these applications. In our article, we discuss the potential of miRNAs use as diagnostic tools, prognostic biomarkers and therapeutic targets in PAH.

Clinical Nurse Specialist Practice: Impact on Improving Sedation Practice in Critical Care

PURPOSE/OBJECTIVES

Prolonged mechanical ventilation results from deeper levels of sedation. This may lead to impaired respiratory muscle functioning that develops into pneumonia, increases antibiotic use, increases delirium risk, and increases length of hospitalization. A trauma and surgical intensive care unit interdisciplinary team conducted a quality improvement project to lighten sedation levels and shorten mechanical ventilation time.

DESCRIPTION OF THE PROJECT

The project included multimodal elements to improve sedation practice. Standardizing the spontaneous awakening trial algorithm, creation of electronic health record tools, integration of sedation practices into daily rounds, and focused education for nursing were implemented in April 2021 through October 2021.

OUTCOME

A reduction of median hours spent on mechanical ventilation was achieved. Mechanical ventilation hours decreased from 77 to 70. Richmond Agitation Sedation Scale levels improved from a median of -2 to -1, and daily spontaneous awakening trials increased from 10% to 27% completed.

CONCLUSION

The quality improvement project demonstrated that, with increased daily spontaneous awakening trials and lighter sedation levels, the time patients spent on mechanical ventilation was shortened. There was no increase to self-extubation with lighter sedations levels. Shorter time on mechanical ventilation can reduce patient harm risks.

Association between fluid intake and extubation failure in intensive care unit patients with negative fluid balance: a retrospective observational study

BACKGROUND

Negative fluid balance (NFB) is associated with reduced extubation failure. However, whether achieving more NFB can further improve extubation outcome has not been investigated. This study aimed to investigate whether more NFB and restricted fluid intake were associated with extubation success.

METHODS

We performed a retrospective study of adult patients with mechanical ventilation (MV) admitted to Medical Information Mart for Intensive Care (MIMIC-III) from 2001 to 2012. Patients with duration of MV over 24 hours and NFB within 24 hours before extubation were included for analysis. The primary outcome was extubation failure, defined as reintubation within 72 hours after extubation. Association between fluid balance or fluid intake and extubation outcome were investigated with multivariable logistic models.

RESULTS

A total of 3433 extubation events were recorded. 1803 with NFB were included for the final analysis, of which 201(11.1%) were extubation failure. Compared with slight NFB (- 20 to 0 ml/kg), more NFB were not associated improved extubation outcome. Compared with moderate fluid intake (30 to 60 ml/kg), lower (< 30 ml/kg, OR 0.75, 95% CI [0.54, 1.05], p = 0.088) or higher (> 60 ml/kg, OR 1.63, 95% CI [0.73, 3.35], p = 0.206) fluid intake was not associated with extubation outcome. Duration of MV, chronic obstructive pulmonary disease (COPD), hypercapnia, use of diuretics, and SAPSIIscore were associated with extubation failure.

CONCLUSIONS

More NFB or restricted fluid intake were not associated with reduced extubation failure in patients with NFB. However, for COPD patients, restricted fluid intake was associated with extubation success.

Use of a Multidisciplinary Mechanical Ventilation Weaning Protocol to Improve Patient Outcomes and Empower Staff in a Medical Intensive Care Unit

BACKGROUND

Prolonged duration of mechanical ventilation is associated with higher mortality and increased patient complications; conventional physician-directed weaning methods are highly variable and permit significant time that weaning is inefficient and ineffective.

OBJECTIVES

The primary objective of this quality improvement project was to implement a registered nurse (RN)- and respiratory therapist (RT)-driven mechanical ventilation weaning protocol in a medical intensive care unit (ICU) at a tertiary care academic medical center.

METHODS

This quality improvement project used a quasi-experimental design with a retrospective usual care group who underwent physician-directed (conventional) weaning (n = 51) and a prospective intervention group who underwent protocol-directed weaning (n = 54). Outcomes included duration of mechanical ventilation, ICU length of stay, reintubation rates, and RN and RT satisfaction with the weaning protocol.

RESULTS

Patients in the RN- and RT-driven mechanical ventilation weaning protocol group had significantly lower duration of mechanical ventilation (74 vs 152 hours; P = .002) and ICU length of stay (6.7 vs 10.2 days; P = .031). There was no significant difference in reintubation rates between groups. Staff surveys indicate that both RN and RTs were satisfied with the process change.

DISCUSSION

Implementation of a multidisciplinary mechanical ventilation weaning protocol is a safe and effective way to improve patient outcomes and empower ICU staff.

Intelligent decision support with machine learning for efficient management of mechanical ventilation in the intensive care unit - A critical overview

BACKGROUND

Effective management of Mechanical Ventilation (MV) is vital for reducing morbidity, mortality, and cost of healthcare.

OBJECTIVE

This study aims to synthesize evidence for effective MV management through Intelligent decision support (IDS) with Machine Learning (ML).

METHOD

Databases that include EBSCO, IEEEXplore, Google Scholar, SCOPUS, and the Web of Science were systematically searched to identify studies on IDS for effective MV management regarding Tidal Volume (TV), asynchrony, weaning, and other outcomes such as the risk of Prolonged Mechanical ventilation (PMV). The quality of the articles identified was assessed with a modified Joanna Briggs Institute (JBI) critical appraisal checklist for cross-sessional research.

RESULTS

A total of 26 articles were identified for the study that has IDS for TV (n = 2, 7.8 %), asynchrony (n = 9, 34.6 %), weaning (n = 12, 46.2 %), and others (n = 3, 11.5 %). It was affirmed that implementing IDS in MV management will enhance seamless ICU patient management following the utilization of various Machine Learning (ML) algorithms in decision support. The studies relied on (n = 14) ML algorithms to predict the TV, asynchrony, weaning, risk of PMV and Positive End-Expiratory Pressure (PEEP) changes of 11-20262 ICU patients records with model inputs ranging from (n = 1) for timeseries analysis of TV to (n = 47) for weaning prediction.

CONCLUSIONS

The small data size, poor study design, and result reporting, with the heterogeneity of techniques used in the various studies, hampered the development of a unified approach for managing MV efficiency in TV monitoring, asynchrony, and weaning predictions. Notwithstanding, the ensemble model was able to predict TV, asynchrony, and weaning to a higher accuracy than the other algorithms.

Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness

There is a growing population of children with prolonged intensive care unit (ICU) hospitalization. These children with chronic critical illness (CCI) have a high health care utilization. Emerging data suggest a mismatch between the ICU acute care models and the daily care needs of these patients. Clinicians and parents report that the frequent treatment alterations typical for ICU care may be interrupting and jeopardizing the slow recoveries typical for children with CCI. These frequent treatment titrations could therefore be prolonging ICU stays even further. The aim of this study is to evaluate and summarize existing literature regarding pace and consistency of ICU care for patients with CCI. We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (of September 2018). PubMed (biomedical and life sciences literature), Excerpta Medica database (EMBASE), and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for English-language studies with data about CCI, care models, and pacing of clinical management. Four unique papers were identified. Our most important finding was that quality data on chronic ICU management, particularly for children, is sparse. All papers in this review confirmed the unique needs of chronic patients, particularly related to respiratory management, which is a common driver of ICU length of stay. Taken together, the papers support the hypothesis that protocols to reduce interdisciplinary management variability and to allow for slower management pacing should be studied for their impact on patient and health system outcomes. Optimizing value in ICU care requires mapping of resources to patient needs, particularly for patients with the most intense resource utilization. For children with CCI, parents and clinicians report that rapid treatment changes undermine recovery and prolong ICU stays. This review highlights the lack of quality pediatric research in this area and supports further investigation of a "slow and steady" approach to ICU management for children with CCI.

The effect of aromatherapy with rose and lavender on anxiety, surgical site pain, and extubation time after open-heart surgery: A double-center randomized controlled trial

To determine the effect of aromatherapy with rose and lavender on the patient outcomes after open-heart surgery (OHS). In the clinical trial, patients were randomized to four groups. One group received routine care, the placebo group received a cotton swab soaked in water and the other two groups received either a cotton swab containing three drops of rose or lavender essence (0.2 ml). A total of 160 patients were randomized into four groups. Intergroup anxiety was not significantly different; however, the reciprocal time-group effect was significant among the four groups. The extubation time was significant among the four groups which related to rose essence group compared with the control group (p < .001) and placebo group (p = .029). The surgical site pain was significant in the rose essence and lavender groups compared to the control group. Aromatherapy can reduce extubation time, surgical site pain severity, and anxiety in patients undergoing OHS.

Use of excessive supplemental oxygen in mechanically ventilated patients is based on unit culture. A multiple-methods study in a regional intensive care unit

BACKGROUND

Administration of supplemental oxygen is widely used in the management of critically ill patients; however, there is evidence that excessive supplemental oxygen exposure is associated with increased mortality. There is limited research evaluating what factors clinicians take into consideration when managing oxygenation in critically ill adults.

OBJECTIVES

The purpose of this study was to explore intensive care unit (ICU) clinicians' experience and decision-making when managing supplemental oxygen therapy in mechanically ventilated patients in a regional intensive care unit.

METHODS

A multiple-methods observational study that included (i) a cross-sectional ICU staff survey and (ii) focus group discussions with critical care nurses was conducted. Descriptive statistics were used to summarise the key outcomes of the staff survey. Thematic analysis was used to analyse the focus group discussions and open-ended questions on the staff survey. The staff survey was completed by 49 ICU clinicians, and 11 critical care nurses participated in the two focus group discussions.

RESULTS

Survey data showed that staff acknowledged the problem of excessive oxygen exposure; 79.6% (n = 39) reported that the minimum acceptable fraction of inspired oxygen for mechanically ventilated patients was 0.3. The majority (89.8%, n = 44) reported that there was an interdisciplinary approach to decision-making in the unit. Two major themes were chosen from the focus group discussions and staff survey data: (i) Decision-making is based on unit culture rather than evidence and (ii) the process of weaning is driven by interdisciplinary team collaboration. Participants acknowledged that there needed to be a culture change from a liberal approach to oxygen therapy.

CONCLUSIONS

Although participants acknowledged the adverse consequences of excessive oxygen use, achieving oxygenation targets with the minimum level of supplemental oxygen was not a key focus of care. The findings highlight the need to develop and evaluate evidence-based protocols to support a conservative approach to supplemental oxygen management.

Prognostic factors associated with mortality in mechanically ventilated patients in the intensive care unit: A single-center, retrospective cohort study of 905 patients

Data on outcomes of patients receiving mechanical ventilation (MV) in China are scarce.To investigate factors associated with the prognosis of patients given MV in the intensive care unit (ICU).A 12-year (January 1, 2006-December 31, 2017) retrospective cohort study.ICU of Beijing Geriatric Hospital, China.A total of 905 patients aged ≥16 years given MV during the study period.None.Among 905 patients included (610 men; median age, 78 years; Acute Physiology and Chronic Health Evaluation [APACHE]-II score, 27.3 ± 8.9), 585 survived (388 men; median age, 77 years; average APACHE-II score, 25.6 ± 8.4), and 320 died in the ICU (222 men; median age, 78 years; APACHE-II score, 30.6 ± 8.9). All-cause ICU mortality was 35.4%. In patients aged <65 years, factors associated with ICU mortality were APACHE-II score (odds ratio [OR], 1.108; 95% confidence interval [95% CI], 1.021-1.202; P = .014), nosocomial infection (OR, 6.618; 95% CI, 1.065-41.113; P = .043), acute kidney injury (OR, 17.302; 95% CI, 2.728-109.735; P = .002), invasive hemodynamic monitoring (OR, 10.051; 95% CI, 1.362-74.191; P = .024), MV for cardiopulmonary resuscitation (OR, 0.122; 95% CI, 0.016-0.924; P = .042), duration of MV (OR, 0.993; 95% CI, 0.988-0.998; P = .008), successful weaning from MV (OR, 0.012; 95% CI, 0.002-0.066; P < .001), and renal replacement therapy (OR, 0.039; 95% CI, 0.005-0.324; P = .003). In patients aged ≥65 years, factors associated with mortality were APACHE-II score (OR, 1.062; 95% CI, 1.030-1.096; P < .001), nosocomial infection (OR, 2.427; 95% CI, 1.359-4.334; P = .003), septic shock (OR, 2.017; 95% CI, 1.153-3.529; P = .014), blood transfusion (OR, 1.939; 95% CI, 1.174-3.202; P = .010), duration of MV (OR, 0.999; 95% CI, 0.999-1.000; P = .043), and successful weaning from MV (OR, 0.027; 95% CI, 0.015-0.047; P < .001).APACHE-II score, successful weaning, and nosocomial infection in the ICU are independently associated with the prognosis of patients given MV in the ICU.

Feasibility of a protocol to wean patients from continuous renal replacement therapy: A retrospective pilot observation

PURPOSE

To evaluate the feasibility of a protocol-based algorithm to wean acute kidney injury (AKI) patients from continuous renal replacement therapy (CRRT).

METHODS

The protocol was introduced on one of two similarly equipped ICUs, while on the other (reference) ICU, CRRT discontinuation was based on clinical judgement. Patients were allocated to either ICU and were subjected to physician- or protocol-directed weaning, respectively. According to the algorithm, periodical withdrawal trials (WTs) were mandatory. Interventions were recommended (administration of diuretics, fluid, vasopressors, inotropes, or human albumin) to achieve specific goals (sufficient urine output, balanced fluid status, adequate renal perfusion pressure, optimal oxygen delivery, normoalbuminemia). Clearly stated criteria defined when to abort a WT and to resume RRT for one cycle, followed by another WT.

RESULTS

Urine output and S_cvO₂ during WTs were higher with protocol-directed weaning, as well as the amount of administered fluids. WT abort ratio was 48% with a tendency to prolonged WT duration, compared to 64% in the reference patients. No relevant adverse side effects were observed.

CONCLUSION

Our data show the feasibility of a structured approach to wean AKI patients from RRT that bundles established interventions and brings the weaning into the physician's focus.

The patient needing prolonged mechanical ventilation: a narrative review

BACKGROUND

Progress in management has improved hospital mortality of patients admitted to the intensive care units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients, caregivers and health services, as well as high human and financial resources consumption, despite poor long-term outcomes. An effort should be made to improve the management of these patients. This narrative review summarizes the main concepts in this field.

MAIN BODY

There is great variability in terminology and definitions of prolonged mechanical ventilation.There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of protocols, early mobilisation and physiotherapy, specialised weaning units.There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival of these patients.Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised controlled trials on this critical issue. End of life decisions should result from appropriate communication among professionals, patients and surrogates and national legislations should give clear indications.

CONCLUSION

Present medical training of clinicians and locations like traditional intensive care units do not appear enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects of management are needed.