The art and science of predicting patient readiness for weaning from mechanical ventilation

L’autonomie décisionnelle d’infirmières de soins intensifs lors du sevrage de la ventilation mécanique : une analyse de concept

Nurses have a leading role in weaning patients from mechanical ventilation (WMV) given their constant presence and their continuous monitoring. To promote proper WMV, nurses must exercise autonomy and be involved in decision-making. However, in certain care contexts, there is little involvement of nurses. The purpose of this text is to establish the characteristics of the concept of autonomous decision-making applied to nursing during WMV. An analysis of this concept was carried out according to the evolutionary method of Rodgers. The identification of the attributes, antecedents, and consequences made it possible to note ambiguity in the definition of this concept. Nurses use autonomous decision-making for the execution of assigned tasks and when they make decisions according to a pre-prescribed decision-making algorithm. Significant foundations for the decision-making autonomy of critical care nurses during WMV emerged from this analysis : scope of practice, in-depth knowledge of the patient, and commitment to the success of WMV. Participation in interdependent decision-making allows nurses to bring the patient’s perspective into decisions. Avenues of reflection have also emerged, including decisions based on evidence to provide new avenues for autonomous decision-making.

A systematic review of nurse-led weaning protocol for mechanically ventilated adult patients

OBJECTIVES

The aim of this systematic review is to synthesize the current best evidence for the effectiveness of weaning protocols led by nurses compared with usual physician-led care.

BACKGROUND

Protocol-directed weaning has been shown to reduce the duration of mechanical ventilation. Studies have reported that a weaning protocol administered by nurses leads to a reduction in the duration of mechanical ventilation and has a major effect on weaning outcomes. This can have especially positive consequences for critically ill patients.

STUDY DESIGN

Systematic review with meta-analysis.

SEARCH STRATEGY

The databases CINAHL, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched from as far back as the database allowed until January 2016.

INCLUSION AND EXCLUSION CRITERIA

Searches were performed to identify the best available evidence including quantitative studies of nurse-led weaning protocols for mechanically ventilated adult patients. We excluded all studies of weaning protocols implemented by non-nurses and non-invasive mechanical ventilation and studies that addressed patient populations younger than 18 years of age.

RESULTS

The database searches resulted in retrieving 369 articles. Three eligible studies with a total of 532 patients were included in the final review. Pooled data showed a statistically significant difference in favour of the nurse-led weaning protocol for reducing the duration of mechanical ventilation (mean differences = -1.69 days, 95% confidence interval = -3.23 to 0.16), intensive care unit length of stay (mean differences = -2.04 days, 95% confidence interval = -2.57 to -1.52, I²  = 18%, and p = 0.00001); and hospital length of stay (mean differences = -2.9 days, 95% confidence interval = -4.24 to -1.56, I²  = 0%, and p = 0.00001).

CONCLUSION

There is evidence that the use of nurse-led weaning protocols for mechanically ventilated adult patients has a positive impact on weaning outcomes and patient safety.

RELEVANCE TO CLINICAL PRACTICE

This review provides evidence supporting intensive care unit nurses' crucial role and abilities to lead weaning from mechanical ventilation.

Predictive Associations of Music, Anxiety, and Sedative Exposure on Mechanical Ventilation Weaning Trials

BACKGROUND

Weaning from mechanical ventilation requires increased respiratory effort, which can heighten anxiety and later prolong the need for mechanical ventilation.

OBJECTIVES

To examine the predictive associations of music intervention, anxiety, sedative exposure, and patients' characteristics on time to initiation and duration of weaning trials of patients receiving mechanical ventilation.

METHODS

A descriptive, correlational design was used for a secondary analysis of data from a randomized trial. Music listening was defined as self-initiated, patient-directed music via headphones. Anxiety was measured daily with a visual analog scale. Sedative exposure was operationalized as a daily sedation intensity score and a sedative dose frequency. Analyses consisted of descriptive statistics, graphing, survival analysis, Cox proportional hazards regression, and linear regression.

RESULTS

Of 307 patients, 52% were women and 86% were white. Mean age was 59.3 (SD, 14.4) years, mean Acute Physiology and Chronic Health Evaluation III score was 62.9 (SD, 21.6), mean duration of ventilatory support was 8 (range, 1-52) days, and mean stay in the intensive care unit was 18 (range, 2-71) days. Music listening, anxiety levels, and sedative exposure did not influence time to initial weaning trial or duration of trials. Clinical factors of illness severity, days of weaning trials, and tracheostomy placement influenced weaning patterns in this sample.

CONCLUSIONS

Prospective studies of music intervention and other psychophysiological factors during weaning from mechanical ventilation are needed to better understand factors that promote successful weaning.

Holistic Care for Patients During Weaning from Mechanical Ventilation: A Qualitative Study

BACKGROUND

Weaning patients from mechanical ventilation is a complex and highly challenging process. It requires continuity of care, the overall assessment of patients, and a focus on all aspects of patients' needs by critical care nurses.

OBJECTIVES

The aim of the present study was to explore holistic care while patients are being weaned from mechanical ventilation from the perspective of the critical care nurses.

METHODS

The study was carried out in the intensive care units (ICUs) of six hospitals in Ahvaz, Iran, from 2014 to 2015. In this qualitative study, 25 ICU staff including nurses, nurse managers, and nurse educators were selected by means of purposive sampling. Semi-structured interviews were used for data collection. The interview transcripts were then analyzed using qualitative content analysis.

RESULTS

The four main themes that emerged to explain nurses' experiences of holistic care when weaning patients from mechanical ventilation include continuous care, a holistic overview of the patient, promoting human dignity, and the overall development of well-being.

CONCLUSIONS

It was found that avoiding routine pivotal expertise, increasing consciousness of the nonphysical aspects of patients while providing treatment and presenting exclusive care, utilizing experienced ICU nurses, and placing more emphasis on effective communication with patients in order to honor them as human beings can all enhance the holistic quality of care.

Continuous care and patients' basic needs during weaning from mechanical ventilation: A qualitative study

BACKGROUND

Mechanical ventilation is associated with a number of risks and complications. Thus, rapid and safe weaning from mechanical ventilation is of great importance. Weaning is a complex and challenging process, requiring continuous care and knowledge of the patient.

AIMS

The aim of the present study was to describe the continuous care process during weaning as well as to analyse the facilitators and obstacles to the weaning process from start to finish from the perspective of intensive care unit (ICU) staff, particularly nurses.

RESEARCH DESIGN

Twenty-two ICU staff members, including nurses and physicians, and three patients hospitalised in the ICU were enrolled in this qualitative study. Semi-structured interviews were used for data collection and the transcripts were analysed using qualitative content analysis.

FINDINGS

'Continuous care' was found to be the patients' basic need during weaning from mechanical ventilation. Uninterrupted, stable, comprehensive and dynamic care and monitoring with immediate response to all physiological and psychological changes were features of continuous care. The three main themes identified by this study were time spent with the patient, comprehensive supervision and maintenance of the quality of care during shifts.

CONCLUSION

Continuous and constant care should be provided during the weaning process. Such care will help to provide health care staff with a deeper understanding of the patient and his or her continuous changes, leading to a timely and favourable response during weaning. To achieve this goal, skill, communication and organisational changes are essential.

The influence of music during mechanical ventilation and weaning from mechanical ventilation: A review

Mechanical ventilation (MV) causes many distressing symptoms. Weaning, the gradual decrease in ventilator assistance leading to termination of MV, increases respiratory effort, which may exacerbate symptoms and prolong MV. Music, a non-pharmacological intervention without side effects may benefit patients during weaning from mechanical ventilatory support. A narrative review of OVID Medline, PsychINFO, and CINAHL databases was conducted to examine the evidence for the use of music intervention in MV and MV weaning. Music intervention had a positive impact on ventilated patients; 16 quantitative and 2 qualitative studies were identified. Quantitative studies included randomized clinical trials (10), case controls (3), pilot studies (2) and a feasibility study. Evidence supports music as an effective intervention that can lesson symptoms related to MV and promote effective weaning. It has potential to reduce costs and increase patient satisfaction. However, more studies are needed to establish its use during MV weaning.

Weaning from mechanical ventilation: factors that influence intensive care nurses' decision-making

AIM

The aim of the study was to describe the factors that influence intensive care nurses' decision-making when weaning patients from mechanical ventilation.

BACKGROUND

Patients with failing vital function may require respiratory support. Weaning from mechanical ventilation is a process in which the intensive care nurse participates in both planning and implementation.

DESIGN AND METHOD

A qualitative approach was used. The data were collected by means of semi-structured interviews with 22 intensive care nurses. The interviews were transcribed and analysed using qualitative content analysis.

FINDINGS

One theme emerged: 'A complex nursing situation where the patient receives attention and which is influenced by the current care culture'. There was consensus that the overall assessment of the patient made by the intensive care nurse was the main factor that influenced the decision-making process. This assessment was a continuous process consisting of three factors: the patient's perspective as well as her/his physical and mental state. On the other hand, there was a lack of consensus about what other factors influenced the decision-making process. These factors included the care culture constituted by the characteristics of the team, the intensive care nurses' professional skills, personalities and ability to be present.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

The individual overall assessment of the patient enabled nursing care from a holistic perspective. Furthermore, the weaning process can be more effective and potential suffering reduced by creating awareness of the care culture's impact on the decision-making process.

Practical knowledge of experienced nurses in critical care: a qualitative study of their narratives

BACKGROUND

Scholars of nursing practices have claimed practical knowledge is source of knowledge in its own right, nevertheless we know little about this knowledge associated with day-to-day practice. The purpose of this study is to describe knowledge that the more experienced nurses the in ICU make use of and discover the components of care it includes. Understanding this knowledge can contribute to improving the working practices of nurses with less experience.

METHODS

We used a phenomenologic and hermeneutic approach to conduct a qualitative study. Open in-depth dialogue interviews were conducted with 13 experienced ICU nurses selected by intentional sampling. Data was compiled on significant stories of their practice. The data analysis enabled units of meaning to be categorised and grouped into topics regarding everyday practical knowledge.

RESULTS

Knowledge related to everyday practice was evaluated and grouped into seven topics corresponding to how the ICU nurses understand their patient care: 1) Connecting with, calming and situating patients who cannot communicate; 2) Situating and providing relief to patients in transitions of mechanical respiration and non-invasive ventilation; 3) Providing reassurance and guaranteeing the safety of immobilised patients; 4) The "connection" with patients in comas; 5) Taking care of the body; 6) The transition from saving life to palliative care; and 7) How to protect and defend the patient from errors. The components of caretaking that guarantee success include: the calm, care and affection with which they do things; the time devoted to understanding, situating and comforting patients and families; and the commitment they take on with new staff and doctors for the benefit of the patient.

CONCLUSIONS

These results show that stories of experiences describe a contextual practical knowledge that the more experienced nurses develop as a natural and spontaneous response. In critical patients the application of everyday practical knowledge greatly influences their well-being. In those cases in which the nurses describe how they have protected the patients from error, this practical knowledge can mean the difference between life and death. The study highlights the need to manage practical knowledge and undertake further research. The study is useful in keeping clinical practice up-to-date.

Critical care nurses management of prolonged weaning: an interview study

BACKGROUND

For most critically ill patients requiring mechanical ventilation in the intensive care unit (ICU) weaning is uncomplicated. For the remainder, weaning is a challenge and may result in further complications and increased risk of mortality. Critical care nurses (CCNs) require substantial knowledge and experience to manage patients experiencing prolonged weaning.

AIM

The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU.

DESIGN

A descriptive qualitative design.

METHODS

Semi-structured interviews with 19 experienced CCNs were conducted. Data were analysed using content analysis.

RESULTS

Participants used various strategies for weaning that were grouped into four categories: individualized planning for the weaning process, assessing patient's capacity, managing the process and team interaction. The overall theme that emerged was: CCNs drive the weaning process using both a patient centred and targeted approach.

CONCLUSION

CCNs in these ICUs performed weaning using a patient centred approach to plan, initiate, assess and establish a holistic weaning process. Team collaboration among all health care practitioners was important. CCNs have a key role in prioritizing weaning and driving the process forward.

RELEVANCE TO CLINICAL PRACTICE

Closeness to the patient and a key role in management of the mechanical ventilated patient in ICU gives the CCN unique potential to develop and create models and tools for prolonged weaning. These tools, specially designed for patients undergoing prolonged weaning, would give focus on continuous planning, collaborating, managing and evaluation in the process of liberating patients from mechanical ventilation.

Difficult to wean patients: cultural factors and their impact on weaning decision-making

AIMS AND OBJECTIVES

To examine the elements of the intensive care environment and consider the impact on nurses' involvement in decision-making when weaning from mechanical ventilation.

BACKGROUND

Optimal management of difficult to wean patients requires the dynamic collaboration of all clinicians and the contribution of their knowledge and skills. The introduction of weaning protocols has increased nurses' input in decision-making, but there are various elements of the decision environment that impact on their involvement, which have been given little consideration.

DESIGN

Ethnography was used as the research design for this study.

METHODS

Fieldwork took place in two tertiary hospitals in Greece and Scotland for five months each to unveil clinicians' behaviour and interactions during the weaning practice. Observation was based on the weaning process of 10 Scottish and 9 Greek long-term ventilated patients. Semi-structured interviews followed with nurses (n = 33) and doctors (n = 9) in both settings to understand nurses' perceived involvement in weaning decision-making. Thematic analysis of interviews and field notes followed using the Qualitative Data Analysis software NVivo. Clinicians' participation was voluntary.

RESULTS

The main themes identified were the (1) organisation of the units (time and structure of the ward rounds, staff levels and staff allocation system), (2) the inter- professional relationships, (3) the ownership and accountability in weaning decision-making and (4) the role of the weaning protocols. These elements described the culture of the ICUs and defined nurses' role in weaning decision-making.

CONCLUSIONS

Clinical decision-making is a multi-dynamic process specifically in complex clinical situations such as weaning from mechanical ventilation. This paper suggests that weaning practice should be considered in relation to the elements of the clinical environment to provide an individualised and patient-centred weaning approach.

RELEVANCE TO CLINICAL PRACTICE

Methods to enhance nurses' role in teamwork and collaborative decision-making are suggested.

The factors which influence nurses when weaning patients from mechanical ventilation: findings from a qualitative study

The aim of the study was to describe the factors that influence critical care nurses when deciding to wean patients from mechanical ventilation. The study adopted a qualitative methodology, using semi-structured interviews and a vignette. An invited sample of critical care nurses (n=24) from one Irish intensive care unit was employed. Each nurse was interviewed once and a vignette was used to structure the interview questioning. The findings were analysed using thematic content analysis. Six major themes influencing nurses' decision to wean emerged, as follows: physiological influences; clinical reassessment and decision making; the nurse's experience, confidence and education; the patient's medical history and current ventilation; the intensive care working environment; and use of protocols. The findings highlight the complex nature of weaning patients from mechanical ventilation and the major role of the nurse in this process.

The importance of knowing the patient in weaning from mechanical ventilation

AIM

The aim of the research was to understand how nurses used technology to wean patients from mechanical ventilation.

BACKGROUND

The literature concerned with the development of critical care centres on the role of technology with little emphasis on the nursing contribution.

DESIGN

An ethnographic approach was used to understand how nurses used technology to wean patients from mechanical ventilation.

METHODS

Data were gathered by participant observation and interviewing over a 6-month period. In total, 250 h of field notes were recorded.

RESULTS

Data were analysed by the content analysis method. Knowing the patient was a central theme identified. Three sub-themes were identified: ways of knowing, continuity of care and the role of the patient in the weaning trajectory.

CONCLUSION

'Knowing the patient' was implied during the interviews as essential to the delivery of patient-centred care. There were two main factors that needed to be present in order for nurses to know their patients: continuity of care and expertise. 'Ways of knowing' was reliant on gaining information about the patient. The role of the patient was a passive recipient of treatment.

IMPLICATIONS FOR PRACTICE

Knowing the patient has been defined as a characteristic of expert nursing. To be truly patient-centred nursing needs to address the barriers that prevent nurses from getting to 'know' their patients.

Outcome of physical therapy intervention on ventilator weaning and functional status

Our study aimed to understand the characteristics of ventilator dependence in patients at a respiratory care center and the potential effects of physical therapy on ventilator weaning and patients' functional status. Prospective data collection consisted of the following: (1) demographic data, including name, gender, age, diagnosis, the Acute Physiology and Chronic Health Evaluation as a severity of the disease, modified Glasgow Coma Scale, mobility at the time of admission, and days of hospitalization; (2) Rapid shallow breathing index (RSBI) as a predictive indicator of ventilator weaning, including indicators of ventilator weaning were collected from the respiratory flow sheet; and (3) Barthel index. Between July 1 and December 31, 2007, 126 patients were admitted to the respiratory care center, and those who required mechanical ventilation for more than 14 days were enrolled. Fifty-five subjects received physical therapy. The RSBI in patients who received physical therapy was 75.7 +/- 37.9 before therapy and 80.0 +/- 48.5 afterwards, while the Barthel index increased from 0.8 +/- 1.4 to 1.9 +/- 2.5 (p < 0.05). The RSBI decreased as time of physical therapy lengthened, but not significantly (r = 0.12, p = 0.44). The success rate of ventilator weaning in patients receiving physical therapy intervention versus non-physical therapy intervention was 58.2% and 40.9%, respectively. The results indicated that lengthening the physical therapy intervention time enhanced the ventilator weaning success rate while mobility was not affected (r = -0.11, p = 0.41). Physical therapy may be offered to ventilator-dependent patients in line with their individual needs to improve or maintain basic mobility.

Observing the approaches to weaning of the long-term ventilated patients

BACKGROUND

The weaning process from mechanical ventilation is a complicated issue for patients with respiratory failure who require long-term respiratory support. Although the application of weaning protocols reduces weaning time, and enhances patient outcome, little is known about the actual approaches that clinicians use for the weaning of these patients.

AIM

The purpose of this paper is to explore approaches to weaning of long-term ventilated patients in a Scottish Intensive Care Unit. The findings are part of a larger study on decision-making during the weaning of long-term ventilated patients.

METHOD

Data were collected through participant observation and follow-up interviews with the nursing staff. Twenty-four-hour chart and medical notes review and informal conversation with the bedside nurse were also used to collect information on the weaning process.

FINDINGS

Nine patients were recruited to the study. Two patients were extubated and three patients were extubated but then required a tracheostomy. A further four patients had a tracheostomy performed. Thematic analysis of the data showed that weaning was individualized, and physician led, regardless of the existence of the weaning protocol. Six different weaning approaches were identified. Nurses followed a conservative approach to weaning in comparison to doctors who appeared more aggressive.

CONCLUSION

There are many varieties in the approaches clinicians use when weaning long-term ventilated patients, which acts on the continuity of their care. A shift of focus to identify ways of maintaining continuity of care and a combined 'wake and wean' approach needs to be considered.

Successful mechanical ventilation weaning experiences at respiratory care centers

A phenomenological qualitative study was conducted on the experiences of patients who had been successfully weaned from mechanical ventilation, including essential elements of the patient support system during the weaning process. In-depth interviews were conducted with 20 participants who had been recruited through purposive sampling from three respiratory care centers in Taiwan. The experiences of participants who had been successfully weaned from mechanical ventilation could be categorized into five themes, which were (a) dealing with the unfamiliar context presented by the weaning program, (b) experiencing various psychological responses and self-endurance ambiguity, (c) being tortured by helplessness, (d) wondering whether to continue or give up, (e) and release from self-breathing. Findings were intended to give nurses an increased understanding of patient experiences and help in raising their competence in managing patient emotional reactions that arise during the weaning process. As patient conditions gradually improve, nurses should assess the criteria for mechanical ventilation weaning and provide preparatory information and clarify patient questions to avoid potential negative responses during the process. Participants also reported that the professionalism of nurses and concern from family members were essential sources of support for successful weaning. Nurses can apply recommendations to develop effective patient support systems that encourage family members to accompany patients at critical times during the weaning process. Therefore, the results of this study may assist healthcare personnel to develop strategies to ensure successful weaning from mechanical ventilation.

Experiences of intensive care nurses assessing sedation/agitation in critically ill patients

BACKGROUND

Patients admitted to the intensive care unit (ICU) will more often than not require sedative and analgesic drugs to enable them to tolerate the invasive procedures and therapies caused as a result of their underlying condition and/or necessary medical interventions.

AIM

This article reports a study exploring the perceptions and experiences of intensive care nurses using a sedation/agitation scoring (SAS) tool to assess and manage sedation and agitation amongst critically ill patients. The principle aims and objectives of this study were as follows: to explore nurse's everyday experiences using a sedation scoring tool; to explore and understand nurse's attitudes and beliefs of the various components of assessing and managing sedation among critically ill patients.

METHOD

Using a descriptive qualitative approach, semistructured interviews were carried out with a purposive sample of eight ICU nurses within a district general hospital ICU. The interviews focused on nurses own experiences and perceptions of using a sedation scoring tool in clinical practice. Burnards 14-stage thematic content analysis framework was employed to assist in the data analysis process.

RESULTS

Three key themes emerged that may have implications not only for clinical practice but for further research into the use of the SAS tool. Benefits to patient care as a direct result of using a sedation scoring tool. The concerns of nursing staff. The implications of using such a tool in clinical practice.

CONCLUSION

This paper reinforces the potential benefits to patients as a direct result of implementing the SAS scoring tool and clinical guidelines. Furthermore, it highlights the reluctance of a number of staff to adhere to such guidelines and discusses the concerns regarding less experienced nurses administering sedative agents. Attention was also drawn to the educational requirements of nursing and medical staff when using the SAS scoring tool.

Weaning from ventilation: does a care bundle approach work?

There has been renewed interest in weaning from mechanical ventilation in critical care since the publication of the Modernisation Agency paper in 2002. There have been many papers reporting ways of improving the weaning process but these are specific to single elements and neglect the contextual issues that influence the weaning process. Care bundles have been introduced nationally to standardise patient care and improve patient outcome. Examples in critical care are the ventilator care bundle and sepsis care bundle. However, since care bundles have become linked with targets and part of the 10 High Impact Changes there is a tendency to want to call everything a care bundle. A care bundle is a small but critical set of processes that when implemented together improve outcome. One critical care network has written a weaning care bundle. This is an example of a service improvement initiative the aim of which was to improve weaning from mechanical ventilation. This paper reviews this approach and presents results from a pilot in one teaching hospital.

Intensive care nurses’ perceptions of protocol-directed weaning—A qualitative study

The aim of this study was to identify intensive care nurses' perceptions of protocol-directed weaning, by means of focus group interviews and qualitative content analysis. The results showed that the nurses perceived the protocol as useful. When prescribed, it represented interprofessional agreement that allowed them to act in the absence of a physician. It focused on weaning, saved time, was easy to use and led to a feeling of safety and continuity in the weaning process. Barriers to its use were related to lack of instructions from physicians. Nurses reported three ways of handling the situation in the absence of a weaning plan: taking action, waiting, and giving weaning low priority, which could lead to undesired variations. Nurses in this study reported that they would like an interdisciplinary approach to weaning and expressed the need for a shared "language" or knowledge base in order to improve communication. It is important that different disciplines meet to share each other's knowledge. Contact is vital in order to learn about and respect different types of professional knowledge.

Issues in weaning from mechanical ventilation: literature review

AIM

The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation.

BACKGROUND

Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process.

METHOD

In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations.

DISCUSSION

Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level.

CONCLUSION

Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.

A comparative study examining the decision-making processes of medical and nursing staff in weaning patients from mechanical ventilation

A prolonged period of mechanical ventilation is costly for both the patient, in terms of the risk of complications such as ventilator-acquired pneumonia, and to the health service due to the high cost of maintaining a patient in intensive care. The recognition of the role nurses can play in the weaning process and the desire to try and reduce weaning times led to the introduction of nurse-managed weaning on the intensive care unit which is the focus of this study. This means that both doctors and nurses are now responsible for making decisions about weaning. Flexible guidelines for weaning were devised which still require a large element of individual, clinical decision-making during the process. At every stage in the weaning process clinicians are required to make judgments about patient responses, using these judgments as the basis for their decision-making. This study examined the ways doctors and nurses make these decisions. Semi-structured interviews were conducted with doctors and senior nurses. A grounded theory approach was used to analyse the results and the key themes of Treatment, Balance, Making Progress and The Individual were identified which were found to be linked with particular methods of decision-making.

Evidence-based clinical improvement for mechanically ventilated patients

Bundling or grouping together evidence-based interventions to improve care for the mechanically ventilated patient was piloted by a 10-bed medical-surgical critical care unit of a hospital. The bundled care interventions included: (a) keeping the head of bed elevated at 30 degrees, (b) instituting daily interruption of continuous sedative infusion, (c) assessing readiness to wean using a rapid-wean assessment guide, (d) initiating deep venous thrombosis prophylaxis, and (e) implementing peptic ulcer disease prophylaxis. The interventions were implemented using a plan-do-check-act quality-improvement methodology. Results indicated that the use of bundled interventions for mechanically ventilated patients could decrease average ventilator times and average length of stay with no concomitant increase in reintubations. Average mortality rates and the number of adverse events per 100 patient days also were reduced.

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

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

Biofeedback as a supportive method in weaning long-term ventilated critically ill patients

Weaning a patient from mechanical ventilation is occasionally a difficult process complicated by the patient's emotional state. Anxiety, agitation, depression and other emotional disturbances can start a vicious circle between fear of losing breath and dyspnea that impairs the process of withdrawing ventilatory support. A biocybernetic loop model is suggested that integrates psychological variables (e.g., capacity of self-control, self-confidence, sense of self-efficacy) as important factors for a successful weaning. The paradigm of biofeedback is regarded as a suited approach to strengthen these psychological factors. It means the externalization of physiological functions especially of those from the autonomous nervous system so that a patient becomes aware of them. In the case of the ventilated patient, it is assumed that the transformation of the respiratory activities into perceptible (acoustic and visual) signals supports the patient's self-controlling behaviour during the weaning process. He gets positive reinforcement for his efforts to influence his breathing intentionally and, by continuous and immediate information, he regains self-confidence to control his somatic functions effectively. The application of biofeedback is mainly described in single case studies. They all report a decrease in the respiratory rate and an increase in the tidal volume. The need for a controlled study is suggested that would answer the question of whether biofeedback is an appropriate psychological tool to facilitate the weaning process in mechanically ventilated patients.

Subjective Perceptions and Physiological Variables During Weaning From Mechanical Ventilation

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

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

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

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

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

[Weaning from mechanical ventilation. The aim of nursing research]

Management of patients difficult to wean from the ventilator is a practical challenge in which professional nurses are deeply involved.The clinical research applied over the last years has tried to describe the characteristics of weaning phenomenon and the associated factors, to find predictive outcomes to guide clinical decisions, to search new strategies to conduct the protocols and to identify the most effective modes of weaning. In this paper a critical review of the current knowledge from a nursing perspective is done. The weaning conceptual model proposed by the American Association of Critical Care Nurses (AACN) group has been used as a theoretical framework.