The use of a weaning and extubation protocol to facilitate effective weaning and extubation from mechanical ventilation in patients suffering from traumatic injuries: a non-randomized experimental trial comparing a prospective to retrospective cohort

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

Effects of Mechanical Ventilator Weaning Education on ICU Nurses and Patient Outcomes: A Scoping Review

BACKGROUND

Assessment of mechanical ventilator (MV) weaning is a complex process that requires education for nurses. This scoping review aimed to clarify the effects of MV weaning education on intensive care unit nurses and patient outcomes.

METHOD

Four databases were searched. The inclusion criteria were studies on MV weaning education for nurses, outcome measures for patients or nurses, and quantitative research.

RESULTS

In total, 663 studies were identified. The criteria for a full review (n = 15) were educational protocols (n = 13) and the Burns Wean Assessment Program (n = 2). Patient outcomes determined the MV duration. The weaning protocol was convenient for nurses. Nevertheless, their clinical judgment skills must be improved, regardless of the availability of a protocol. Education is crucial for producing positive outcomes.

CONCLUSION

Education for nurses on MV weaning showed shortened MV duration. No significant effects were found for other outcomes. [J Contin Educ Nurs. 2023;54(4):185-192.].

Predicting mechanical ventilation effects on six human tissue transcriptomes

BACKGROUND

Mechanical ventilation (MV) is a lifesaving therapy used for patients with respiratory failure. Nevertheless, MV is associated with numerous complications and increased mortality. The aim of this study is to define the effects of MV on gene expression of direct and peripheral human tissues.

METHODS

Classification models were applied to Genotype-Tissue Expression Project (GTEx) gene expression data of six representative tissues-liver, adipose, skin, nerve-tibial, muscle and lung, for performance comparison and feature analysis. We utilized 18 prediction models using the Random Forest (RF), XGBoost (eXtreme Gradient Boosting) decision tree and ANN (Artificial Neural Network) methods to classify ventilation and non-ventilation samples and to compare their prediction performance for the six tissues. In the model comparison, the AUC (area under receiver operating curve), accuracy, precision, recall, and F1 score were used to evaluate the predictive performance of each model. We then conducted feature analysis per each tissue to detect MV marker genes followed by pathway enrichment analysis for these genes.

RESULTS

XGBoost outperformed the other methods and predicted samples had undergone MV with an average accuracy for the six tissues of 0.951 and average AUC of 0.945. The feature analysis detected a combination of MV marker genes per each tested tissue, some common across several tissues. MV marker genes were mainly related to inflammation and fibrosis as well as cell development and movement regulation. The MV marker genes were significantly enriched in inflammatory and viral pathways.

CONCLUSION

The XGBoost method demonstrated clear enhanced performance and feature analysis compared to the other models. XGBoost was helpful in detecting the tissue-specific marker genes for identifying transcriptomic changes related to MV. Our results show that MV is associated with reduced development and movement in the tissues and higher inflammation and injury not only in direct tissues such as the lungs but also in peripheral tissues and thus should be carefully considered before being implemented.

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.

Cross mapping between clinical indicators for assistance in intensive care and nursing interventions

OBJECTIVE

Identify the main clinical indicators for assistance in the Intensive Care Unit (ICU) and map them in the nursing interventions described by the Nursing Interventions Classification (NIC).

METHODS

Integrative literature review study, followed by cross-mapping between clinical indicators for assistance in the ICU care and NIC nursing interventions and activities.

RESULTS

36 articles were identified, which resulted in 285 clinical indicators for ICU care, with mechanical ventilatory assistance, pain, sedation, psychomotor agitation, delirium, anxiety, altered heart rate, diet by naso tube / oroenteral and diarrhea the clinical indicators for assistance in the ICU the most prevalent. These were mapped in 12 Nursing Interventions Classification interventions and 130 nursing activities.

FINAL CONSIDERATIONS

It is concluded that the clinical indicators for ICU care associated with Nursing Interventions Classification are concrete data that assist intensive care nurses in their clinical practice.

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.

IMPACT OF A VENTILATORY WEANING PROTOCOL IN AN INTENSIVE CARE UNIT FOR ADULTS

ABSTRACT Objective: to evaluate the impact of a ventilatory weaning protocol on the weaning quality and on the outcomes of the patients. Method: a quasi-experimental quantitative study, consisting of comparing a prospective study with a retrospective study. Data was collected through a weaning log sheet applied between September and December 2015 at an intensive care unit in northern Portugal following the implementation of a weaning protocol and compared with a base-line constituted in the year preceding the implementation of the ventilatory weaning protocol. Results: the experimental group had a score mean of higher overall quality of weaning, with a reduction in the timing for initiating the weaning in 27.3% and the weaning time in 36.6%. Conclusion: the implementation of the ventilatory weaning protocol improved the overall quality of the weaning, facilitating the identification of patients with criteria to initiate the process, starting earlier, resulting in a reduction in ventilatory weaning time.

Factors Influencing Weaning Older Adults From Mechanical Ventilation: An Integrative Review

This study aim was to describe the influences that affect weaning from mechanical ventilation among older adults in the intensive care unit (ICU). Adults older than 65 years comprised only 14.5% of the US population in 2014; however, they accounted up to 45% of all ICU admissions. As this population grows, the number of ICU admissions is expected to increase. One of the most common procedures for hospitalized adults 75 years and older is mechanical ventilation. An integrative review methodology was applied to analyze and synthesize primary research reports. A search for the articles was performed using the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases; using the keywords and Boolean operators "older adults," "weaning," "mechanical ventilation," and intensive care unit. Although physiologic changes that occur with aging place older adults at higher risk for respiratory complications and mortality, there are many factors, other than chronological age, that can determine a patient's ability to be successfully weaned from mechanical ventilation. Of the 6 studies reviewed, all identified various predictors of weaning outcome, which included maximal inspiratory pressure, rapid shallow breathing index, fluid balance, comorbidity burden, severity of illness, emphysematous changes, and low serum albumin. Age, in and of itself, is not a predictor of weaning from mechanical ventilation. More studies are needed to describe the influences affecting weaning older adults from mechanical ventilation.

Relationship between pre-extubation positive end-expiratory pressure and oxygenation after coronary artery bypass grafting

Introduction

After removal of endotracheal tube and artificial ventilation, ventilatory support should be continued, offering oxygen supply to ensure an arterial oxygen saturation close to physiological.

Objective

The aim of this study was to investigate the effects of positive-end expiratory pressure before extubation on the oxygenation indices of patients undergoing coronary artery bypass grafting.

Methods

A randomized clinical trial with seventy-eight patients undergoing coronary artery bypass grafting divided into three groups and ventilated with different positive-end expiratory pressure levels prior to extubation: Group A, 5 cmH₂O (n=32); Group B, 8 cmH₂O (n=26); and Group C, 10 cmH₂O (n=20). Oxygenation index data were obtained from arterial blood gas samples collected at 1, 3, and 6 h after extubation. Patients with chronic pulmonary disease and those who underwent off-pump, emergency, or combined surgeries were excluded. For statistical analysis, we used Shapiro-Wilk, G, Kruskal-Wallis, and analysis of variance tests and set the level of significance at P<0.05.

Results

Groups were homogenous with regard to demographic, clinical, and surgical variables. There were no statistically significant differences between groups in the first 6 h after extubation with regard to oxygenation indices and oxygen therapy utilization.

Conclusion

In this sample of patients undergoing coronary artery bypass grafting, the use of different positive-end expiratory pressure levels before extubation did not affect gas exchange or oxygen therapy utilization in the first 6 h after endotracheal tube removal.

An Overview of the Predictor Standard Tools for Patient Weaning from Mechanical Ventilation

Most patients staying in the intensive care unit (ICU) require respiratory support through a ventilator. Since prolonged mechanical ventilation and weaning from the ventilator without criteria or at the inappropriate time can result in many complications, it is required that patients be weaned off the ventilator as soon as possible. This study was conducted to investigate a few standard tools that predict successful and timely weaning of patients from the ventilator. In the literature, SOFA and APACHE II scores, along with various tools, including Burn, Morganroth, and Corgian, have been used in weaning patients from the ventilator. In most of these studies, the increase or decrease in the APACHE II score was correlated with the patient’s weaning time, and this score could be used as a criterion for weaning. Several authors have expressed their belief that the SOFA score in the ICU is a good indicator of the prognosis of patient’s weaning from the ventilator, length of stay, mortality, and rate of recovery. Several studies have compared SOFA and APACHE II scores and have shown that there is a positive correlation between the SOFA and APACHE II scores and that both mortality and dependence on the ventilator are related to these two scores. Another tool is Burn’s weaning program. A higher Burn score indicates successful weaning off of the ventilator, successful extubation, lower length of mechanical ventilation, and shorter stay in the hospital. However, the capabilities of the Morganroth scale and the Gluck and Corgian scoring systems were evaluated only for successful weaning off of the ventilator, and a decrease in the Morganroth and Gluck scores indicated successful weaning.

Developing minimum clinical standards for physiotherapy in South African intensive care units: the nominal group technique in action

RATIONALE, AIMS AND OBJECTIVES

Physiotherapists form an important part of the inter-professional team that cares for critically ill patients in intensive care units (ICU). No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for physiotherapy within critical care, which poses a threat to physiotherapy practice and professional credibility.

METHODS

The aim of this paper was to describe the nominal group technique (NGT) used to identify the minimum standards of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs.

RESULTS

Twenty-five subjects participated in one of three forums. Sixty-six concepts were considered in the three domains (knowledge, skills and attitudes). Not all concepts were discussed by all three focus groups. Just over half (54% n=14) the concepts generated in the knowledge domain; a third of the concepts (35% n=7) generated in the skills domain and only 10% (n=2) of attitudes were consistently raised by all three groups. Almost two-thirds of the concepts generated (62% n=41) were considered in more than one domain. Only six concepts reached the threshold consensus level across all three focus groups, four knowledge parameters and two skills.

CONCLUSION

The NGT allowed for the cross-stimulation of ideas in an engaging yet anonymous and structured manner. The importance of discussion in reaching consensus is highlighted. Going forward, it is intended to use the concepts generated through this process as the foundation for further consensus-building activities among the wider physiotherapy and intensive care communities.